Chapter 9: Unintentional Injuries & Violence

What steps can you take to reduce the chances of accidental injuries?

How can you reduce chances of injuries from violence?

Chapter 9 Learning Outcomes

By the end of this chapter you will be able to:

  • Recognize the common types of unintentional and intentional injuries
  • Identify ways to reduce chances of unintentional and intentional injuries
  • Explain how risk from injury changes throughout life stages.

There are many choices you make in life that impact your health and well-being and some of those choices, like smoking cigarettes, have a direct connection to a negative health implication, like lung cancer.  Although the choices you make may or may not directly impact the possibility of suffering intentional and unintentional injuries, understanding the most common reasons for injury can help you increase your safety.

Introduction to Intentional and Unintentional injuries

Throughout the world, injuries, both unintentional and violence-related, take the lives of 4.4 million people each year (nearly 8% of all deaths).  For people ages 5-29, three of the top five causes of death are injury-related. In the United States, unintentional injuries are the leading cause of death in children, adolescents, and adults younger than 45 years.  In 2018, unintentional injuries were the cause of 24.8 million people to visit their doctor and 97.9 million to visit the emergency room with an additional 1.2 million visited the emergency room due to an assault.  Unintentional injuries ranked as the 4th overall leading cause of death in 1980, increased to the 3rd leading cause of death by 2018, and moved back to 4th in 2020 when COVID took the 3rd ranking.   Some good news is that data from 1950-2018 show a reduction in deaths due to unintentional injuries from 78 per 100,000 to 48 per 100,000, however homicide has remained relatively the same from 5.1 to 5.9 per 100,000 people [1].

Injuries and violence cost billions of dollars each year in health care costs, lost productivity and law enforcement. There are also numerous costs to personal well-being including:

  • Premature death
  • Years of potential life lost
  • Disability and disability-adjusted life years lost
  • Poor mental health
  • Increased risk of suicide
  • High medical costs
  • Lost productivity
  • Chronic diseases like heart disease, diabetes and cancer
  • Social problems such as poverty, crime and violence

Both intentional and unintentional injuries are public health concerns that are addressed worldwide and in the U.S.  The National Center for Injury Prevention and Control (NCIPC) was launched in 1992 to focus specifically on injuries as an important topic for public health.  The NCIPC, along with the CDC and NIH, provide research-based evidence and resources to meet goals to reduce injuries.

Table 9.1: Year 2020 Intentional and Unintentional Death Rates[2]
Cause of Death Number of Deaths Deaths per 100,000 people
Unintentional fall deaths 42,112 12.8
Motor Vehicle traffic deaths 40,698 12.4
Unintentional Poisoning deaths 87,404 26.5
All poisoning deaths 97,034 29.5
Firearm homicides 19,384 5.9
All firearm deaths 45,222 13.7
All homicide deaths 24,576 7.5
Firearm suicides 24,292 7.4
Suffocation suicides 12,495 3.8
Poisoning suicides 5,528 1.7
All suicides 45,979 14.0
All injury deaths 278,345 84.5
All unintentional deaths 200,995 61

Unintentional injuries

Unintentional injuries are often referred to as “accidents,” meaning something that was not intended.  These include falls, drowning, motor vehicle crashes, fires, and poisoning.


For adults over 65 years, falls are the leading cause of death due to injury. In 2019 older adult falls caused 34,000 deaths, 3 million visits to the emergency room, and over 800,000 hospitalizations attributing to over $50 billion in medical costs annually. It is estimated that more than one out of four older people fall each year with one out of five falls causing serious injury.  Traumatic brain injuries (TBI) and hip fractures are the most common serious injuries.  The injuries associated with falls impact a persons quality of life making it hard for a person to get around, do everyday activities, or live on their own.  Many people who fall, even if they’re not injured, become afraid of falling. This fear may impact their quality of life by causing a person to cut down on their everyday activities. When a person is less active, they become weaker and this increases their chances of falling.

Fall risk and prevention tips include:

  • Lower body weakness, difficulties with walking and balance, or foot pain or poor footwear
    • Do exercises that make your legs stronger and improve your balance. Tai Chi is a good example of this kind of exercise.
    • Ask your doctor or healthcare provider to evaluate your risk for falling and talk with them about specific things you can do.
  • Vitamin D deficiency (that is, not enough vitamin D in your system)
    • Ask your doctor or healthcare provider about taking vitamin D supplements.
  • Use of medicines, such as tranquilizers, sedatives, or antidepressants. Even some over-the-counter medicines can affect balance and how steady you are on your feet.
    • Ask your doctor or pharmacist to review your medicines to see if any might make you dizzy or sleepy. This should include prescription medicines and over-the counter medicines.
  • Vision problems
    • Have your eyes checked by an eye doctor at least once a year, and be sure to update your eyeglasses if needed.
    • If you have bifocal or progressive lenses, you may want to get a pair of glasses with only your distance prescription for outdoor activities, such as walking. Sometimes these types of lenses can make things seem closer or farther away than they really are.
  • Home hazards or dangers such as broken or uneven steps, and throw rugs or clutter that can be tripped over.
    • Get rid of things you could trip over.
    • Add grab bars inside and outside your tub or shower and next to the toilet.
    • Put railings on both sides of stairs.
    • Make sure your home has lots of light by adding more or brighter light bulbs.
    • Keep items you use often in cabinets you can reach easily without using a step stool.
    • Use non-slip mats in the bathtub and on shower floors.


Drowning is the process of experiencing respiratory impairment from submersion or immersion in liquid.  Drowning can happen in seconds and is often silent. It can happen to anyone, any time there is access to water. Not all drownings are fatal, drowning injuries can cause brain damage and other serious outcomes, including long-term disability. Drowning kills nearly 4,000 people each year in the United States and is the leading cause of injury death for children 1 to 4 years of age.  For every child who dies from drowning, another eight receive emergency department care for non-fatal drowning.  Not all drownings are fatal, drowning injuries can cause brain damage and other serious outcomes, including long-term disability.

Drowning risk and prevention tips include:

  • Not being able to swim
    • Adults and children should participate in formal swim lessons.
  • Missing or ineffective fences around water
    • A four-sided isolation fence which separates the pool area from the house and yard reduces a child’s risk of drowning by 83% compared to three-sided property-line fencing (which encloses the entire yard, but does not separate the pool from the house).
  • Lack of close supervision
    • Drowning can happen quickly and quietly anywhere there is water, especially to unsupervised children. It happens in lakes and oceans, pools, bathtubs, and even buckets of water. Drowning can occur when lifeguards are present.
    • Use the buddy system!  Always swim with another person.
  • Location
    • The highest risk locations for drowning vary by age. Among infants under 1 year old, two thirds of all drownings occur in bathtubs. Most drownings happen in home swimming pools among children ages 1-4. More than half of fatal and nonfatal drownings among people 15 years and older occur in natural waters like lakes, rivers, or oceans.
    • It is important to know the risks or natural water, such as ocean rip currents.
  • Not wearing life jackets
    • Life jackets can prevent drowning during water activities, especially boating and swimming. The U.S. Coast Guard reported 613 boating-related deaths in 2019, 79% of these deaths were drowning related, and of those who died from drowning 86% were not wearing life jackets.
  • Drinking alcohol or using drugs
    • Among adolescents and adults, alcohol use is involved in:
      • up to 70% of deaths associated with water recreation,
      • nearly 1 in 4 emergency department visits for drowning, and
      • about 1 in 5 reported boating deaths.

Motor Vehicle Crashes

In 2020, more than 40,000 people died in motor vehicle crashes in the United States, that is more than 110 people killed in crashes every day.  There were over 2.1 million emergency department visits for injuries from motor vehicle crashes in 2020.  Deaths from crashes in 2020 resulted in over $430 billion in total costs—including medical costs and cost estimates for lost quality of life and lives lost.  Motor vehicle injuries are often associated with distracted, impaired, or inexperienced drivers.

Distracted Drivers

  • Distracted driving is doing another activity that takes the driver’s attention away from driving that can increase the chance of a motor vehicle crash.  There are three main types of distracted driving: visual (taking your eyes off the road), manual (taking your hands off the wheel), and cognitive (taking your mind off driving).
  • In 2019,  3,100 people were killed and about 424,000 were injured in crashes involving a distracted driver.  Not all persons killed by distracted drivers were in cars, about 1 in 5 were walking, riding their bikes, or otherwise outside a vehicle.
  • Prevention:  Do not multitask while driving. Whether it’s adjusting your mirrors, selecting music, eating, making a phone call, or reading a text or email―do it before or after your trip, not during.

Child Passenger Safety

  • Motor vehicle injuries are a leading cause of death among children in the United States. But many of these deaths can be prevented. Always buckling children in age- and size-appropriate car seats, booster seats, and seat belts reduces serious and fatal injuries by up to 80%.


  • Although most drivers follow these safety measures on every trip, there are still millions who don’t. In fact, it is estimated that 2,549 lives (of people 5 years and older) could have been saved in 2017 alone if all motor vehicle occupants were restrained on every trip.

Teen Drivers

  • In 2019, almost 2,400 teens in the United States aged 13–19 were killed and about 258,000 were treated in emergency departments for injuries suffered in motor vehicle crashes. That means that every day, about seven teens died due to motor vehicle crashes, and hundreds more were injured. In addition, motor vehicle crash deaths among teens 15–19 years of age resulted in about $4.8 billion in medical and work loss costs for crashes that occurred in 2018.
  • Teens who are at especially high risk for motor vehicle crashes are: Males, teens driving with teen or young adult passengers, and newly licensed teens.
  • Risk factors include: Inexperience, nighttime and weekend driving, not using a seat belt, distracted driving, speeding, alcohol/drug use

Older drivers

  • In 2019, about 8,000 older adults (aged 65+) were killed in traffic crashes, and more than 250,000 were treated in emergency departments for crash injuries. This means that each day, more than 20 older adults are killed and almost 700 are injured in crashes. Drivers aged 70+ have higher crash death rates per mile driven than middle-aged drivers (aged 35-54). Higher crash death rates among this age group are primarily due to increased vulnerability to injury in a crash. Across all age groups, males have substantially higher death rates than females.
  • Age-related declines in vision and cognitive functioning (ability to reason and remember), as well as physical changes, might affect some older adults’ driving abilities.

Impaired driving

  • Every day, 29 people in the United States die in motor vehicle crashes that involve an alcohol-impaired driver, this is one death every 50 minutes. The annual cost of alcohol-related crashes totals more than $44 billion.
  • Drugs other than alcohol (legal and illegal) are involved in about 16% of motor vehicle crashes.  In 2018, 12.6 million people reported driving under the influence of marijuana or other illicit drugs.
  • Drugs other than alcohol (legal and illegal) are involved in about 16% of motor vehicle crashes.

Pedestrian Safety

  • More than 7,000 pedestrians were killed on our nation’s roads in crashes involving a motor vehicle in 2020. That’s about one death every 75 minutes.
  • Alcohol, speeding, and location are major risk factors for pedestrian deaths caused by motor vehicles.
  • Adults aged 65 years and older accounted for 20% of all pedestrian deaths in 2020, yet were only about 17% of the U.S. population.
  • Pedestrian injuries can be reduced by:  increasing your visibility, using cross walks, using designated sidewalks/paths, avoiding distractions while walking like headphones, and avoid walking when impaired.

Motorcycle Safety

  • More than 5,500 motorcyclists died on our nation’s roads in 2020, and more than 180,000 were treated in emergency departments for crash injuries.
  • Motorcycle helmets are important to save lives.  In 2017, helmets saved an estimated 1,872 lives and an additional 749 more lives could have been saved if all motorcyclists had worn helmets. Motorcycle helmets are 37 percent (for riders) and 41 percent (for passengers) effective in preventing deaths. Helmets reduce the risk of head injury by 69%.

Bicycle Safety

  • Bicycle trips make up only 1% of all trips in the United States. However, bicyclists account for over 2% of people who die in a crash involving a motor vehicle on our nation’s roads. Nearly 1,000 bicyclists die and over 130,000 are injured in crashes that occur on roads in the United States every year.
  • Adults ages 55-69 have the highest bicycle death rates and adolescents, teens, and young adults have the highest rates of bicycle-related injuries treated in emergency departments (EDs).
  • Male bicyclists have death rates 6 times higher and injury rates 5 times higher than females.


Fire is fast, in less than 30 seconds a small flame can turn into a major fire.  In 2019, there were 1,291,500 fires which caused 3,704 deaths, 16,600 injuries, and accounts for $14.8 billion.

Home fire safety:

  • Smoke alarms
    • Put smoke alarms on every level of your home and inside/outside of all sleeping areas.
    • Test them often to make sure they work and replace them after 10 years.
  • In the kitchen
    • Do not leave the room when cooking, if you leave the kitchen turn off the burners.
    • Move flammable objects away from the cooking area.
    • Turn pot handles toward the back of the stove to avoid unintentionally knocking them.
  • Home heating
    • Move flammable objects away from fireplaces, wood stoves, space heaters, or radiators.
    • Never use an extension cord with a space heater.
    • Ensure space heaters have an auto turn off if tipped over.
    • Have your chimney inspected.
  • Smoking in the house
    • If you smoke in your home you have an increased risk of home fires.
    • Never smoke in bed or when drowsy
    • Ensure all cigarettes are completely put out- use water to ensure!
  • Young children and older adults
    • Keep children away for anything that gets hot.
    • Keep matches and lighters out of reach of children.
    • Teach children how to escape the home if you cannot help them in the event of a home fire.
    • Older adults may need assistance to escape a home fire.


Poisoning is one of the top three causes of fatal unintentional injuries.  In response to public health concerns regarding poisoning, in 1980 the National Capital Poison Center (NCPC) was founded, which is an independent, not-for-profit 501(c)(3) organization. There are 2 ways to get help from Poison Control: online at webPOISONCONTROL® or by phone at 1-800-222-1222.

As the primary organization providing help with poisoning, the NCPC data provides a picture of the commonality of injuries associated with poisoning.   In 2020, the 55 U.S. poison control centers provided telephone guidance for over 2.1 million human poison exposures, which included:

  • 6.4 poison exposures/1000 population,
  • 37.9 poison exposures in children younger than 6 years/1000 children,
  • 1 poison exposure reported to U.S. poison control centers every 15 seconds.
  • In 2020, adults comprised almost half of all exposures (47%), followed by children younger than 6 (39%), then teens (8%).

Common types of poisoning include food poisoning, poisonous plants, and carbon monoxide poisoning.

Food poisoning symptoms can be anywhere from mild to very serious and may include: Upset stomach, stomach, cramps, nausea, vomiting, diarrhea, and fever.  Some foods are more associated with foodborne illnesses and food poisoning than others, such as raw animal foods. While certain foods are more likely to make you sick, any food can get contaminated in the field, during processing, or during other stages in the food production chain, including through cross-contamination with raw meat in kitchens.

Many native and exotic plants are poisonous to humans when ingested or if there is skin contact with plant chemicals. However, the most common problems with poisonous plants arise from contact with the sap oil of several native plants that cause an allergic skin reaction—poison ivy, poison oak, and poison sumac.

Everyone is at risk for Carbon monoxide (CO) poisoning. CO, an odorless, colorless gas, that can cause sudden illness and death. CO is found in fumes produced any time you burn fuel in cars or trucks, small engines, stoves, lanterns, grills, fireplaces, gas ranges, or furnaces. CO can build up indoors and poison people and animals who breathe it. The most common symptoms of CO poisoning are headache, dizziness, weakness, upset stomach, vomiting, chest pain, and confusion. CO symptoms are often described as “flu-like.” If you breathe in a lot of CO it can make you pass out or kill you. People who are sleeping or drunk can die from CO poisoning before they have symptoms.  It is important to use Carbon Monoxide detectors to know if CO is present.

Intentional Injuries: Violence

There are many forms of intentional injury, or violence.  The CDC approaches violence using the “Social-Ecological Model: a Framework for Prevention”.  The framework encourages viewing violence and violence prevention as a multifaceted interconnected dynamic including the individual, their relationships, their community, and our society.

  • The Individual
    • Individuals factors such as age, education, income, substance use, or history of abuse impact the risk of violence.  A focus on attitudes, beliefs, behaviors, along with training on conflict resolution, safe dating, and healthy relationship may positively impact their risk of violence.
  • Relationships
    • A person’s closest social circle-peers, partners and family members-influences their behavior and contribute to their experience.  Parenting, mentors, effective communication, and problem solving may support effective relationships to prevent violence.
  • Community
    • Where a person lives, works, or goes to school can impact their risk of violence.  Creating safe physical and social environments may reduce violence in the community.
  • Societal
    • A focus on society asks us to understand and look at how our society either encourages or inhibits violence, for example how social or cultural norms use violence to resolve conflicts or how wealth and health inequalities impact violence risk.

Community Violence

Community violence is interpersonal violence generally outside the home that is perpetrated by individuals who are not intimately related to the victim and who may or may not know each other. Examples include assaults, homicides, fights among groups, and shootings in public places, such as schools and on the streets. Acts of community violence include but are not limited to riots, sniper attacks, gang wars, drive-by shootings, bullying, workplace assaults, terrorist attacks, torture, bombings, war, ethnic cleansing, and widespread sexual, physical, and emotional abuse.

Young people are disproportionately impacted by violence in their communities, including firearm injuries and deaths.  Violence is a leading cause of death and nonfatal injuries among adolescents and young adults; over half of US homicides in 2019 occurred among those ages 15 to 34.  Unfortunately, data show significant increases in homicide rates in 2020 compared to 2019.

People’s health outcomes are influenced by the conditions in which they live, work, play, and learn. These conditions are called social determinants of health. Systemic racism, bias, and discrimination; economic instability; concentrated poverty; and limited housing, education, and healthcare access drive health inequities, such as violence. Communities of color often disproportionately experience these negative conditions, placing residents at greater risk for poor health outcomes. For example, Black or African American, American Indian, and Alaskan Native, and Hispanic or Latino persons have higher homicide rates than other racial and ethnic demographic groups.  Research indicates that youth and young adults (ages 10-34), particularly those in communities of color, are disproportionately impacted.

Community violence can cause significant physical injuries and mental health conditions such as depression, anxiety, and post-traumatic stress disorder (PTSD). Living in a community experiencing violence is also associated with increases in risk of developing chronic diseases, as concerns about violence may prevent someone from engaging in healthy behaviors, such as walking, bicycling, using parks and recreational spaces, and accessing healthy food outlets. Violence scares people out of participating in neighborhood activities; limits business growth and prosperity; strains education, justice, and medical systems; and slows community progress.

The Division of Violence Prevention (DVP) at the Centers for Disease Control and Prevention (CDC) is focused on preventing community violence by identifying and implementing science-based programs, policies, and practices with partners and communities to disseminate, implement, and scale-up strategies based on the best available evidence to create safer communities, such as:

  • Changing social norms through street outreach/violence interruption programs.
  • Changing the physical environment through Crime Prevention Through Environmental Design (CPTED).
  • Preventing future risk and lessening the harms of violence exposure through hospital-community partnerships, and treatment services such as Trauma-Focused Cognitive Behavior Therapy ®(TF-CBT) and Multisystemic Therapy® (MST).
  • Strengthening economic supports through job training and summer jobs programs.
  • Strengthening youth’s skills through universal school-based programs to help youth develop skills to prevent violence and engage in healthy behaviors.
  • Connecting youth to caring adults and activities such as mentoring and after-school programs.

Intimate and Partner Violence

Intimate partner violence (IPV) is abuse or aggression that occurs in a romantic relationship.  “Intimate partner” refers to both current and former spouses and dating partners. IPV is common.  It affects millions of people in the United States each year and often starts early and continues throughout life.  When IPV occurs in adolescence, it is called teen dating violence (TDV).  About 1 in 4 women and nearly 1 in 10 men have experienced contact sexual violence, physical violence, and/or stalking by an intimate partner during their lifetime and reported some form of IPV-related impact. About 11 million women and 5 million men who reported experiencing contact sexual violence, physical violence, or stalking by an intimate partner in their lifetime said that they first experienced these forms of violence before the age of 18. Youth from groups that have been marginalized, such as sexual and gender minority youth, are at greater risk of experiencing sexual and physical dating violence.

IPV can vary in how often it happens and how severe it is and might include:

  • Physical violence is when a person hurts or tries to hurt a partner by hitting, kicking, or using another type of physical force.
  • Sexual violence is forcing or attempting to force a partner to take part in a sex act, sexual touching, or a non-physical sexual event (e.g., sexting) when the partner does not or cannot consent.
  • Stalking is a pattern of repeated, unwanted attention and contact by a partner that causes fear or concern for one’s own safety or the safety of someone close to the victim.
  • Psychological aggression is the use of verbal and non-verbal communication with the intent to harm another partner mentally or emotionally and/or to exert control over another partner.

IPV Prevention includes:

Teach safe and healthy relationship skills

  • Social-emotional learning programs for youth
  • Healthy relationship programs for couples

Engage influential adults and peers

  • Men and boys as allies in prevention
  • Bystander empowerment and education
  • Family-based programs

Disrupt the developmental pathways toward partner violence

  • Early childhood home visitation
  • Preschool enrichment with family engagement
  • Parenting skill and family relationship programs
  • Treatment for at-risk children, youth and families

Create protective environments

  • Improve school climate and safety
  • Improve organizational policies and workplace climate
  • Modify the physical and social environments of neighborhoods

Strengthen economic supports for families

  • Strengthen household financial security
  • Strengthen work-family supports

Support survivors to increase safety and lessen harms

  • Victim-centered services
  • Housing programs
  • First responder and civil legal protections
  • Patient-centered approaches
  • Treatment and support for survivors of IPV, including TDV
  • Workplace Injuries

Sexual Violence

Sexual violence is sexual activity when consent is not obtained or freely given. It is a serious public health problem in the United States that affects millions of people each year in the United States and profoundly impacts lifelong health, opportunity, and well-being.  Researchers know the numbers underestimate this problem because many cases are unreported. Victims may be ashamed, embarrassed, or afraid to tell the police, friends, or family about the violence. Victims may also keep quiet because they have been threatened with further harm if they tell anyone or do not think anyone will help them.

Sexual violence impacts every community and affects people of all genders, sexual orientations, and ages. Anyone can experience or perpetrate sexual violence. The perpetrator of sexual violence is usually someone the victim knows, such as a friend, current or former intimate partner, coworker, neighbor, or family member. Sexual violence can occur in person, online, or through technology, such as posting or sharing sexual pictures of someone without their consent, or non-consensual sexting.

The data shows:

  • Sexual violence is common. More than 1 in 3 women and 1 in 4 men have experienced sexual violence involving physical contact during their lifetimes. Nearly 1 in 5 women and 1 in 38 men have experienced completed or attempted rape, and 1 in 14 men was made to penetrate someone (completed or attempted) during his lifetime.
  • Sexual violence starts early. One in 3 female rape victims experienced it for the first time between 11-17 years old and 1 in 8 reported that it occurred before age 10. Nearly 1 in 4 male rape victims experienced it for the first time between 11-17 years old and about 1 in 4 reported that it occurred before age 10.
  • Sexual violence is costly. Recent estimates put the lifetime cost of rape at $122,461 per victim, including medical costs, lost productivity, criminal justice activities, and other costs.

Sexual Violence Prevention includes:

Promote Social Norms that Protect Against Violence

  • Bystander approaches
  • Mobilizing men and boys as allies

Teach Skills to Prevent Sexual Violence

  • Social-emotional learning
  • Teaching healthy, safe dating and intimate relationship skills to adolescents
  • Promoting healthy sexuality
  • Empowerment-based training

Provide Opportunities to Empower and Support Girls and Women

  • Strengthening economic supports for women and families
  • Strengthening leadership and opportunities for girls

Create Protective Environments

  • Improving safety and monitoring in schools
  • Establishing and consistently applying workplace policies
  • Addressing community-level risks through environmental approaches

Support Victims/Survivors to Lessen Harms

  • Victim-centered services
  • Treatment for victims of SV
  • Treatment for at-risk children and families to prevent problem behavior including sex offending

Firearm Violence

A firearm injury is a gunshot wound or penetrating injury from a weapon that uses a powder charge to fire a projectile. Weapons that use a power charge include handguns, rifles, and shotguns. Injuries from air- and gas-powered guns, BB guns, and pellet guns are not considered firearm injuries as these types of guns do not use a powder charge to fire a projectile.

Firearm violence is a serious public health problem that impacts the health and safety of Americans. Important gaps remain in our knowledge about the problem and ways to prevent it. Addressing these gaps is an important step toward keeping individuals, families, schools, and communities safe from firearm violence and its consequences.

Firearm injuries are a serious public health problem. In 2020, there were 45,222 firearm-related deaths in the United States, that’s about 124 people dying from a firearm-related injury each day. More than half of firearm related deaths were suicides and more than 4 out of every 10 were firearm homicides.

More people suffer nonfatal firearm-related injuries than die. More than seven out of every 10 medically treated firearm injuries are from firearm-related assaults. Nearly 2 out of every 10 are from unintentional firearm injuries. There are few intentionally self-inflicted firearm-related injuries seen in hospital emergency departments. Most people who use a firearm in a suicide attempt, die from their injury.

Firearm injuries affect people in all stages of life. In 2020, firearm-related injuries were among the 5 leading causes of death for people ages 1-44 in the United States.

Some groups have higher rates of firearm injury than others. Men account for 86% of all victims of firearm death and 87% of nonfatal firearm injuries. Rates of firearm violence also vary by age and race/ethnicity. Firearm homicide rates are highest among teens and young adults 15-34 years of age and among Black or African American, American Indian or Alaska Native, and Hispanic or Latino populations. Firearm suicide rates are highest among adults 75 years of age and older and among American Indian or Alaska Native and non-Hispanic white populations.

There are many types of firearm injuries, which can be fatal or nonfatal:

  • Intentionally self-inflicted
    • Includes firearm suicide or nonfatal self-harm injury from a firearm
  • Unintentional
    • Includes fatal or nonfatal firearm injuries that happen while someone is cleaning or playing with a firearm or other incidents of an accidental firing without evidence of intentional harm
  • Interpersonal violence
    • Includes firearm homicide or nonfatal assault injury from a firearm
  • Legal intervention
    • Includes firearm injuries inflicted by the police or other law enforcement agents acting in the line of duty
      • For example, firearm injuries that occur while arresting or attempting to arrest someone, maintaining order, or ensuring safety
    • The term legal intervention is a commonly used external cause of injury classification. It does not indicate the legality of the circumstances surrounding the death.
  • Undetermined intent
    • Includes firearm injuries where there is not enough information to determine whether the injury was intentionally self-inflicted, unintentional, the result of legal intervention, or from an act of interpersonal violence.

It is important to store all firearms safely when not in use. Putting a firearm out of sight or out of reach is not safe storage and not enough to prevent use by children or unauthorized adults.

Drug Overdose

Drug overdoses are now the leading cause of injury deaths in the United States, and most overdoses involve opioids.  More than 932,000 people have died since 1999 from a drug overdose. In 2020, 91,799 drug overdose deaths occurred in the United States. The age-adjusted rate of overdose deaths increased by 31% from 2019 (21.6 per 100,000) to 2020 (28.3 per 100,000).  Opioids, mainly synthetic opioids (other than methadone), are currently the main driver of drug overdose deaths. 82.3% of opioid-involved overdose deaths involved synthetic opioids. Research shows that people who have had at least one overdose are more likely to have another. In 2020, an estimated 41.1 million Americans needed substance use disorder treatment, but only 2.6 million people with a substance use disorder in the past year received treatment.

Prevention Startegies include:

  • Increase and maximize use of prescription drug monitoring programs, which are state-run databases that track prescriptions for controlled substances and can help improve opioid prescribing, inform clinical practice, and protect those at risk.
  • Learn about the risks of prescription opioids and about the help and resources that are available for someone who may be struggling with opioid use disorder.
  • Treat opioid use disorder by increasing access to substance use disorder treatment services, including Medication-Assisted Treatment (MAT) and Medications for Opioid Use Disorder (MOUD).
  • Reverse overdose by expanding access to naloxone, a drug used to reverse overdose, for community members (family members and neighbors) and service providers (i.e., first responders).

Child Abuse and Neglect

Child abuse and neglect are serious public health problems that can have long-term impact on health, opportunity, and wellbeing.  At least 1 in 7 children have experienced child abuse or neglect in the past year in the United States. however this is likely an underestimate because many cases are unreported. In 2020, 1,750 children died of abuse and neglect in the United States. Experiencing poverty can place a lot of stress on families, which may increase the risk for child abuse and neglect. Rates of child abuse and neglect are 5 times higher for children in families with low socioeconomic status. In the United States, the total lifetime economic burden associated with child abuse and neglect was about $592 billion in 2018. This economic burden rivals the cost of other high-profile public health problems, such as heart disease and diabetes.

This issue includes all types of abuse and neglect of a child under the age of 18 by a parent, caregiver, or another person in a custodial role (such as a religious leader, a coach, a teacher) that results in harm, the potential for harm, or threat of harm to a child. There are four common types of abuse and neglect:

  • Physical abuse is the intentional use of physical force that can result in physical injury. Examples include hitting, kicking, shaking, burning, or other shows of force against a child.
  • Sexual abuse involves pressuring or forcing a child to engage in sexual acts. It includes behaviors such as fondling, penetration, and exposing a child to other sexual activities.
  • Emotional abuse refers to behaviors that harm a child’s self-worth or emotional well-being. Examples include name-calling, shaming, rejecting, withholding love, and threatening.
  • Neglect is the failure to meet a child’s basic physical and emotional needs. These needs include housing, food, clothing, education, access to medical care, and having feelings validated and appropriately responded to.

Risk Factors for Victimization include

Individual Risk Factors

  • Children younger than 4 years of age
  • Children with special needs that may increase caregiver burden (e.g., disabilities, mental health issues, and chronic physical illnesses)

Risk Factors for Perpetration

  • Caregivers with drug or alcohol issues
  • Caregivers with mental health issues, including depression
  • Caregivers who don’t understand children’s needs or development
  • Caregivers who were abused or neglected as children
  • Caregivers who are young or single parents or parents with many children
  • Caregivers with low education or income
  • Caregivers experiencing high levels of parenting stress or economic stress
  • Caregivers who use spanking and other forms of corporal punishment for discipline
  • Caregivers in the home who are not a biological parent
  • Caregivers with attitudes accepting of or justifying violence or aggression

Family Risk Factors

  • Families that have household members in jail or prison
  • Families that are isolated from and not connected to other people (extended family, friends, neighbors)
  • Families experiencing other types of violence, including relationship violence
  • Families with high conflict and negative communication styles

Community Risk Factors

  • Communities with high rates of violence and crime
  • Communities with high rates of poverty and limited educational and economic opportunities
  • Communities with high unemployment rates
  • Communities with easy access to drugs and alcohol
  • Communities where neighbors don’t know or look out for each other and there is low community involvement among res
  • dents
  • Communities with few community activities for young people
  • Communities with unstable housing and where residents move frequently
  • Communities where families frequently experience food insecurity

Prevention Strategies include:

Strengthen economic supports to families

  • Strengthening household financial security
  • Family-friendly work policies

Change social norms to support parents and positive parenting

  • Public engagement and education campaigns
  • Legislative approaches to reduce corporal punishment

Provide quality care and education early in life

  • Preschool enrichment with family engagement
  • Improved quality of child care through licensing and accreditation

Enhance parenting skills to promote healthy child development

  • Early childhood home visitation
  • Parenting skill and family relationship approaches

Intervene to lessen harms and prevent future risk

  • Enhanced primary care
  • Behavioral parent training programs
  • Treatment to lessen harms of abuse and neglect exposure
  • Treatment to prevent problem behavior and later involvement in violence


Suicide is death caused by injuring oneself with the intent to die. A suicide attempt is when someone harms themselves with any intent to end their life, but they do not die as a result of their actions.

Suicide rates increased 30% between 2000–2018, and declined in 2019 and 2020. Even with the decline in 2020, Suicide was still a leading cause of death in the United States, with nearly 46,000 deaths in 2020. This is about one death every 11 minutes. In 2020, suicide was among the top 9 leading causes of death for people ages 10-64 and was the second leading cause of death for people ages 10-14 and 25-34.  The number of people who think about or attempt suicide is even higher. In 2020, an estimated 12.2 million American adults seriously thought about suicide, 3.2 million planned a suicide attempt, and 1.2 million attempted suicide.

Americans with higher than average rates of suicide are veterans, people who live in rural areas, and workers in certain industries and occupations like mining and construction. Young people who identify as lesbian, gay, or bisexual have higher rates of suicidal thoughts and behavior compared to their peers who identify as heterosexual. People who have experienced violence, including child abuse, bullying, or sexual violence have a higher suicide risk.

Suicide and suicide attempts cause serious emotional, physical, and economic impacts. People who attempt suicide and survive may experience serious injuries that can have long-term effects on their health. They may also experience depression and other mental health concerns. The good news is that more than 90% of people who attempt suicide and survive never go on to die by suicide.

Suicide and suicide attempts affect the health and well-being of friends, loved ones, co-workers, and the community. When people die by suicide, their surviving family and friends may experience shock, anger, guilt, symptoms of depression or anxiety, and may even experience thoughts of suicide themselves.

Being connected to family and community support and having easy access to health care can decrease suicidal thoughts and behaviors.

Suicide Prevention strategies include:

  • Strengthen economic supports
    • Strengthen household financial security
    • Housing stabilization policies
  • Strengthen access and delivery of suicide care
    • Coverage of mental health conditions in health insurance policies
    • Reduce provider shortages in underserved areas
    • Safer suicide care through systems change
  • Create protective environments
    • Reduce access to lethal means among persons at risk of suicide
    • Organizational policies and culture
    • Community-based policies to reduce excessive alcohol use
  • Promote connectedness
    • Peer norm programs
    • Community engagement activities
  • Teach coping and problem-solving skills
    • Social-emotional learning programs
    • Parenting skill and family relationship programs
  • Identify and support people at risk
    • Gatekeeper training
    • Crisis intervention
    • Treatment for people at risk of suicide
    • Treatment to prevent re-attempts
  • Lessen harms and prevent future risk
    • Postvention
    • Safe reporting and messaging about suicide

Need help? Know someone who does?

Contact the National Suicide Prevention Lifeline

Both are free and confidential. You’ll be connected to a skilled, trained counselor in your area.

For more information, visit the National Suicide Prevention Lifelineexternal icon.

You can also connect 24/7 to a crisis counselor by texting the Crisis Text Line.external icon Text HOME to 741741.

Chapter 9 Key Takeaways

  • Unintentional injuries have routinely been ranked 3rd-4th for overall causes death.
  • For people ages 5-29, three of the top five causes of death are injury-related
  • Common unintentional injuries result from falls, drowning, motor vehicle crashes, fires, and poisoning.
  • Common intentional injuries results from community violence, intimate partner violence, sexual violence,  firearm violence, drug overdoses, child abuse/neglect, and suicide.
  • Understanding how injuries occur can help you to make safer choices for yourself and help others who may need assistance.

  1. National Center for Health Statistics. Health, United States, 2019: Table 005. Hyattsville, MD. 2021. Available from:
  2. Suggested Citation: Centers for Disease Control and Prevention, National Center for Health Statistics. National Vital Statistics System, Mortality 1999-2020 on CDC WONDER Online Database, released in 2021. Data are from the Multiple Cause of Death Files, 1999-2020, as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program. Accessed at on Jun 7, 2022 6:31:25 PM


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