CDC

Injury Fact Book 

National Center for Injury Prevention and Control

Centers for Disease Control and Prevention 

Atlanta, Georgia

November 2006
The CDC Injury Fact Book is a publication of the National Center for Injury Prevention and 

Control, Centers for Disease Control and Prevention.

Centers for Disease Control and Prevention

Julie Louise Gerberding, MD, MPH

Director

Coordinating Center for Environmental Health and Injury Prevention

Henry Falk, MD, MPH

Director

National Center for Injury Prevention and Control

Ileana Arias, PhD

Director

Acknowledgments

Thank you to the staff of the National Center for Injury Prevention and Control (NCIPC), 

CDC’s Injury Center, for help in compiling the CDC Injury Fact Book. Special thanks go to 

Carole Craft and Sue Swensen for editing material found in this book and to Kendra Godbold 

for editorial assistance; Krista Hopkins Cole, Sandee L. Coulberson, Michele Huitric, Alida Knuth, 

Marie Legg, Jennifer Middlebrooks, Jane Mitchko, Sarah Olson, Kelly Sarmiento, and Robin Sloan 

for their prompt, cheerful responses to the seemingly endless requests for data and program 

descriptions; Tracey Foster-Butler for identifying and obtaining photographs; Sara Cote for 

desktop publishing and creative solutions; Julie Hentz, Robert Noble, and Sevena Quattlebaum 

for graphics support; and Sandra Bonzo for her counsel, broad knowledge of injury topics, and 

diligence beyond the norm. To those who are dedicated to the Injury Center, this book celebrates 

your achievements and contributions.

Suggested citation: National Center for Injury Prevention and Control. CDC Injury Fact Book. 

Atlanta (GA): Centers for Disease Control and Prevention; 2006.
iii

Directors’ Messages, v

Introduction, 1

Injuries in a Changing America, 2

The Public Health Approach to Injury Prevention, 4

The Public Health Approach at Work, 5

Planning for the Future, 9

Timeline, 10

Data for Injury Prevention and Control, 15

Data Sources, 16

Data Sharing, 18

Capacity Building and Surveillance, 19

Partners in Prevention, 21

Federal Agencies, 22

State and Local Agencies, 24

Organizations for State and Local Health Professionals, 25

National Nonprofit Organizations, 26

Academic Institutions, 28

Academic Organizations, 29

Cross-cutting Partnerships, 29

International Agencies, 30

Injury—A Risk at Any Stage of Life, 31

Preventing Injuries in America: Public Health in Action, 35

Acute Injury Care and Treatment, 36

Alcohol-related Motor Vehicle Injuries, 39

Child Maltreatment, 42

Child Passenger Safety, 46

Community Resilience, 49

Emergency Preparedness and Response, 51

Intimate Partner Violence, 55

Older Adult Drivers, 60

Older Adult Falls, 62

Pedestrian Injuries, 66

Residential Fires, 68

Road Traffic Safety, 71

School Violence, 72

Sexual Violence, 75

Sports- and Recreation-related Injuries, 79

Suicide, 81

Supervision of Children, 85

Teens Behind the Wheel, 87

Traumatic Brain Injury, 90

Water-related Injuries, 94

Youth Violence, 97

Publications and Resources, 103

Contents

Every day, the Centers for Disease Control and Prevention’s (CDC) 

extraordinary team of dedicated men and women works around the 

clock and around the globe to protect Americans’ health. CDC has two 

overarching goals for health protection:

n All people—and especially those at greatest risk for health disparities—

will achieve their optimal lifespan with the best possible quality of health 

in every stage of life. 

n People in all communities will be protected from infectious, 

occupational, environmental, and terrorist threats. 

CDC’s National Center for Injury Prevention and Control (NCIPC) plays 

a critical role in reaching these goals. From protecting infants and toddlers 

against injuries in the home, to preventing youth violence, to researching how 

communities can best prepare for and handle large-scale emergencies, NCIPC 

is dedicated to keeping Americans safe from injuries and violence—and 

reducing their resulting disabilities, death, and costs—across all life stages.

Julie L. Gerberding, MD, MPH

Director, Centers for Disease Control and Prevention

The work of NCIPC contributes greatly to CDC’s efforts to address the safety needs of its most important client—the American people. NCIPC 

provides national leadership in identifying research priorities and promoting 

tools for injury and violence prevention, joins with partners to turn research 

into actions that reduce injuries and disabilities, and prompts action for a 

safer, healthier nation through a wide range of programs. 

Henry Falk, MD, MPH

Director, Coordinating Center for 

Environmental Health and Injury Prevention 

Preventable injuries and violence take the lives of thousands of Americans each year. One of CDC’s health impact goals is to reduce deaths from 

injuries. At NCIPC, we take that goal seriously, and we work tirelessly to 

meet or exceed it. And we’re making progress. We have seen reductions in 

bullying, fewer young children who ride unrestrained in cars, and fewer older 

adults who die in residential fires. But there is much more to do. As you will 

see by the programs described in this fact book, we are studying how, when, 

and why injuries occur; developing and testing new strategies to prevent 

injuries; and disseminating to at-risk populations the prevention strategies 

that have been proven to work. We pledge to continue our efforts until 

injuries are no longer a leading cause of death.

Ileana Arias, PhD

Director, National Center for 

Injury Prevention and Control

Directors’ Messages

Introduction

America is rapidly changing—its population is 

more mobile, more diverse, and older. Health 

care costs are soaring and our country is more 

vulnerable to outside threats. What hasn’t 

changed, and continues to be a public health 

concern, is the toll injuries take on individuals 

and on the nation.
 Introduction

Injuries Affect Everyone

Regardless of gender, race, or economic 

status, injuries remain a leading cause 

of death for Americans of all ages, 

accounting for more than 161,000 

deaths in 2002. But injury deaths are only 

part of the picture. Millions of Americans 

are injured each year and survive. In 

2004, about 29.6 million people were 

treated for an injury in U.S. hospital 

emergency departments, of which nearly 

2 million injuries were severe enough to 

require hospitalization. For many people, 

the injury causes temporary pain and 

inconvenience; but for some, the injury 

leads to disability, chronic pain, and a 

profound change in lifestyle.

An injury affects more than just the 

person injured—it affects everyone 

involved in the injured person’s life. With 

a fatal injury, family, friends, coworkers, 

employers, and other members of the 

injured person’s community feel the loss. 

In addition to experiencing grief, they 

may experience a loss of income or the 

loss of a primary caregiver, as well.

With a nonfatal injury, family members 

are often called upon to care for the injured 

person, which can result in stress, time 

away from work, and possibly lost income. 

They may also experience a change in their 

relationship with the injured person and 

with others in the family. For example, 

if a wife and mother is seriously injured, 

her spouse may find himself in the role 

of primary caregiver—not only for his 

wife, but also for their children. Friends 

of the injured person may be called upon 

to help and, like family members, may 

experience a change in their relationship 

with the injured person. The injured 

person’s employer may struggle with 

the temporary or permanent loss of 

a valued employee. Others in the 

community—volunteer groups, 

religious organizations, neighbors—

may also feel the effects of the injury.

Injuries in a Changing America

10 Leading Causes of Death by Age Group – 2003

The financial and 

economic impact of 

injuries in the United 

States is serious. 

However, by expanding 

our science-based injury 

prevention programs, 

we can drastically 

reduce these costs and 

even more importantly 

help people live longer 

and healthier lives.

CDC Director, Dr. Julie Gerberding

‘

‘‘

Source: National Vital Statistics System, National Center for Health Statistics, CDC.

Produced by: Office of Statistics and Programming, National Center for Injury Prevention and Control, CDC.

‘
 Introduction

Persons Medical

reporting expenditures Injury-attributable

treatment for attributable medical expenditures ($)

an injury† to injuries† 

Characteristic (%) No.§ % MEPS¶ NHA** NHA

* In millions.

† On the basis of Medical Expenditure Panel Survey (MEPS) estimates.

§ Results were weighted to be nationally representative.

¶ In billions. MEPS estimate of U.S. medical expenditures in 2000 is restricted to the civilian, 

noninstitutionalized population.

** In billions. National Health Accounts (NHA) estimates include the U.S.-based military and institutionalized 

populations and are calculated by multiplying the NHA estimate of U.S. medical expenditures in 

2000 by the percentage of medical expenditures attributable to injuries estimated by MEPS.

The Cost of Injuries

Society at large is profoundly affected 

by injuries. Unintentional injuries 

are the leading cause of death for 

Americans ages 1 to 44. Homicide 

and suicide are the second and third 

leading causes of death for persons 

ages 15 through 34 years. More than 

16% of the population (44.7 million) 

reported needing treatment for at least 

one injury in 2000. Insurance costs and 

out-of-pocket spending for all medical 

services are quantified by the Medical 

Expenditure Panel Survey (MEPS), 

a nationally-representative survey of 

the U.S. civilian noninstitutionalized 

population. MEPS reported that injuries 

in 2000 contributed to 10% of U.S. 

medical expenditures; when MEPS 

percentages were applied to the annual 

National Health Accounts data (which 

trace expenditures within the health 

care system), injury-related medical 

expenditures were estimated to cost 

Americans $117 billion each year.

Medical spending due to injuries is of 

the same magnitude as costs associated 

with other leading public health 

concerns such as obesity and smoking. 

By age group, costs ranged from $5 

billion for 20- to 29-year-olds to $37.9 

billion for ages 45 to 64, with the 

greatest injury-related medical costs 

($23.3 billion) for women ages 45 to 

64. Overall, injury-attributable medical 

costs were higher for males ($59.8 

billion) than females ($57.4 billion).

Although staggering, these costs still 

underestimate the overall societal burden 

caused by injury. When other losses are 

considered, a more definitive cost estimate 

emerges. Productivity losses, emotional 

toil, loss of patient and caregiver time, 

nonmedical expenditures (e.g., wheelchair 

ramps), litigation, diminished quality of 

life, and long-term consequences (e.g., 

rehabilitation and mental health care 

costs) must also be considered. A future 

CDC study will examine the cost of 

injuries from this broader perspective. 

Already, CDC’s Injury Center activities 

interdisciplinary research, data collection 

and analysis, information sharing, and 

relationships with states—elements the 

council and IOM deemed important. And 

unlike other federal agencies involved in 

injury prevention, CDC had no regulatory 

or enforcement role. In 1997, IOM’s 

Committee on Injury Prevention and 

Control recommended that no one agency 

could effectively serve as the sole leader for 

injury. Rather, agencies should collaborate 

on injury prevention and control activities, 

with each agency leading in its area of 

expertise. As it is, CDC’s Injury Center 

now functions as the focal point for the 

public health approach to preventing 

and treating injuries, a paradigm that 

enriches the entire injury field.

such as effective interventions and 

prevention programs are paving the 

way for substantial reduction of the 

economic burden of injury in this 

country (Finkelstein et al. 2004). 

Injury Prevention and CDC

Injuries have been a leading cause of 

death and disability throughout history; 

consequently, many people and agencies 

have undertaken prevention efforts. In 

1985, the National Research Council 

and the Institute of Medicine (IOM) 

recognized the need for a coordinated 

effort to prevent injuries in the United 

States. They identified CDC as the 

federal agency best suited to lead injury 

research. CDC had a strong history of 

TABLE. Percentage and number* of persons reporting treatment for an 

injury and percentage and amount of medical expenditures attributable 

to injuries, by selected characteristics — United States, 2000

Total (16.3) 44.7 10.3 64.7 117.2 427

Sex

 Male (17.3) 23.1 12.5 33.2 59.8 448

 Female (15.4) 21.6 9.2 31.8 57.4 409

Age group (yrs)

<10 (11.9) 4.8 7.8 3.1 5.7 141

10–19 (17.9) 7.2 16.6 7.4 13.4 333

20–29 (15.8) 5.7 6.8 2.7 5.0 137

30–44 (17.8) 11.3 12.2 14.6 26.5 417

45–64 (16.7) 10.2 10.6 20.9 37.9 621

 >65 (16.7) 5.5 8.7 16.0 29.0 881

Sex by age group

 Male

<10 (13.7) 2.8 9.4 1.6 3.0 145

10–19 (20.7) 4.3 26.3 5.1 9.2 445

20–29 (18.0) 3.2 7.9 1.0 1.7 98

30–44 (20.0) 6.2 15.3 7.5 13.6 438

45–64 (15.5) 4.6 7.9 7.6 13.7 463

>65 (14.2) 2.0 11.8 9.6 17.4 1,233

 Female

<10 ( 9.9) 1.9 6.7 1.3 2.3 118

10–19 (15.0) 3.0 11.9 3.0 5.4 272

20–29 (13.6) 2.5 4.8 1.4 2.5 139

30–44 (15.7) 5.1 9.4 6.7 12.1 373

45–64 (17.9) 5.7 12.5 12.9 23.3 732

>65 (18.5) 3.5 6.7 7.1 12.9 680

Per capita,
 Introduction

To solve public health problems—including injuries—CDC uses 

a systematic process called the public 

health approach. This approach has 

four steps: define the problem, identify 

risk and protective factors, develop and 

test prevention strategies, and assure 

widespread adoption of effective injury 

prevention principles and strategies.

Define the problem

Before we can address an injury 

problem, we need to know how big 

the problem is, where it is, and whom 

it affects. CDC accomplishes this 

by gathering and analyzing data—

processes often called “surveillance.” 

These data can show us how an injury 

problem changes over time, alert us 

to troubling trends in a particular 

type of injury, and let us know what 

impact prevention programs are having. 

Decision makers use these critical data 

in allocating programs and resources to 

the areas most in need.

Identify risk and protective factors

It is not enough to know that a certain 

type of injury is affecting a certain 

group of people in a certain area. We 

also need to know why. What factors 

put people at risk for that injury? 

And conversely, what factors protect 

people from it? CDC conducts and 

supports research to answer these 

important questions. Once we have 

that information, we can develop and 

implement programs to eliminate or 

reduce risk factors for injuries and to 

capitalize on or increase factors that 

protect people from being injured.

Develop and test 

prevention strategies 

In this step, we put knowledge into 

action. Using information gathered in 

our research, CDC develops strategies 

to prevent particular injury problems. 

We implement these strategies in 

communities that are experiencing the 

problem. And we study the effects of 

these strategies to determine whether 

and how well they’re working. We 

use this information to identify 

any elements we need to change 

to eliminate difficulties or increase 

effectiveness.

Assure widespread adoption

What we learn in the developing and 

testing step has little benefit if we 

keep the information to ourselves. 

In this final step of the public health 

approach, CDC shares its knowledge 

and may provide funding or expert 

consultation so that communities can 

replicate these successful strategies.

The Public Health Approach to Injury Prevention

The Public Health Approach

Assure

Widespread

Adoption

Identify Risk 

and 

Protective 

Factors

Define

the 

Problem

Develop

and Test

Prevention

Strategies
 Introduction

Defining the Problem

For some injury issues, CDC has 

already moved through the first three 

steps of the public health approach and 

is encouraging widespread adoption 

of programs that work. For other 

issues, CDC is working to fully define 

the problem. Always, CDC addresses 

injury issues that affect diverse 

populations, in every stage of life. 

The examples in this book demonstrate 

how the public health approach is at 

work in CDC’s Injury Center.

Violent death in America

In the United States in 2002, 17,638 

people died as a result of homicide and 

31,655 died from suicide. Although 

public health officials may know 

how many people die from violence 

each year, information about the 

circumstances surrounding those 

deaths is often lacking. Federal, state, 

and local agencies all have detailed 

data that could answer important, 

fundamental questions about 

violence patterns and trends, but the 

information is fragmented and difficult 

to access. The system that pulls 

together this vital information to be 

shared among states and communities 

is the National Violent Death 

Reporting System (NVDRS). NVDRS 

gathers data from states that can be 

used to increase our understanding of 

violent deaths in America. NVDRS 

data can assist policy makers and 

community leaders in making 

informed decisions about strategies 

and programs to prevent violence. 

Currently, 17 states have been funded 

to implement the system. 

Injury mortality among Native 

American children and youth

Native Americans ages 19 years 

and younger are at greater risk of 

preventable injury-related deaths than 

are other children and youth in the 

United States. A 2003 study published 

in CDC’s Morbidity and Mortality 

Weekly Report found 

that injuries and 

violence account for 

75% of all deaths 

among Native 

Americans in this 

age group—a rate 

that is about twice 

that of all children 

and youth in the 

United States. Motor 

vehicle crashes were 

the leading cause of 

injury-related death, 

followed by suicide, 

homicide, drowning, 

and fires. Between 

1989 and 1998, 

more than 3,300 Native American 

children and youth living on or near 

reservations died from injuries or 

violence (Wallace et al. 2003). 

Intimate partner and 

sexual violence

An estimated 2.3 million Americans—

1.5 million of them women—are raped 

or physically assaulted by an intimate 

partner each year. But inconsistencies 

in data collection and different ways 

of describing the problem have 

fostered a lack of consensus about its 

magnitude. In 2002, CDC’s Injury 

Center revised its publication of 

definitions designed to improve data 

collected about intimate partner 

violence. This publication standardized 

the terminology used by all parties 

involved in the problem: the criminal 

justice system, hospitals, and others. 

Similar standards for sexual violence 

were also published in 2002. Uniform 

definitions and recommended data 

elements for both intimate partner 

violence and sexual violence are 

important to ensure consistency in the 

use of terminology and to standardize 

data collection. Consistent data allow 

researchers to better gauge the scope of 

the problem, identify high-risk groups, 

and monitor the effects of prevention 

programs.

Report to Congress on mild TBI

Evidence indicates that mild traumatic 

brain injury (MTBI) is a public 

health problem, the magnitude and 

impact of which are underestimated 

by current surveillance systems. Much 

research is needed to determine the 

full magnitude of MTBI, to identify 

preventable and modifiable risk 

factors, to develop and test strategies 

to reduce MTBI, and to improve 

outcomes for those who sustain these 

injuries. Such research will inform the 

development of more effective primary 

prevention strategies and policies to 

address the service and rehabilitation 

needs of persons with MTBI. The 

recommendations in the CDC report 

to Congress, Mild Traumatic Brain 

Injury in the United States: Steps to 

Prevent a Serious Public Health Problem, 

can help shape that research.

Nonfatal drownings at 

recreational water sites

In 2004, CDC scientists published 

in the Morbidity and Mortality Weekly 

Report the first national estimate for 

nonfatal drowning injuries treated 

in emergency departments (Gilchrist 

et al. 2004). Findings for the United 

States in 2001 and 2002 showed more 

than 4,100 people sought care in an 

emergency department each year for 

nonfatal drowning injuries, with more 

The Public Health Approach at Work
 Introduction

than half requiring hospital admission 

or transfer for higher levels of care. 

Children ages 4 and under and males 

of all ages were at the greatest risk. The 

most common locations of nonfatal 

injuries for very young children were 

residential pools. As children grew 

older, more injuries occurred in 

natural water settings. The study also 

confirmed that injuries happen most 

often on weekends and during summer 

months—times when people typically 

enjoy water-related activities.

Identifying Risk and 

Protective Factors

Suicide 

More than 31,000 people took 

their own lives in 2002. Public 

health officials want to expand the 

understanding of what puts people 

at risk for committing or attempting 

suicide and what prevents them 

from doing so. Injury Center staff 

and CDC-funded researchers have 

begun studying factors that may 

increase or decrease a person’s risk for 

suicide. One study in Texas, which 

interviewed people who experienced 

nearly lethal suicide attempts, found 

that many factors—in addition to 

mental health factors—may influence 

suicidal behavior including alcohol 

use, geographic mobility, exposure 

to suicidal behavior, hopelessness, 

help-seeking behavior, impulsiveness, 

and physical illness. Researchers at 

Emory University examined suicide 

risk factors among African Americans 

ages 18 to 44 and found a strong 

connection between intimate partner 

violence and suicidal behavior among 

African-American women.

Human behavior in 

residential fires

CDC is directing development of 

the Human Behavior in Fire Study 

to identify behavioral factors in 

residential fires that are associated 

with injuries and fatalities. Researchers 

will interview survivors of residential 

fires to gather information about the 

sequence of events and learn more 

about their behaviors before, during, 

and after the fire. Researchers will 

gather and analyze data about the root 

cause of the fire, the events that led to 

an injury, the state of awareness and 

impairment level of those involved, 

and the actions taken in response to 

the fire. Results from this study will 

inform public health interventions 

to reduce the number of injuries and 

deaths in residential fires. CDC is 

developing this study with the Battelle 

Centers for Public Health Research 

and Evaluation, in collaboration with 

the Department of Fire Protection 

Engineering at the University of 

Maryland at College Park.

Developing and Testing 

Prevention Strategies

Targeting injury problems 

in states

Solving the problems of injury and 

violence in America requires a strong 

public health response. Both research 

and effective injury prevention 

programs in states are needed to 

help those at risk and to avoid costly 

injuries and needless deaths. In 2002, 

CDC began funding the Targeted 

Injury Intervention Program in four 

states to individually plan, develop, 

and implement prevention programs 

that target an important injury 

problem identified in each state. Maine 

and Virginia have each developed 

suicide prevention programs, while 

Washington and Michigan have 

focused on fall prevention. In 2002–

2003, state injury experts planned and 

developed their prevention programs, 

and in 2004 the programs were 

implemented. The targeted programs 

continued through 2005, as the 

states tested prevention strategies in 

preparation to share the results. 

Parenting strategies to 

prevent child maltreatment

CDC has launched several initiatives 

aimed at preventing child maltreatment 

through evidence-based parenting 

programs. These programs and policies 

encourage and promote positive 

parent-child interactions. Improving 

parenting skills will help parents and 

caregivers better manage behavior 

before violence can occur. CDC is 

funding the University of South 

Carolina to examine the effectiveness 

of the Triple P–Positive Parenting 

Program in reducing the risk of 

child maltreatment by enhancing the 

knowledge, skills, and confidence 

of parents. Even the most effective 

parenting programs will have a limited 

impact on child maltreatment if 

parents either do not attend or do not 

learn to apply alternative parenting 

skills. CDC is working with Purdue 

University and the University of 

Oklahoma Health Sciences Center 

to test ways to reduce attrition and 

improve engagement and compliance 

in parenting programs.

Community-based cognitive 

therapy for suicide attempters

CDC is working with the University 

of Pennsylvania to test the effectiveness 

of a cognitive therapy intervention for 

suicide attempters. Trained therapists 

at community mental health centers 

are conducting the intervention. 

The target group—people who have 

attempted suicide—consists largely of 

ethnic minorities and economically 

disadvantaged individuals exhibiting 

high rates of mental health and 

substance-use disorders. A previous 

study found that a brief cognitive 

intervention designed specifically 

for this high-risk population and 

delivered in a university setting 

reduced subsequent suicide attempts. 

The current study will implement 

the program in the community and 

evaluate its effectiveness for preventing 

subsequent suicide attempts.
 Introduction 

Violence prevention for 

middle school students

CDC is testing one of the largest 

efforts to date to assess the effectiveness 

of school-based violence prevention 

among middle school students. It 

teaches students conflict resolution 

and problem-solving skills, trains 

teachers about violence prevention, 

and engages family members in 

program activities. The project is being 

conducted in 37 middle schools in 

four states. Affiliations include Virginia 

Commonwealth University, University 

of Illinois–Chicago, University of 

Georgia, and Duke University.

A boost for children ages 4 to 8

CDC’s Injury Center funded state 

health departments in Colorado, 

Kentucky, and New York to develop, 

implement, and evaluate communitybased programs to increase booster 

seat use among children ages 4 

to 8. Between 2000 and 2003, 

grantees implemented and evaluated 

community awareness campaigns 

and school-based programs, aired 

public service announcements, 

posted billboards, and conducted 

booster seat distribution events and 

car seat checkpoints. Evaluation data 

from Colorado showed a significant 

increase in booster seat use in target 

communities when compared with 

control communities. Results from 

these intervention evaluations will help 

guide future efforts to increase booster 

seat use.

Fall prevention strategies and 

effectiveness: Dane County 

SAFE Study

In October 2002, CDC’s Injury Center 

funded the Wisconsin Department 

of Health, in collaboration with 

the University of Wisconsin, to 

conduct a randomized controlled 

trial to assess the effectiveness of a 

comprehensive approach to preventing 

falls among higher-risk adults age 

65 and older. This project will use 

two complementary strategies: a 

comprehensive at-home assessment 

(followed by individualized risk 

reductions) and a broad-based program 

to educate primary care physicians and 

other health practitioners. To learn 

more about preventing falls among 

older adults, visit www.cdc.gov/ncipc/

pub-res/toolkit/toolkit.htm.

Remembering When: a fire and 

fall prevention program

In October 2000, CDC began funding 

state health departments in Arkansas, 

Maryland, Minnesota, North Carolina, 

and Virginia to implement and evaluate 

Remembering When: A Fire and Fall 

Prevention Program for Older Adults. 

This curriculum, which was developed 

by the National Fire Protection 

Association, the U.S. Consumer 

Product Safety Commission, CDC, 

and other partners, is the first program 

of its kind to educate older adults 

about prevention of both fall- and firerelated injuries. To date, more than 

510 group presentations (with 12,427 

attendees) and 3,566 individual/

home presentations have been 

conducted. More than 4,300 smoke 

alarms and 525 grab bars have been 

installed in the homes of older adults. 

Research is underway to measure the 

program’s effectiveness.

Assuring Widespread 

Adoption

Effective interventions against 

alcohol-impaired driving

In systematic reviews of published 

research studies, CDC researchers 

found strong evidence for the 

effectiveness of 0.08% blood 

alcohol concentration (BAC) laws, 

minimum legal drinking age laws, 

sobriety checkpoints, and mass 

media campaigns that meet certain 

conditions (i.e., careful audience 

research, adequate audience exposure, 

and presence of other alcohol-impaired 

driving prevention activities). They 

also found sufficient evidence of the 

effectiveness for lower BAC laws 

specific to young or inexperienced 

drivers (“zero tolerance” laws) and 

intervention training programs for 

alcohol servers. Finally, they found 

sufficient evidence that school-based 

education programs decrease riding 

with alcohol-impaired drivers (though 

there was insufficient evidence 
 Introduction

TBI tool kit for health care 

professionals 

In 2002, CDC produced Heads Up: 

Brain Injury in Your Practice specifically 

for primary care physicians—CDC’s 

first educational tool kit related 

to traumatic brain injury (TBI). 

The tool kit contains practical, 

easy-to-use clinical information, 

patient information in English and 

Spanish, scientific literature, and 

CD-ROM with printable versions of 

the materials in the kit. More than 

150,000 copies have been distributed 

to health care providers nationwide 

and internationally. Although the 

tool kit was originally developed for 

physicians, many other health care 

providers, such as nurse practitioners 

and physical therapists, have requested 

the materials. CDC has received 

positive feedback from more than 

2,000 recipients of the tool kit.

regarding the programs’ effects on 

alcohol-impaired driving itself). 

These school-based interventions 

were effective in reducing fatal and 

nonfatal alcohol-related motor vehicle 

crashes. The reviews were published 

in The Guide to Community Preventive 

Services (2005) and are online at www.

thecommunityguide.org.

Smoke alarm installation and 

fire-safety education

CDC has funded states to install 

smoke alarms and to provide fire-safety 

education in high-risk communities, 

targeting households with children ages 

5 years and younger and adults ages 65 

years and older. An informal sample of 

program homes found that since 1998, 

an estimated 1,071 lives may have been 

saved. In addition, program staff have 

canvassed more than 382,000 homes 

and installed more than 275,000 longlasting smoke alarms.

References

Finkelstein EA, Fiebelkorn IC, Corso 

PS, Binder SC. Medical expenditures 

attributable to injuries—United States, 

2000 [published erratum appears in 

Morbidity and Mortality Weekly Report

2004;53(03):66]. Morbidity and Mortality 

Weekly Report 2004;53(01):1–4.

Gilchrist J, Gotsch K, Ryan GW. Nonfatal 

and fatal submersion injuries in recreational 

water settings—United States, 2001 and 

2002. Morbidity and Mortality Weekly 

Report 2004;53(21):447–452.

Wallace LJD, Patel R, Dellinger A. Injury 

mortality among American Indian and 

Alaska Native children and youth—United 

States, 1989–1998. Morbidity and Mortality 

Weekly Report 2003;52(30):697–701.
 Introduction 

The Agenda sets priorities and serves 

as a blueprint for research, prevention, 

and cost analysis of injury in key areas: 

n At home and in the community;

n Sports, recreation, and exercise;

n Transportation; 

n Intimate partner 

violence, sexual 

violence, 

and child 

maltreatment; 

n Suicidal 

behavior; 

n Youth violence; 

n Acute care; and

n Disability and rehabilitation.

In 2003, the Injury Center reviewed 

its agenda for acute care, disability, and 

rehabilitation and identified that acute 

injury care—in the context of terrorism 

preparedness and response—was not 

addressed. The Injury Center and its 

partners collaborated to revise the acute 

injury chapter to clearly state CDC’s 

highest priorities for acute care research. 

The chapter, “Acute Injury Care 

Research Agenda,” was released at the 

CDC-sponsored 2005 National Injury 

Prevention and Control Conference. 

Implementing the Agenda will be 

a challenge, but improving the 

infrastructure of the nation’s health care 

system is vital to the public’s health. By 

defining research needs in a diverse field, 

CDC’s Injury Center maximizes efficient 

and effective use of resources; encourages 

collaboration among researchers and 

practitioners; and fulfills its public health 

responsibilities. The Agenda also serves as 

a resource for policy makers, educators, 

service providers, and others interested 

in learning more about how the Injury 

Center addresses all phases of the injury 

research framework—from foundational 

research through dissemination 

research—for all major causes of injury 

among all age groups. To view the 

Agenda, log on to www.cdc.gov/ncipc/

pub-res/research_agenda.htm.

Planning for the Future

CDC’s Health 

Protection Goals

CDC has defined specific Health 

Protection Goals to prioritize and focus 

its work, to maximize its investments, 

and to measure progress. With the 

Health Protection Goals in place, CDC 

prepares people for emerging health 

threats and renews its commitment to 

help Americans obtain optimal health 

in every stage of life. 

New strategies, new goals, and 

innovative ways to conduct business 

bring new focus to the agency’s work, 

enabling CDC to do even more to 

protect and improve health. As part of 

CDC, the Injury Center is setting a new 

course to meet these challenges. The 

new goals for the CDC and the Injury 

Center continue to improve upon how 

priorities are set and how resources are 

allocated. To strengthen its leadership 

position in injury prevention, the Injury 

Center is increasing support to state 

agencies and academic institutions, 

informing and guiding others through 

national conferences on injury topics, 

and responding to CDC’s goals 

for preparedness (see pages 49 and 

51). And, along with other national 

centers at CDC, the Injury Center is 

disseminating meaningful health-related 

information in the context of life stages 

and protection needs (see page 31). As 

America changes, CDC’s Injury Center 

is also changing to better support the 

public’s health needs (CDC 2005).

References

Centers for Disease Control and Prevention 

(CDC). CDC Protecting Health for Life; The 

State of the CDC, Fiscal Year 2004. Atlanta 

(GA): CDC; 2005. 

We have a strategic roadmap to improve the health of 

Americans, set forth in Healthy People 

2010 disease prevention and health 

promotion objectives. To meet these 

objectives, CDC’s Injury Center 

developed an agenda to articulate 

its priorities for research and injury 

prevention. And, CDC has refocused 

its mission in the form of new Health 

Protection Goals to make the best 

use of resources and to ensure steady, 

measurable progress toward meeting 

health challenges. Together, these three 

documents set the foundation for an 

even better CDC, with even greater 

health impact. 

Healthy People 2010

Healthy People 2010 is a comprehensive 

set of disease prevention and health 

promotion objectives for the nation 

to achieve in the first decade of this 

century.

Created by scientists and evidence 

based, Healthy People 2010 identifies 

a wide range of public health priorities 

and specific, measurable objectives for 

improving the health of all people. 

Its overarching goals are to increase 

quality and years of healthy life and 

to eliminate health disparities. It 

details 28 focus areas and 467 specific 

objectives for reaching these goals. 

Healthy People 2010 serves as a model 

for state and international disease 

prevention and health promotion 

plans.

Injury Research Agenda

The CDC Injury Research Agenda is 

a five-year plan to help guide CDC’s 

Injury Center activities, thereby 

meeting the objectives of Healthy 

People 2010. The Agenda was 

developed in 2002 with extensive input 

from CDC’s academic research centers, 

national nonprofit organizations, and 

other federal agencies with a stake in 

injury prevention and control. 
The Institute of 

Medicine’s and 

National Academy 

of Sciences’ 

1985 and 1989 

reports prompted 

a national call for 

a consolidated 

federal focus on 

injury prevention. 

Key goals: build 

an infrastructure; 

bring the public 

health perspective 

to injury prevention; 

and apply the same 

proven prevention 

techniques used for 

infectious disease 

transmission and 

chronic illness to 

reducing injury and 

its consequences. 

National Injury Center 

HHS Secretary Donna 

E. Shalala officially 

creates a national center 

to prevent and control 

injuries. On June 25, 

1992, CDC establishes the 

National Center for Injury 

Prevention and Control.

Expanding Injury 

Research 

CDC continues funding 

of 10 Injury Control 

Research Centers (ICRCs) 

to study ways to prevent 

injuries and disabilities. 

ICRCs, started in 1987, 

are located at universities 

nationwide. ICRCs serve 

as training centers and 

conduct research in 

prevention, acute care, 

and rehabilitation. More 

ICRCs were added in 2002 

and in 2004.

National Plan Emerges 

Using recommendations 

of the Secretary’s Advisory 

Committee for Injury 

Prevention and Control, 

the injury control 

community prioritizes 

injury recommendations 

and publishes Injury 

Control in the 1990s: A 

National Plan for Action.

Violence Prevention 

Health Affairs publishes 

a sentinel article about 

violence prevention in 

which CDC scientists call 

for a new vision: people 

and their communities 

approaching violence as 

a problem that can be 

understood and changed. 

This vision emphasizes 

prevention and how 

science is integral to 

identifying effective 

policies and programs.

First National Injury 

Survey 

CDC conducts nationwide 

Injury Control and Risk 

Survey (ICARIS) to assess 

various injury risk factors. 

Data from the first ICARIS 

are published in 1996 and 

highlight the severity of the 

injury problem in the U.S.

Reduction of Bicyclerelated Head Injuries 

CDC-funded Harborview 

ICRC in Seattle determines 

that community 

educational campaigns, 

such as the Washington 

Children’s Bicycle Helmet 

Campaign, can increase 

helmet use and decrease 

incidence of bicyclerelated head injuries.

The next year, CDC 

publishes its first guidelines 

for bicycle helmets in a 

series of Injury Control 

Recommendations 

(Morbidity and Mortality 

Weekly Report

Recommendations and 

Reports). The guidelines 

for state and local 

agencies provide analysis 

of bicycle-related head 

injuries, the value of bicycle 

helmets in reducing head 

injuries, helmet standards, 

performance in crashes, 

barriers that keep people 

from wearing helmets, 

and recommendations for 

CDC’s Injury Center

increasing helmet use.

10 TimelineTimeLine
 Timeline 11

National Violence 

Against Women 

Survey (NVAWS) 

CDC and the National 

Institute of Justice 

sponsor a U.S.-wide 

telephone survey to 

provide national 

estimates of intimate 

partner violence 

(including sexual 

violence and stalking). 

Information about the 

problem and magnitude 

of intimate partner 

violence will help 

practitioners improve 

prevention programs. 

Several publications 

emerge from this survey 

including Extent, Nature, 

and Consequences of 

Intimate Partner 

Violence: Findings From 

the National Violence 

Against Women Survey, 

July 2000.

Website 

CDC launches its injury 

website, providing 

consumers and health 

professionals access to 

information about 

effective ways to 

prevent injury.

National Standards 

CDC’s Guidelines for the 

Surveillance of a Central 

Nervous System Injury is 

released. The Guidelines

serve as the U.S. 

standard for collecting 

information on traumatic 

brain and spinal cord 

injuries, forming the 

basis for international 

guidelines published 

by the World Health 

Organization.

Linking Hospital 

Emergency 

Departments 

CDC hosts a national 

workshop on emergency 

department (ED) data. A 

year later, CDC publishes 

Data Elements for 

Emergency Department 

Systems (DEEDS), which 

sets uniform specifications 

and national standards for 

data entry in EDs’ patient 

records.

School Violence 

CDC releases findings 

from the first nationwide 

investigation of schoolassociated violent deaths. 

Data collection continues 

and CDC releases updated 

findings in December 2001.

Brain Injury 

CDC funds 15 state health 

departments to track the 

incidence of traumatic 

brain injury (TBI), a 

disability affecting more 

than 5 million Americans 

(four times the people 

with HIV or AIDS). The 

information will inform 

states’ decisions on 

developing TBI prevention 

programs, educate the 

public and policy makers 

about TBI, and document 

the need for additional 

services.

Youth Violence 

Compendium 

CDC publishes Measuring 

Violence-Related Attitudes, 

Behaviors, and Influences 

Among Youths: A Compendium 

of Assessment Tools. The 

Compendium provides 

researchers and prevention 

specialists with tools to 

assess factors related to 

youth violence and to evaluate 

prevention programs. A second 

edition is published in 2005.

Smoke Alarms

CDC begins a three-year 

program to reduce injuries 

from house fires by funding 

14 states to install long-lasting 

smoke alarms in high-risk 

homes with young children 

and older adults. The results: 

more than 161,000 home 

visits, more than 116,000 

smoke alarm installations, and 

more than 7 million people 

reached with media-based fire 

education campaigns. In 2002, 

340 lives are saved. Key to this 

success was earlier CDC injury 

research: 

n In 1997, a New England 

Journal of Medicine study 

finds that Oklahoma City’s 

targeted program for highrisk populations reduces 

incidents of residential firerelated injuries. 

n CDC funds a small business 

research project that 

develops a smoke alarm 

with a long-lasting, lithiumpowered battery and hush 

buttons. The result: homes 

are adequately protected 

for a longer period by a 

functional alarm.

Fall Prevention 

A Tool Kit to Prevent Senior 

Falls, a program to combat 

the leading cause of injury 

death for Americans over 

65, is launched. The tool 

kit is distributed to more 

than 6,000 older adults in 

fall prevention programs 

nationwide. Program 

materials (in English and 

Spanish) are distributed 

through senior centers, 

hospitals, and health 

departments.

Intimate Partner 

Violence 

CDC publishes Intimate 

Partner Violence 

Surveillance: Uniform 

Definitions and 

Recommended Data 

Elements to improve and 

standardize data collection. 

These standards will help 

eliminate inconsistencies 

in surveillance data and 

allow researchers to 

better gauge the problem, 

identify high-risk groups, 

and monitor the effects 

of prevention programs. 

In 2002, a second edition 

is published, along with 

uniform definitions and 

recommended data 

elements for sexual 

violence. 

Concussion and 

Brain Injury

CDC publishes Facts About 

Concussion and Brain 

Injury, an easy-to-read 

brochure for the public that 

explains what happens 

after a concussion, how to 

get better, and where to 

go for information when 

needed.
12 Timeline

DUI and Children 

CDC research shows

nearly two thirds of 

children killed in drinking 

driver-related crashes rode 

with the impaired driver, 

spurring some states to 

introduce legislation that 

creates special penalties 

for persons who transport 

children under age 16 

while driving drunk.

Youth Violence 

Because the homicide rate 

for youth under 19 years 

old averages nine deaths 

a day, CDC issues Best 

Practices of Youth Violence 

Prevention: A Sourcebook 

for Community Action, the 

first of its kind for youth 

violence. CDC draws upon 

real-world experiences to 

prevent violence among 

children and adolescents.

National Academic 

Centers of Excellence 

on Youth Violence 

CDC funds 10 colleges and 

universities to establish 

the National Academic 

Centers of Excellence on 

Youth Violence. The centers 

foster efforts between 

university researchers and 

communities to address 

youth violence.

State Profiles 

CDC enhances State Injury 

Profiles, reports containing 

easy-to-read maps and 

charts, state-by-state 

comparisons and rankings, 

and overviews of CDCsupported injury prevention 

research and programs in 

each state.

Rape Prevention 

The Violence Against 

Women Act of 2000 shifts 

CDC responsibility for 

the Rape Prevention and 

Education Grant Program 

to the Injury Center. CDC’s 

injury prevention team 

funds states and territories 

to strengthen awareness, 

establish hotlines, and 

further education and 

training. This move puts 

CDC injury prevention 

funding into every state 

and U.S. territory.

Lifeguard 

Effectiveness 

CDC publishes its 

assessment of lifeguard 

services as a strategy for 

preventing drowning and 

water-related injuries. 

Findings indicate that 

most drownings occur at 

sites without lifeguards. 

Surgeon General’s 

Report on Youth 

Violence 

The Surgeon General’s 

report on youth violence 

is released, with an 

epidemiology chapter 

written by Injury Center 

staff. The report highlights 

risk and protective 

factors for youth 

violence and identifies 

effective, research-based 

prevention strategies.

Child Maltreatment 

Congress appropriates 

funding for child 

maltreatment prevention, 

laying groundwork for 

today’s research and 

prevention activities, 

including a focus on 

parenting.

Injury Surveillance 

First State Injury 

Indicators Report

is published in 

partnership with The 

State and Territorial 

Injury Prevention 

Directors Association 

and the Council of 

State and Territorial 

Epidemiologists. 

This report includes 

surveillance data on 

injury and risk factors 

from 12 states. A second 

report in 2004 features 

data from 26 states.

School Health 

Guidelines 

CDC collaborates on 

School Health Guidelines 

to Prevent Unintentional 

Injuries and Violence. 

Recommendations 

identify effective school 

policies and practices 

to prevent unintentional 

injuries such as 

playground and sports 

injuries, violence, and 

youth suicide.

National Suicide 

Prevention Strategy 

CDC plays a key role 

in the Federal Steering 

Group for the Surgeon 

General’s National 

Strategy for Suicide 

Prevention. The Strategy

provides national 

goals and objectives 

for preventing suicide, 

promotes awareness 

about suicide as a 

preventable public health 

problem, and discusses 

how to develop and 

evaluate prevention 

programs and enhance 

tracking systems for 

suicide.

WISQARSTM

CDC introduces WISQARS, 

Web-based Injury Statistics 

Query and Reporting 

System, an interactive 

database that provides 

researchers, policy makers, 

media, and the public with 

customized reports about 

injury mortality data. Using 

the U.S. Consumer Product 

Safety Commission’s 

nonfatal injuries database 

(National Electronic Injury 

Surveillance Systems–All 

Injury Program, or NEISS–

AIP), nonfatal injury data 

are added to WISQARS in 

2001. 

Injury Prevention 

in Vietnam

After studying the injury 

problem in Vietnam, CDC 

assists the Vietnamese 

government and UNICEF 

in developing and 

implementing the Safe 

Vietnam initiative. As a 

result in 2001, Vietnam’s 

prime minister approves 

a national policy on injury 

prevention designed to 

reduce injuries by 30% to 

40% by 2010.

State Core Programs 

Addressing gaps in state 

injury prevention programs, 

CDC funds 24 states to 

develop injury surveillance 

and prevention programs. 

States with limited 

resources can now build 

and maintain programs to 

address state-identified 

injury priorities.

SafeYouth.org 

CDC helps create the 

National Youth Violence 

Prevention Resource 

Center (NYVPRC), a single, 

user-friendly source of 

youth violence information 

and effective strategies 

to control and prevent 

violence. Designed for 

parents, teenagers, 

health care providers, 

law enforcement officials, 

and other professionals, 

NYVPRC also offers a 

Spanish/English toll-free 

information number and 

Internet site.
 Timeline 13

World Trade Center 

Attacks

CDC’s injury surveillance 

team conducts rapid 

assessment of type and 

severity of injuries among 

WTC survivors examined at 

five New York City hospital 

emergency departments 

during first 48 hours after 

attack. Study reveals most 

of the injured had eye 

and inhalation problems 

and were treated on an 

outpatient basis within 

hours of the attack.

Injury Center Celebrates 

10th Anniversary

CDC celebrates 

establishment of its Injury 

Center and a decade of 

progress by holding four 

regional meetings across 

the country. The meetings, 

which highlight successes 

in injury prevention fostered 

by CDC injury research 

and state program funding, 

feature experts in youth 

violence, suicide, drowning, 

motor vehicle-related, and 

other types of injury. 

CDC Injury Research 

Agenda

The CDC Injury Research 

Agenda identifies priorities 

for injury prevention and 

control research that must 

be addressed to fulfill CDC’s 

public health responsibilities. 

In 2003, the Injury Center 

updates the Agenda to 

address priorities for acute 

care research. By defining 

research needs in a diverse 

field, CDC maximizes 

use of resources and 

encourages collaboration 

between researchers and 

practitioners.

Reporting Violent 

Deaths 

Six states begin collecting 

data for the National Violent 

Death Reporting System 

(NVDRS), which combines 

data about violent deaths 

to enable data sharing, 

to better understand 

violence in America, and 

to help policy makers 

and community leaders 

make informed prevention 

strategies. By 2005, 17 

states are funded to 

implement NVDRS. 

Preparedness and 

Response

CDC launches a website to 

help the public, clinicians, and 

public health professionals 

prepare for and respond 

to mass casualty events. 

The site includes a rapid 

injury assessment tool to 

help collect core data for 

investigating the number, 

type, timing, and severity 

of injuries associated with 

a mass trauma event. CDC 

also funds activities to 

strengthen collaboration 

among professionals in 

acute medical care, trauma, 

emergency medical services, 

and state and local health 

departments.

Injury Surveillance–XIX 

Winter Olympic Games 

Salt Lake City

CDC’s injury prevention 

scientists assist the Utah 

Department of Health in 

injury surveillance. The 

public health team monitors 

nonathlete injury visits to the 

Olympic venue medical aid 

stations and area hospital 

emergency departments. 

Their timely reporting of 

injury data rapidly identifies 

potential public health 

hazards. This information 

helps decision makers guide 

public health interventions 

and helps event planners 

involved in future large crowd 

events.

Poison Control 

CDC, the Health Resources 

and Services Administration 

(HRSA), and the American 

Association of Poison Control 

Centers launch the nation’s first 

comprehensive toll-free poison 

hotline. Callers from anywhere 

in the U.S. are routed to poison 

control centers. 

World Report on 

Violence 

CDC collaborates with the 

World Health Organization 

on the first World Report 

on Violence and Health

to document and raise 

awareness of violence 

as a global public health 

problem.

End Residential Fire 

Deaths Challenge 

CDC works in partnership 

with the United States Fire 

Administration (USFA), the 

U.S. Consumer Product 

Safety Commission (CPSC), 

and several nongovernment 

organizations to eliminate 

residential fire deaths by the 

year 2020. Activities include 

surveillance, research, 

evaluation, and community 

programs in high-risk 

populations, including older 

adults and children.

Injury Maps 

CDC launches Injury Maps, 

a Web-based, interactive 

system that enables users 

to create customized injuryrelated mortality and injury 

maps at the national, state, 

regional, and county levels. 
14 Timeline

Injury and Violence 

Conference 

More than 750 injuryand violence-related 

experts gather for the 

2005 National Injury 

Prevention and Control 

Conference, Injury and 

Violence in America: 

Meeting Challenges, 

Sharing Solutions. 

Featured are more than 

260 presentations on 

topics ranging from 

violence among teens to 

coalition building and risk 

communication.

Adolescent Health 

Trailblazers: Teen 

Driving 

The Injury Center 

contributes to CDC’s 

comprehensive, 

coordinated approach 

to improving adolescent 

health by sponsoring 

and conducting research 

and program activities to 

reduce injuries and deaths 

related to teen driving. 

CHOOSE RESPECT 

Campaign 

Pilot testing begins 

for CHOOSE RESPECT, 

a communication 

campaign targeting ages 

11–14 years. It promotes 

healthy relationships by 

demonstrating positive, 

respectful messages and 

helps youth recognize and 

avoid dating abuse. Launch 

is scheduled for spring 2006.

Public Health Injury 

Surveillance and 

Prevention Program 

Funding for core state 

injury control and 

prevention programs and 

traumatic brain injury 

programs is combined to 

strengthen collaboration 

and programs. This 

approach funds more states. 

Coordinating Center 

CDC creates four 

Coordinating Centers to 

increase communication 

and innovation across 

organizational boundaries. 

The Injury Center becomes 

part of the Coordinating 

Center for Environmental 

Health and Injury Prevention. 

Community Guide 

CDC’s findings about 

community efforts to 

increase child safety seat 

use appear in The Guide 

to Community Preventive 

Services. The Community 

Guide, published by an 

independent task force, 

provides public health 

decision makers with 

recommendations about 

interventions to promote 

health and safety and to 

prevent disease, injury, 

disability, and premature 

death.

Road Safety Worldwide 

CDC partners with the World 

Health Organization for World 

Health Day 2004 to focus 

on road traffic safety. Injury 

Center researchers help plan, 

develop, write, and launch 

the World Report on Road 

Traffic Injury Prevention, 

the first report of its kind to 

underscore the threat that 

unsafe road traffic systems 

pose for global public health 

and development. 

CDC also helps develop 

UN resolutions on traffic 

injuries and public health 

and prepares an HHS 

position statement for the 

UN General Assembly.

Traumatic Brain Injury 

in the U.S.

CDC publishes a report that 

provides detailed information 

about TBI-related deaths, 

hospitalizations, and 

emergency department visits 

in the U.S. for 1995–2001. 

Supervision and 

Injury Prevention 

CDC convenes experts 

to assess the role of 

supervision in preventing 

unintentional injuries 

among children and to 

identify areas where 

research is needed. 

Suggestions for models 

of supervision and 

intervention research 

emerge.

Cost of Intimate 

Partner Violence 

CDC reports on the 

incidence, prevalence, and 

cost of intimate partner 

violence against women 

in the U.S. The report 

estimates that healthrelated costs of rape, 

physical assault, stalking, 

and homicide by intimate 

partners exceed $5.8 billion 

each year. 

National Injury 

Conference 

The National Injury 

Prevention and Control 

Conference “Safety in 

Numbers” convenes 

hundreds of professionals 

working to prevent injuries 

and resultant deaths and 

disabilities. The conference 

highlights effective 

prevention strategies, 

advances in injury 

research, and opportunities 

to improve programmatic 

and research skills. It 

also provides a forum for 

building partnerships and 

enhancing collaboration.

Injury among Native 

Americans 

A CDC study reveals that 

injuries and violence 

account for three fourths 

of deaths among Native 

Americans ages 19 and 

under—a rate about twice 

that of all U.S. children and 

youth. 

Traumatic Brain Injury 

CDC publishes Heads 

Up: Brain Injury in Your 

Practice, a tool kit to help 

physicians recognize and 

manage traumatic brain 

injury. It contains practical 

clinical information and 

patient materials in English 

and Spanish.

Falls Prevention 

Action Plan 

CDC helps develop Falls 

Free: Promoting a National 

Falls Prevention Action Plan

that outlines strategies 

to reduce fall dangers for 

older adults and addresses 

barriers to a national falls 

prevention initiative.

Heads Up: Concussion 

in High School Sports 

CDC and partners develop 

and widely distribute a 

tool kit for coaches to help 

them educate athletes, 

athlete’s parents, and 

others about preventing, 

recognizing, and managing 

sports-related concussion.

Injury in Asia 

Injury Center staff partner 

with The Alliance for Safe 

Children to address the 

injury problem in Asia. 

Researchers examine data 

about childhood injuries 

and economic indicators 

related to injury in China 

and Thailand and engage 

Thailand’s health ministry 

in discussions about 

capacity building for injury 

prevention.

Prehospital Trauma 

Care 

CDC helps the World 

Health Organization (WHO) 

develop Prehospital Trauma 

Care Systems, a manual 

focusing on promising 

interventions and 

components of prehospital 

trauma care, particularly 

those that require minimal 

training and resources. 

CDC and WHO host an 

expert meeting about 

prehospital trauma care to 

coincide with the release of 

the report.
Data for Injury Prevention 

and Control

Many Americans do not understand the 

magnitude of the injury problem in this 

country. Data allow us to show how many 

people are injured each year and how many die 

or suffer permanent disabilities as a result of 

those injuries. Data show us where the biggest 

injury problems are so we can best focus our 

resources. And data let us know whether our 

efforts to prevent injuries are effective. CDC 

obtains injury data from a number of sources 

and shares the data through several channels.
16 Data for Injury Prevention and Control

CDC obtains data from several federal- and state-run systems 

that routinely capture information 

about injuries and deaths. Data also 

come from surveys conducted by staff 

and partners to obtain information 

about particular injuries or conditions. 

Examples of these data sources follow.

Behavioral Risk Factor 

Surveillance System

The Behavioral Risk Factor 

Surveillance System (BRFSS) monitors 

risk behaviors associated with the 

leading causes of injury and death 

among Americans 18 and older. The 

survey, conducted by the states, consists 

of standard questions CDC developed 

to facilitate state-by-state comparisons. 

Injury-related data in BRFSS include 

falls among older adults, seat belt use, 

alcohol-impaired driving, and firearm 

storage. CDC has also developed two 

optional modules to help states better 

assess the problem of intimate partner 

violence, sexual violence, and resulting 

injuries. BRFSS data can be analyzed 

by age, race and ethnicity, income level, 

and education. 

Central nervous system 

surveillance: traumatic brain injury

As early as 1989, CDC began 

promoting the development of a 

multistate traumatic brain injury (TBI) 

surveillance system. The surveillance 

system is used to assess the extent of 

injury among individuals with a TBI; 

to identify high-risk populations and 

examine trends; to guide development, 

implementation, and evaluation of 

prevention and control programs; 

to prioritize the distribution of TBI 

resources; and to build a foundation for 

research and prevention of secondary 

conditions (e.g., depression and alcohol 

abuse). CDC developed two guides to 

help states collect, format, evaluate, 

and submit TBI surveillance data.

The Guidelines for the Surveillance of 

Central Nervous System Injury ensured 

that the multistate TBI surveillance 

system generated consistent, valid, 

and timely information (Thurman et 

al. 1995). Later, this information was 

updated and compiled into the Central 

Nervous System Injury Surveillance Data 

Submission Standards, 2002 (Marr and 

Coronado 2004). Though developed 

for participating states, these guides are 

also a resource for states conducting 

TBI surveillance independent of the 

CDC system.

Fatality Analysis Reporting System

The Fatality Analysis Reporting 

System (FARS), managed by the 

National Highway Traffic Safety 

Administration, contains data about all 

fatal traffic crashes on public roadways 

within the 50 states, the District of 

Columbia, and Puerto Rico. FARS 

provides descriptions of each fatal 

crash reported, with more than 100 

coded data elements that characterize 

the crash, the vehicles, and the people 

involved.

National Crime Victimization 

Survey

Run by the Bureau of Justice Statistics, 

part of the U.S. Department of Justice, 

the National Crime Victimization 

Survey provides representative data 

about the frequency, characteristics, 

and consequences of crime in the 

United States, including violent 

crimes such as rape, physical and 

sexual assault, and homicide. Survey 

data include type of crime; time and 

location of the crime; relationship 

between victim and offender; 

characteristics of the offender; 

consequences of the victimization; 

whether the crime was reported to the 

police and reasons for reporting or not 

reporting; and offender use of weapons, 

drugs, or alcohol. Basic demographic 

information is also included.

National Electronic Injury 

Surveillance System–All Injury 

Program

The National Electronic Injury 

Surveillance System–All Injury Program 

(NEISS–AIP), operated by the U.S. 

Consumer Product Safety Commission 

(CPSC), provides injury data from 

inner city, urban, suburban, rural, and 

children’s hospitals. Originally, NEISS 

collected data only about nonfatal 

injuries related to consumer products 

and recreational activities. In July 2000, 

through a cooperative effort between 

CPSC and CDC, NEISS–AIP began 

collecting data about all nonfatal 

injuries treated in hospital emergency 

departments. CDC uses NEISS–AIP 

data to generate estimates of nonfatal 

injuries in the United States and to 

guide decisions and policies about 

injury prevention and control.

National Hospital Discharge Survey

Each year, the National Hospital 

Discharge Survey, administered by 

CDC’s National Center for Health 

Statistics (NCHS), provides information 

about persons who survive injuries and 

are discharged from inpatient hospital 

care. NCHS gathers data annually 

from about 270,000 inpatient records 

acquired from a national sample of about 

500 hospitals. Data include patient’s age, 

sex, race, ethnicity, marital status, and 

expected sources of payment. Patient 

data also includes diagnosis, length of 

hospital stay, procedures performed, and 

condition at the time of discharge.

National Uniform Crime Reports

More than 17,000 city, county, and state 

law enforcement agencies voluntarily 

participate in the nationwide Uniform 

Crime Reports system, managed by the 

U.S. Federal Bureau of Investigation. 

From this system, CDC gets important 

information about violent crimes—

rapes, physical and sexual assaults, and 

murders—committed in this country. 

Data can be broken down by geographic 

areas, municipalities of varying 

population sizes, and specific cities.

Data Sources
Data for Injury Prevention and Control 17

National Violent Death 

Reporting System

Currently, 17 states are part of the 

National Violent Death Reporting 

System (NVDRS). These states gather, 

share, and link state-level data to gain 

a more accurate understanding of 

violence. The system includes data 

collected from medical examiners, 

coroners, police, crime labs, and death 

certificates. 

National Vital Statistics System

Each state must send information 

about deaths that occur within its 

borders to CDC’s National Center 

for Health Statistics, which manages 

the National Vital Statistics System. 

For each death—including those 

caused by injuries and violence—the 

system contains information about 

the decedent’s age, sex, race, ethnicity, 

education level, and cause of death.

Youth Risk Behavior 

Surveillance System 

The Youth Risk Behavior Surveillance 

System (YRBSS) monitors health-risk 

behaviors among the nation’s 9ththrough 12th-grade students. State and 

local departments of education and 

health conduct this self-administered 

survey biennially, and CDC assists in 

analyzing the data. The survey includes 

several injury-related behaviors: 

seat belt use, driving after drinking 

alcohol, riding with a driver who 

has been drinking, wearing bicycle 

and motorcycle helmets, carrying a 

weapon to school, being in a physical 

fight, experiencing dating violence 

and forced sexual intercourse, and 

attempting suicide or having suicidal 

thoughts. Data can be analyzed by sex, 

grade in school, and race and ethnicity.

References

Marr AL, Coronado V. Central Nervous 

System Injury Surveillance Data Submission 

Standards, 2002. Atlanta (GA): Centers for 

Disease Control and Prevention, National 

Center for Injury Prevention and Control; 

2004.

Thurman DJ, Sniezek JE, Johnson D, 

Greenspan A, Smith SM. Guidelines for 

Surveillance of Central Nervous System 

Injury. Atlanta (GA): Department of 

Health and Human Services (US), Centers 

for Disease Control and Prevention; 1995.
18 Data for Injury Prevention and Control

WISQARSTM

WISQARS 

(pronounced 

“whiskers”), the 

Web-based Injury 

Statistics Query 

and 

Reporting System, 

is an interactive database of injury 

morbidity and mortality data. It offers 

prompt, customized reports about both 

unintentional and violent injuries, 

including leading causes of death 

reports, leading causes of nonfatal 

injury reports, and years of potential 

life lost reports. Data are updated each 

year in the fall. Tutorials, frequently 

asked questions, and a help file ensure 

that users obtain the data they need. 

To use WISQARS, go to www.cdc.gov/

ncipc/wisqars.

Downloadable leading 

causes charts 

To assist partners in communicating 

the threat of injury to public health, 

CDC’s Injury Center has released 

several charts on its website. The charts 

show ten leading causes of death and 

nonfatal injury, highlighting both 

unintentional injury and violence. 

Available in several file formats, 

the charts can be used in slide 

presentations, Web pages, and print 

documents. To download a chart, go to 

www.cdc.gov/ncipc/osp/charts.htm.

State Injury Profiles

CDC’s State Injury Profiles give policy 

makers and health care workers an 

easy way to look at statistics about 

injuries to help them make informed 

decisions about where to allocate 

limited prevention resources. Maps and 

graphs in the Profiles show each state’s 

death rates from motor vehicle crashes, 

falls, poisoning, drowning, suffocation, 

fires and burns, suicide, homicide, 

traumatic brain injuries, and injuries 

related to firearms. The graphics show 

how each state compares with others 

in the nation and with mortality rates 

in the United States as a whole. The 

Profiles also contain a table showing the 

ten leading causes of death for each state 

and for the United States overall. In 

2001, the Injury Center began offering 

a free CD-ROM with data from the 

State Injury Profiles in slide presentation 

format to facilitate communication 

about injuries. To access the Profiles on 

the Web, go to www.cdc.gov/ncipc/

StateProfiles/index.htm. 

To help injury professionals, policy makers, and researchers better 

understand the injury problem and 

develop strategies to reduce it, CDC 

shares injury data through a variety 

of means. Following are examples of 

communication channels.

Injury Maps

Launched in 2002, Injury Maps is an 

interactive Web application that creates 

maps from injury mortality rates. 

Injury Maps enables injury mortality 

rates to be mapped, displayed in an 

easy-to-interpret format, and compared 

across states and counties. The 

appearance of a map can be tailored by 

changing colors, zooming in on specific 

areas, or adding features such as major 

cities and towns, highways, bodies of 

water and Congressional districts. The 

maps are printable and downloadable. 

To access Injury Maps, visit www.cdc.

gov/ncipc/maps. 

Data Sharing

A Note About CDC’s Injury Data

As you read the CDC Injury Fact Book, you will note that data are 2 to 3 years old. These data 

were the most recent available when this book was first developed. CDC must compile injury 

data from numerous sources, verify those data, and prepare data in a way that is useful and 

meaningful for the public. While this process may result in lag time between data collection 

and data release, it ensures that CDC provides the public with accurate, reliable information.

Please visit CDC’s Injury Center website for current data: www.cdc.gov/injury.
Data for Injury Prevention and Control 19

n Traumatic Brain Injury Extended 

Surveillance (TBIES) Program.

The TBIES Program supports efforts 

to provide expanded information 

on the incidence of TBI. It provides 

centralized, statewide electronic 

surveillance of TBI using linked and 

unduplicated data from hospital 

discharge and vital statistics databases.

n Traumatic Brain Injury Emergency 

Department (TBIED) Surveillance 

Program. In addition to performing 

basic electronic surveillance, the 

program supports efforts to provide 

information on the incidence of TBI 

treated in the emergency department.

n Traumatic Brain Injury Service 

Linkage (TBISL) Program.

Supports efforts to link individuals with 

TBI to information about services. 

The PHISP Program is one of many 

ways in which CDC helps fulfill its 

Healthy People 2010 responsibilities 

to prevent injury and violence while 

leveraging resources and increasing 

efficiency. For more information about 

the PHISP Program, log on to www.

cdc.gov/injury.

Surveillance is key to developing effective public health programs. 

By knowing the magnitude of a 

problem and the affected populations, 

resources can be directly applied and 

capacity can be built to control or 

prevent the injury or violence-related 

problem. One way to build capacity 

and to strengthen the infrastructure 

is by integrating programs, thereby 

leveraging resources and increasing 

efficiency through coordinated efforts.

Public Health Injury Surveillance 

and Prevention Program

In 2005, CDC began funding the 

Public Health Injury Surveillance 

and Prevention (PHISP) Program. 

The PHISP Program is designed to 

combine the Integrated Core Injury 

Prevention and Control Program with 

specialized TBI programs. Funding 

for the specialized TBI programs is 

awarded to certain states in varying 

combinations (see map for 2005-

funded programs). 

This departure from traditional singleprogram funding increased the number 

of states receiving core injury funding 

from 28 to 30; states receiving funding 

to conduct basic, electronic TBI 

surveillance increased over 100%—

from 12 to 30.

The PHISP Program funding makes 

it possible to integrate the “core” 

Integrated Core Injury Prevention and 

Control Program (which includes basic 

TBI surveillance) with specialized TBI 

programs:

n Integrated Core Injury Prevention 

and Control (ICIPC) Program.

The “core” ICIPC Program 

systematically collects information 

about TBIs, drownings, fire-related 

injuries, motor vehicle injuries, 

poisonings, homicides, suicides, 

and injuries resulting from mass 

casualty events and then analyzes 

these data to direct future injury 

prevention plans. The ICIPC 

Program also focuses on building 

capacity and strengthening essential 

infrastructure support. Through this 

program, CDC encourages states 

to build coalitions with partners 

from academic, nonprofit, private, 

local government, and professional 

organizations.

2005 Recipients of Public Health Injury Surveillance 

and Prevention (PHISP) Program Funding 

ICIPC (“Core”) Funded States

 TBI Service Linkage

TBI Extended Surveillance 

TBI Emergency Department Surveillance

Rhode Island

Capacity Building and Surveillance

Partners in Prevention

CDC’s Injury Center could not do its job without 

its partners. They are essential at every stage in 

the public health approach—collecting data about 

injuries, sharing insight about risk factors and 

strategies for prevention, developing and testing 

programs to prevent and control injury, and 

helping effective programs reach people at risk. 

CDC’s Injury Center works with private industry, 

other federal agencies, state and local agencies 

and health professionals, national nonprofit 

organizations, academic organizations and 

institutions, and international agencies to achieve 

its goal of preventing injuries and resulting deaths 

and disabilities.

The list of partners found in this section is far 

from exhaustive. It is merely a sample of the wide 

variety of organizations and agencies with which 

we work closely. While we value our relationships 

with all our partners, there simply is not space to 

list them all in the CDC Injury Fact Book.
22 Partners in Prevention

CDC works with many federal agencies to address injury issues 

that span all life stages. Below are 

examples of activities underway with 

some of the Injury Center’s federal 

partners.

Defense and Veterans 

Brain Injury Center 

The Defense and Veterans Brain Injury 

Center (DVBIC) works to ensure that 

military personnel and veterans with 

brain injury receive the best possible 

evaluation, treatment, and follow-up. 

CDC’s Injury Center is collaborating 

with DVBIC to study outcomes of 

traumatic brain injury (TBI) among 

military personnel using methods 

developed through CDC-funded TBI 

follow-up studies.

Health Resources and 

Services Administration 

CDC’s Injury Center recently 

partnered with the Health Resources 

and Services Administration (HRSA) 

to support the expansion of the 

Institute of Medicine’s Future of 

Emergency Care in the U.S. Health 

System study. This expansion will 

include focused assessments of 

pediatric emergency care and issues 

relating to pre-hospital emergency 

medical services. HRSA is also a 

partner in efforts to improve how states 

use traumatic brain injury data. 

Indian Health Service

The Indian Health Service (IHS) is a 

valuable partner in efforts to prevent 

injuries and deaths among Alaska 

Natives and Native Americans. For 

example, the IHS partnered with CDC 

to research Native American childhood 

injuries and disseminate findings 

throughout the IHS and among tribes.

National Highway Traffic 

Safety Administration

In its efforts to prevent transportationrelated injuries and deaths, CDC 

works closely with the National 

Highway Traffic Safety Administration 

(NHTSA), part of the U.S. 

Department of Transportation. 

NHTSA and CDC jointly published 

strategies to improve bicycle safety 

and child pedestrian injuries. The 

organizations also collaborated for 

World Health Day 2004 to organize 

and implement a comprehensive 

strategy for promoting road safety 

in the United States. Joint research 

projects have involved graduated 

licensing for teens, alcohol-impaired 

driving, and systematic reviews of what 

works to prevent motor vehicle crashes 

and related deaths. CDC and NHTSA 

are collaborating with the Task Force 

on Community Preventive Services 

to summarize what is known about 

the effectiveness of interventions to 

reduce alcohol-impaired driving and 

increase seat belt use (available at www.

thecommunityguide.org). NHTSA also 

offers vital data about motor vehicle 

crashes and related deaths.

Federal Agencies

“Many of the 

nearly 50 million injuries 

that occur each year 

in the United States 

are preventable . . . 

we need greater recognition 

of the value of our 

prevention efforts . . . 

the benefits of preventing 

motor vehicle crashes, falls, 

residential fires, childhood 

abuses, and other injuries 

are significant.”

NCIPC Director, Dr. Ileana Arias

‘‘

‘‘
Partners in Prevention 23

U.S. Consumer Product 

Safety Commission

The U.S. Consumer Product Safety 

Commission (CPSC) has long been an 

important partner in injury prevention. 

CPSC manages the National Electronic 

Injury Surveillance System (NEISS), 

which collects vital information about 

nonfatal injuries. Recently, CPSC 

collaborated with CDC and the 

U.S. Food and Drug Administration 

(FDA) to determine the feasibility 

and usefulness of enhancing NEISS 

for monitoring adverse drug events. 

Based on the feasibility and utility 

demonstrated by this project, CDC, 

CPSC, and FDA now conduct ongoing 

adverse drug event surveillance 

(“medication injury monitoring”) in 64 

NEISS–All Injury Program hospitals. 

Additionally, CPSC helped develop 

a program to prevent fire- and fallrelated injuries among older adults, and 

it is one of several agencies evaluating 

current and prototypic smoke alarm 

technologies. 

U.S. Department of Education

Since 1992, CDC’s Injury Center 

has worked with the Department 

of Education (ED) to conduct a 

national study of school-related 

violent deaths. This study allows 

public health officials to monitor 

trends in violence that occur in 

and around our nation’s schools. 

CDC and ED have also launched 

a social and character development 

research program to evaluate the 

effectiveness of interventions 

designed to promote positive social 

and character development, increase 

positive behaviors, and reduce 

antisocial behaviors among elementary 

school children. In addition, ED’s 

National Institute of Disability and 

Rehabilitation Research (NIDRR) 

funds the Traumatic Brain Injury 

Model Systems (TBIMS). The 17 

TBIMS centers now funded are 

involved in a prospective, longitudinal 

multicenter effort to examine the 

course of recovery and outcomes 

following TBI. CDC’s Injury Center 

funds a collaborative study with 

NIDRR to compare TBI Model 

Systems data with population-based, 

CDC-funded surveillance and 

outcomes data in South Carolina.

U.S. Department of Justice

CDC works with the U.S. Department 

of Justice (DOJ) on various injury and 

violence issues. For example, DOJ was 

one of the two agencies CDC worked 

with to conduct its national school 

violence study. DOJ also cosponsored 

the 2002 and 2004 National Sexual 

Violence Prevention Conferences 

and the National Violence Against 

Women Survey, resulting in estimates 

of stalking, rape, and physical assault 

among women in the United States.

U.S. Fire Administration

CDC works with the U.S. Fire 

Administration (USFA), now part of 

the U.S. Department of Homeland 

Security (DHS), to address fire-related 

injuries and deaths in America. This 

agency is one of several partners 

working with the Injury Center to 

evaluate the performance of various 

smoke alarms. Additionally, through 

an interagency agreement, CDC 

evaluates outcomes of USFA-funded 

fire prevention programs.
24 Partners in Prevention

CDC relies heavily on state and local agencies. These agencies 

provide critical data about injuries, 

offer important perspectives on how 

injuries affect communities nationwide, 

and help reach communities in ways 

that CDC, as a federal agency, cannot.

State Health Departments

CDC has cooperative agreements with 

many state health departments. With 

CDC funding, states collect data about 

topics such as traumatic brain injuries, 

violence against women, and emergency 

department visits for injuries. States 

also conduct and evaluate programs to 

prevent sexual violence, distribute smoke 

alarms, promote use of bicycle helmets, 

and implement trauma care systems.

State-funded Programs

Injury is a leading killer in all 50 states, 

but injury problems differ among 

the states. Variations in geography, 

weather conditions, and populations 

cause some states to incur injury issues 

not experienced by the rest of the 

country. To address these issues, CDC 

funds state health departments to 

systematically collect information about 

TBIs, drownings, fire-related injuries, 

motor vehicle injuries, poisonings, 

homicides, suicides, and injuries 

resulting from mass casualty events and 

then analyzes these data to direct future 

injury prevention plans. Thirty states 

receive Integrated Core Injury Prevention 

and Control (ICIPC) Program funding. 

The funding helps states strengthen 

infrastructure and build capacity by 

developing five core components of 

model state injury programs:

n Collect and analyze data;

n Provide technical support and 

training to communities conducting 

injury programs;

n Coordinate and collaborate in injury 

prevention activities; 

n Design, implement, and evaluate 

programs to prevent injury; and

n Inform public policy that supports 

injury prevention. 

To date, most funded states have 

established offices of injury prevention 

and control. Most states have also formed, 

and are actively using, injury community 

planning groups to develop and 

prioritize injury plans. They have built 

partnerships to improve coordination and 

collaboration, and their health agencies 

are paying greater attention to injury as 

a critical public health problem. State 

accomplishments and program profiles are 

available on the Injury Center’s website.

2005 Recipients of Integrated Core Injury Prevention 

and Control (ICIPC) Program Funding

State and Local Agencies

 Funded States

Arizona

California

Colorado

Connecticut

Florida

Georgia

Hawaii

Kansas

Kentucky

Louisiana

Maine 

Maryland

Massachusetts

Minnesota

Nebraska

Nevada

New Mexico 

New York

Ohio

Oklahoma

Oregon 

Pennsylvania

Rhode Island

South Carolina

Tennessee

Utah

Vermont

Virginia 

Washington

Wisconsin
Partners in Prevention 25

CDC works closely with organizations representing state 

and local public health professionals. 

A sampling of those organizations 

follows.

Association of State and 

Territorial Health Officials

Association of State and 

Territorial Health Officials (ASTHO), 

which represents the chief health 

officials for all states, U.S. territories, 

and the District of Columbia, 

formulates and influences public health 

policy and ensures excellence in statebased public health practice. ASTHO 

supports initiatives to improve states’ 

abilities to develop, implement, and 

evaluate injury prevention efforts.

Council of State and 

Territorial Epidemiologists

The Council of State and Territorial 

Epidemiologists (CSTE) and CDC 

work in partnership to improve the 

public’s health by supporting the 

efforts of epidemiologists who work at 

state and local levels. CSTE and CDC 

promote the use of epidemiologic 

data to guide public health practice 

and improve health. CSTE has also 

consulted with CDC about the 

development and implementation of 

the National Violent Death Reporting 

System (NVDRS). This partnership 

provides a valuable link for CDC 

to inform CSTE membership about 

NVDRS through the Council’s 

newsletters, fact sheets, and position 

statements.

National Association of County 

and City Health Officials

National Association of County 

and City Health Officials (NACCHO) 

provides information, education, 

research, and technical assistance 

to more than 3,000 local health 

departments. Its members work to 

ensure that local public health systems 

have the capacity to effectively address 

health and safety issues, including those 

related to injury and violence.

National Association of 

State Emergency Medical 

Service Directors 

The National Association of 

State Emergency Medical Service 

Directors (NASEMSD) provides 

vision and leadership for developing 

and improving EMS systems and 

national EMS policy. CDC supports 

NASEMSD to explore key indicators 

of EMS system readiness in the states 

and territories. This project comprises a 

series of surveys examining three areas: 

involvement of state EMS offices in 

bioterrorism grant and planning efforts; 

programmatic involvement of state 

EMS with prevention programs; and 

state EMS funding. 

National Association of State 

Head Injury Administrators 

The National Association of State 

Head Injury Administrators (NASHIA) 

helps state governments promote 

partnerships and build systems to meet 

the needs of individuals with brain 

injury and those of their families. 

CDC’s Injury Center works with 

NASHIA to coordinate traumatic brain 

injury (TBI) surveillance activities 

and service linkage projects with state 

programs providing TBI services.

State and Territorial Injury 

Prevention Directors Association 

The State and Territorial Injury 

Prevention Directors Association 

(STIPDA) is a national organization 

with a primary mission to promote, 

sustain, and enhance the ability of 

state, territorial, and local public health 

departments to reduce death and 

disability associated with injuries. As 

such, STIPDA is positioned to support 

the mission of CDC’s Injury Center. 

The Injury Center supports STIPDA 

to develop models and standards 

for injury and violence prevention 

programs; to conduct systematic, 

comprehensive reviews of injury and 

violence prevention capacity in state 

health departments; and to provide 

technical assistance for state injury and 

violence prevention programs and staff.

Organizations for State and Local Health Professionals
26 Partners in Prevention

CDC works with many national nonprofit organizations to reach 

various audiences such as public health 

professionals, health care providers, and 

communities at risk for injury. Some of the 

organizations CDC works with follow.

American Academy of Pediatrics

CDC’s Injury Center provides a liaison 

to the American Academy of Pediatrics’ 

(AAP) Committee on Injury and Poison 

Prevention and Committee on Child 

Abuse. CDC contributes scientific expertise 

to help AAP develop policies about child 

maltreatment and childhood injuries.

American Automobile Association 

(AAA) Foundation for Traffic Safety

CDC works with the Office of Traffic 

Safety Policy in the AAA national office in 

Washington, D.C., to evaluate traffic safety 

interventions and to promote research in 

a broad spectrum of traffic safety issues 

such as aging and mobility, child passenger 

safety, teen driving, and impaired driving. 

CarFit, an AAA public awareness program, 

teaches seniors how to adjust seats, mirrors, 

seat belts, etc., so their cars better fit them. 

The program also gives seniors access to 

community resources. CDC also supports 

innovative focus group research on Latinos’ 

use of seat belts. This research explores and 

measures multiple dimensions of seat belt 

use by Hispanics living in the United States.

American College of 

Emergency Physicians 

The American College of Emergency 

Physicians (ACEP) supports quality 

emergency medical care and promotes 

the interests of emergency physicians. 

CDC supports ACEP through the 

Terrorism Injuries: Information, 

Dissemination and Exchange (TIIDE) 

cooperative agreement, which 

promotes collaboration between 

national organizations of professionals 

in emergency care and state and local 

health departments that will be critical 

in the event of a terrorist attack or 

other mass casualty event. CDC also 

supported ACEP’s 2004 Emergency 

Medical Services Week activities. 

American College of Surgeons

The American College of Surgeons (ACS) 

is a scientific and educational association of 

surgeons that was founded to improve the 

quality of care for the surgical patient by 

setting high standards for surgical education 

and practice. CDC supports ACS to 

provide national representative samples 

for Level 1 and Level 2 trauma centers 

through the ACS National Trauma Data 

Bank (NTDB). CDC is assisting ACS 

in planning and developing a national 

and regional probability sample for the 

NTDB to generate population-based 

rates that will help uniformly assess 

improvement in care of the injured. 

American Psychological Association

The American Psychological Association 

recently launched ACT (Adults and 

Children Together Against Violence), 

a national media campaign aimed at 

giving parents and other caregivers of 

young children the tools they need to 

prevent violence. CDC is evaluating the 

dissemination of the program.

American Public Health Association

The American Public Health Association 

(APHA) is an association for local, state, 

and federal public health workers across 

the country. CDC has a long-standing 

relationship with APHA and supports 

it to develop a curriculum outline about 

the interface of the emergency medical 

system and public health. The outline 

is a first step toward professional 

training that integrates public health 

and emergency service practices that 

will enhance day-to-day operations and 

increase readiness in disaster situations.

American Trauma Society

CDC supports the American Trauma 

Society (ATS) Trauma Information 

Exchange Program. Through this 

program, ATS collects data from 

trauma centers and improves access to 

such data. CDC funds ATS through 

the TIIDE cooperative agreement, 

which promotes collaboration between 

national organizations of professionals 

in emergency care and state and local 

health departments. Such collaboration 

will be critical in a terrorist attack or 

mass casualty event. 

Brain Injury Association of America 

CDC’s Injury Center works with the Brain 

Injury Association of America (BIAA) to 

promote education and research about 

traumatic brain injuries. The Injury 

Center serves on BIAA’s task force and 

has funded its pilot study for evaluating 

the development of a national brain 

injury information center. The “onecall” information center is being piloted 

in three states (Michigan, Minnesota, 

and Mississippi). People in these states 

who call the BIAA’s toll-free number 

will be linked automatically to their 

local Brain Injury Association for 

confidential and individalized brain 

injury resources in their state. 

Home Safety Council

CDC works with the Home Safety 

Council (HSC), a national nonprofit 

organization dedicated to preventing 

home-related injuries, on issues about 

injury prevention. HSC and CDC

supported the development of the National 

Council on Aging’s Falls Free: Promoting 

a National Falls Prevention Action Plan, 

which addresses the challenges and barriers 

related to a national falls prevention 

initiative and outlines key strategies 

and ways to help reduce fall dangers for 

older adults. HSC also supported the 

2005 Injury Center conference, “Injury 

and Violence in America: Meeting 

Challenges, Sharing Solutions.”

MetLife Foundation 

Metropolitan Life Insurance Company 

(MetLife) established its Foundation in 

1976 to support civic, educational, cultural, 

and health organizations. In 2004, through 

a partnership of the CDC Foundation 

and the MetLife Foundation, two CDC 

brochures were updated and translated into 

Spanish and Chinese: What You Can Do 

to Prevent Falls and Check for Safety: A 

Home Fall Prevention Checklist for Older 

National Nonprofit Organizations
Partners in Prevention 27

Adults. New posters that promote fall 

prevention activities were also created 

and are available in English, Spanish, 

and Chinese. See www.cdc.gov/ncipc/

pub-res/toolkit/brochures.htm.

National Alliance of Children’s 

Trust and Prevention Funds

The National Alliance of Children’s Trust 

and Prevention Funds initiates and engages 

in national efforts to prevent child abuse and 

neglect. These efforts include promoting 

and supporting services, laws, practices, 

and attitudes that enable families to provide 

their children with a safe, healthy, and 

nurturing childhood. CDC is working with 

the Alliance to expand its leadership role 

in preventing child maltreatment; to foster 

collaborations that respond to emerging 

policy and program issues; and to develop a 

plan to guide prevention activities. 

National Association of Emergency 

Medical Service Physicians 

The National Association of EMS 

Physicians (NAEMSP) is an organization 

of physicians and other professionals 

partnering to provide leadership and foster 

excellence in out-of-hospital emergency 

medical services. CDC’s Injury Center 

supports NAEMSP through the Terrorism 

Injuries: Information Dissemination and 

Exchange cooperative agreement, which 

promotes collaboration between national 

organizations of professionals in emergency 

care and state and local health departments. 

Such collaboration would be critical in 

the event of a terrorist attack or other 

mass casualty event.

National Fire Protection Association

CDC and the National Fire Protection 

Association (NFPA) have collaborated for 

years to prevent injuries from residential 

fires. Together with the U.S. Consumer 

Product Safety Commission and other 

partners, CDC’s Injury Center and NFPA 

developed Remembering When: A Fire 

and Fall Prevention Program for Older 

Adults. CDC evaluated the effectiveness 

of the Remembering When program, 

leading to a revision that CDC and 

NFPA were developing in 2005.

National Safety Council 

In collaboration with the National 

Safety Council (NSC), CDC 

is summarizing evidence of the 

effectiveness of graduated drivers 

licensing (GDL) systems for young, 

beginning drivers; estimating the cost 

of off-the-job injuries in America; 

reviewing CDC brochures on older 

adult falls; and creating fall prevention 

materials. CDC also works with 

NSC’s Research and Statistics Services 

Department to rapidly provide NSC 

with emerging results from CDC 

injury research. A series of articles 

in the Journal of Safety Research will 

feature cutting-edge CDC research on 

injury and violence prevention. 

Parents Anonymous

Parents Anonymous is a national 

child abuse prevention organization 

dedicated to strengthening families 

and building caring communities that 

support safe and nurturing homes for 

children. CDC is working with Parents 

Anonymous to expand its leadership 

role in preventing child maltreatment; 

to foster collaborations that respond to 

emerging policy and program issues; and 

to develop a plan to guide prevention 

activities. 

Prevent Child Abuse America

Prevent Child Abuse America works to 

prevent child abuse and neglect in the 

United States. The organization took 

part in CDC’s expert meeting to develop a 

plan to prevent child maltreatment. When 

the plan was completed, it was shared 

with policy makers, an action that resulted 

in the allocation of funds for research and 

programs to prevent child maltreatment. 

SAFE KIDS Worldwide

CDC and SAFE KIDS have conducted 

three projects to prevent injury among 

children. SAFE KIDS implemented 

and evaluated a drowning prevention 

program in two states with communities 

that have child drowning rates higher 

than the national average. SAFE KIDS, 

with support from CDC, implemented 

a program to reduce injuries among 

children living in low-income housing in 

10 communities across the United States 

and developed a low-literacy home safety 

brochure and a home safety PowerPoint 

presentation for distribution via SAFE 

KIDS coordinators. Additionally, SAFE 

KIDS was one of several cosponsors for 

the Panel to Prevent Pedestrian Injuries, 

a discussion that resulted in published 

strategies to improve safety for child 

pedestrians. CDC’s Injury Center serves 

on the SAFE KIDS Advisory Committee.

Society for Public Health Education 

CDC’s Injury Center works with the Society 

for Public Health Education (SOPHE) 

to provide training in injury prevention 

and behavioral science. A SOPHE 

website on behavioral science and injury 

emphasizes the links between behavioral 

science, health education, and injury and 

violence prevention. It offers injury facts, 

tips for implementing and evaluating 

interventions, links to CDC-funded injury 

control research, and information about 

opportunities for research funding. In 

addition, CDC supports the SOPHE/CDC 

Student Fellowship in Injury and Violence 

Prevention, an annual program for graduate 

students conducting injury research under 

the supervision of faculty mentors. SOPHE, 

comprised of health education professionals 

and students, stimulates research, supports 

performance standards, advocates policy 

and legislation, and develops standards 

for professional development in health 

education and health promotion.

Stop It Now! 

Stop It Now! is a national, public healthbased organization working to prevent 

and ultimately eradicate child sexual 

abuse. Through public education, policy 

advocacy, and research and evaluation, 

STOP IT NOW! calls on abusers and 

potential abusers to stop their abusive 

behavior and seek help. CDC is working 

with Stop It Now! to determine risk 

and protective factors for perpetration 

of sexual abuse and to identify the 

immediate and long-term health 

consequences of child sexual abuse.
28 Partners in Prevention

National Academic Centers of Excellence (ACE) on Youth Violence were 

established in 2000. These universities and colleges foster collaboration between 

university researchers and communities to address the public health problem of youth 

violence. Universities and colleges that receive ACE funding may vary from year to 

year. The following centers were funded in 2005. 

Columbia University University of California-Riverside

Harvard University University of Hawaii

Johns Hopkins University University of Illinois-Chicago

University of California-Berkley Virginia Commonwealth University

Injury Control Research Centers

conduct research in prevention, 

acute care, and rehabilitation and 

serve as training and information 

centers.

Colorado Injury Control Research 

Center (CICRC)

Harborview Injury Prevention and 

Research Center (HIPRC) 

Harvard Injury Control Research 

Center (HICRC)

Injury Research Center at the 

Medical College of Wisconsin 

(IRC-MCW)

Johns Hopkins Center for Injury 

Research and Policy (CIRP)

San Francisco Injury Center for 

Research and Prevention (SFIC)

Southern California Injury Prevention 

Research Center (SCIPRC)

University of Alabama at Birmingham 

Injury Control Research Center 

(UAB-ICRC)

University of Iowa (UI) Injury 

Prevention Research Center (IPRC)

University of North Carolina Injury 

Prevention Research Center 

(UNC IPRC)

University of Pittsburgh Center for 

Injury Research and Control (CIRCL) 

West Virginia University Injury Control 

Research Center (WVU ICRC)

Academic Centers of Excellence

CDC’s Injury Center funds 

eight National Academic Centers of 

Excellence (ACE) on Youth Violence 

Prevention at colleges and universities 

throughout the United States. The

Centers focus on the complex problem

of youth violence by fostering multidisciplinary and multi-sectoral 

interactions that can stimulate scientific 

creativity, speed new developments in 

youth interpersonal violence research 

and practice, and hasten translation of 

knowledge into health and community 

practice. Centers actively foster an 

environment conducive to reciprocally 

beneficial collaborations among 

health scientists, social scientists, 

and the affected communities with 

the common goal of reducing youth 

interpersonal violence. The programs 

Academic Institutions

can be viewed at www.cdc.gov/ncipc/

res-opps/ACE/ace.htm.

Injury Control Research Centers

CDC funds 12 Injury Control 

Research Centers (ICRCs) to conduct 

research in three core phases of injury 

control: prevention, acute care, and 

rehabilitation. ICRCs serve as training 

centers and information centers for the 

public. Research design in these centers 

is interdisciplinary and incorporates 

medicine, engineering, epidemiology, 

law, criminal justice, behavioral and 

social sciences, biostatistics, public 

health, and biomechanics. Full 

descriptions of current research and 

education projects conducted by the 

ICRCs may be accessed at www.cdc.

gov/ncipc/profiles/icrcs/default.htm.

Examples of CDC-funded Programs for Injury Prevention and Control
Partners in Prevention 29

CDC works with academic organizations to ensure that 

universities’ curricula and research 

address injury prevention issues. Some 

academic partners follow:

Association of Schools 

of Public Health

CDC’s collaboration with the 

Association of Schools of Public 

Health (ASPH) led to the development 

of critical partnerships between 

ASPH and other injury and violence 

organizations. For example, the Family 

Violence Prevention Fund helps ASPH 

train additional faculty in violence 

prevention. Through a cooperative 

agreement (2001–2003), CDC funded 

ASPH to facilitate opportunities 

for injury and violence prevention 

research, teaching, and practice in 

schools of public health so that public 

Academic Organizations

health students and professionals could 

be more aware of the importance 

of this public health problem. In 

2002–2003, ASPH inventoried the 33 

accredited schools of public health to 

assess each school’s capacity to advance 

the injury and violence prevention 

field. This inventory will be used by 

the schools of public health to help 

bolster their injury and violence 

training and research programs. 

Society for Advancement of 

Violence and Injury Research

SAVIR (formerly the National 

Association of Injury Control Research 

Centers, NAICRC) is dedicated to the 

improvement of injury and violence 

control research in prevention, acute 

care, and rehabilitation programs. 

SAVIR offers its institutional and 

professional members, and those 

they serve, consultation, education, 

training, research dissemination, 

program development, and evaluation. 

SAVIR works to advance the public’s 

understanding of the benefits of injury 

and violence control research. For more 

information, visit www.savirweb.org.

Cross-cutting Partnerships

CDC partners with groups that represent a variety of interests 

and that work for the common goal of 

injury prevention. The following is one 

example.

SafeUSA

SafeUSA, a nonprofit 

organization in 

Washington, D.C., 

is an alliance of public agencies 

(including CDC’s Injury Center) 

and private organizations whose 

programs include research, service, 

training, communications, and policy 

development related to injury and 

violence prevention. Representatives of 

these organizations assemble regularly 

to exchange information and to 

develop strategies that build support 

for injury and violence prevention.
30 Partners in Prevention

Because injuries and violence occur worldwide, not just in 

America, CDC’s injury partners extend 

beyond our nation’s borders. Recent 

collaborations with international 

partners are described below.

Pan American Health Organization

CDC works with the Pan American 

Health Organization (PAHO) on 

the Inter-American Coalition for the 

Prevention of Violence (IACPV), 

which acts as a catalyst for the 

prevention of violence in the Americas. 

PAHO assists CDC to strengthen 

country and municipality capacity in 

injury surveillance and to establish 

policies and integrated programs 

that prevent violence and road traffic 

injuries. PAHO and CDC collaborated 

on a meeting about Road Safety at the 

United States–Mexico Border, working 

with countries in Latin America and 

the Caribbean to develop a set of 

recommendations and action plans. 

World Health Organization

In 2004, CDC worked closely with the 

World Health Organization (WHO) 

on the first World Report on Road Traffic 

Injury Prevention, the official launch of 

World Health Day celebrations “Road 

Safety is No Accident,” and the Injury 

Center’s U.S. campaign “Family Road 

Safety: Protect the Ones You Love.” 

The Injury Center works with WHO’s 

Department of Injury and Violence 

Prevention to develop and implement 

programs and policies on global injury 

and violence prevention. CDC assists 

WHO in surveillance, intervention 

development, training, evaluation, 

and dissemination. In 2002, WHO 

launched the first World Report on 

Violence and Health to raise awareness 

of violence as a global public health 

problem, to facilitate comparisons 

among nations, to summarize existing 

prevention strategies and policies, 

and to recommend future public 

health actions. More than 160 experts 

from around the world, including 

scientists from CDC, helped develop 

the report. Other projects include a 

five-year strategy for road traffic injury 

prevention, TEACH-VIP (a curriculum 

on injury and violence prevention), 

and coalition building to eliminate 

violence against women. 

International Agencies
Injury—A Risk at 

Any Stage of Life

At every age, from our earliest days to our golden 

years, we are at risk for injury and the disability 

and death that can result. No age is a “safe” age 

when it comes to injuries and violence.

But the injuries and threats of violence that we 

face change as we age and enter different life 

stages. Common sense tells us—and research 

confirms—that the risks a toddler faces are not the 

same as the risks a grandmother faces.

CDC tracks and monitors the injuries and 

violence that occur at different life stages and 

examines factors related to those life stages that 

increase or decrease a person’s risk for injury and 

violence. With that information, we can tailor 

prevention programs to the needs, preferences, 

and life circumstances of particular age groups. 

By focusing on life stages, we can also forge 

partnerships that help us more effectively reach 

people in particular age groups.

Following is a brief overview of how injuries affect 

Americans in different age groups and how CDC 

addresses injury prevention and control at each life 

stage.
32 Injury—A Risk at Any Stage of Life

Infants and Toddlers 

(Ages 0–3)

n Nearly 3,100 children ages 3 and 

under died in 2002 from injuries 

(CDC 2004).

n For children under 1 year old, the 

leading cause of injury death is 

unintentional suffocation due to 

choking or strangulation (CDC 

2004). 

n Motor vehicle crashes are the leading 

cause of death for children ages 1 to 

3 (CDC 2004). In 2003, one third 

of the children ages 4 and younger 

who died in motor vehicle crashes 

were riding unrestrained (NHTSA 

2005).

n Children in this age group are at 

high risk for sustaining a traumatic 

brain injury (CDC 2004).

n Drowning is the second leading 

cause of injury death for children 

in this age group (CDC 2004). 

Children under age 1 most often 

drown in bathtubs, buckets, or 

toilets whereas toddlers most often 

drown in residential swimming pools 

(Brenner et al. 2001). 

n In 2003, more than 1.8 million 

children under age 4 were nonfatally 

injured, and falls were the leading 

cause (CDC 2004). 

n Child maltreatment by blunt trauma 

to the head or by violent shaking 

is a leading cause of head injury 

among infants and young children 

(Committee on Child Abuse and 

Neglect 2001). 

Infants and young children are at 

greater risk for many injuries. This 

increased risk may be attributable to 

many factors. Children are curious 

and like to explore their environment. 

This characteristic may lead children 

to sample the pills in the medicine 

cabinet, play with matches, or venture 

into the family pool. Young children 

have limited physical coordination 

and cognitive abilities. This can lead 

to a greater risk for falls from bicycles 

and playground equipment and 

make it difficult for them to escape 

from a fire. And their small size and 

developing bones and muscles may 

make them more susceptible to injury 

in car crashes if they are not properly 

restrained.

Because babies and young children 

are so dependent on others and often 

cannot express themselves well verbally, 

they may be at higher risk for abuse 

or neglect. A baby or toddler who 

experiences abuse cannot tell someone 

about it, so the abuse may continue. 

And because of their small size, they 

can be seriously injured if hit, pushed, 

or shaken by an adult.

CDC is involved in many efforts to 

keep America’s youngest children safe. 

The Injury Center supports programs 

to increase child safety seat use, prevent 

injuries related to residential fires, and 

prevent child maltreatment. Injury 

Center staff also works with partners to 

explore the roles that supervision and 

parenting play in preventing injuries.

Children (Ages 4–11)

n In 2002, nearly 2,300 children ages 

4 to 11 died from injuries (CDC 

2004). 

n Motor vehicle injuries are the 

leading cause of death for this age 

group (CDC 2004).

n For children 4 to 7 years, beltpositioning booster seats reduce 

injury risk by 59% compared with 

seat belts alone (Durbin et al. 2001). 

Although restrained, only 37% ride 

in age-appropriate belt-positioning 

booster seats (Cody et al. 2002). 

n Drowning is the second leading 

cause of injury-related death among 

children ages 4 to 11 (CDC 2004).

n In 2003, almost one quarter 

(23%) of children ages 5 to 9 who 

were killed in traffic crashes were 

pedestrians (NHTSA 2004a). 

n Among children ages 4 to 11, 

homicide is the fourth leading cause 

of death, taking the lives of 250 

children in 2002. 

n Forty-two percent of homicide 

deaths in this age group were caused 

by firearms (CDC 2004).

n Nearly 3.2 million children ages 

4 to 11 were nonfatally injured in 

2003. Unintentional falls were the 

most common cause of injury (CDC 

2004).

Injury—A Risk at Any Stage of Life
Injury—A Risk at Any Stage of Life 33

CDC’s Injury Center staff is working 

to prevent injuries among this group 

by increasing the use of booster seats, 

encouraging parents to have their 

children ride in the back seat of motor 

vehicles, and promoting pedestrian 

safety. CDC is looking into the 

risk factors for child maltreatment, 

including child sexual abuse, and also 

is exploring prevention programs for 

child maltreatment.

Adolescents (Ages 12–19)

n Nearly 4.7 million adolescents were 

nonfatally injured in 2003; nearly 

12,200 died from injuries in 2002 

(CDC 2004).

n Motor vehicle crashes are the leading 

cause of death for adolescents ages 

12 to 19 (CDC 2004). 

n The risk for motor vehicle crashes 

is higher among 16- to 19-year-olds 

than in any other age group. Per 

mile driven, drivers in this age group 

are four times more likely than older 

drivers to crash (IIHS 2004).

n More than 18% of high school 

students in a 2003 survey reported 

rarely or never wearing seat belts; 

12% reported drinking and driving; 

and 30% reported riding with 

a drinking driver in the month 

preceding the survey (Grunbaum 

et al. 2004).

n Traumatic brain injuries among this 

age group account for more than 

240,000 emergency room visits, 36,000 

hospitalizations, and more than 5,700 

deaths each year (CDC 2004).

n Nearly 63,000 sports-related concussions 

occur annually in high school sports 

(Powell and Barber-Foss 1999).

n Homicide is the second and suicide 

is the third leading cause of death 

in this age group. Most homicides 

and about half of suicides involve a 

firearm (CDC 2004).

n In a 2003 survey, nearly 13% of 

high school students had been in 

a physical fight on school property 

at least once in the preceding year. 

More than 6% had carried a weapon 

at school in the month preceding the 

survey (Grunbaum et al. 2004). 

n Adolescents 10 to 14 years of age have 

the highest rates of sports- and recreationrelated injury (Gotsch et al. 2002).

CDC supports many programs to reduce 

injuries and violence among adolescents 

and teens. CDC now supports several 

activities to evaluate the effectiveness of 

graduated driver licensing (GDL) programs 

and to examine how parental actions affect 

teen driving behavior. Activities include 

implementation in driver’s education classes 

of the Checkpoints Program, developed 

by the National Institutes of Health to 

improve parental management of the 

learning-to-drive process; implementation 

and evaluation of two community-based 

interventions on enforcement and social 

normative programs to improve adherence 

to GDL systems; and support of the 

Council of State Governments’ efforts to 

enhance state legislators’ knowledge about 

teen driver safety issues and help strengthen 

their relationships with one another, CDC, 

and other federal and state agencies. CDC 

is also developing a communications 

campaign to improve the safety of teen

drivers, their passengers, and other 

road users. Recently, CDC developed 

a tool kit to educate coaches and athletes 

about sports-related concussions. CDC

supports several projects now underway 

to identify and address risk factors 

for youth suicide and interpersonal 

violence, including research that 

examines links between different types 

of violence and explores the role of 

violent media on violent behavior.

Adults (Ages 20–49)

n More than 79,500 adults ages 20 

to 49 died from injuries in 2002. 

Motor vehicle crashes were the 

leading cause of those deaths (CDC 

2004). 

n Suicide and homicide ranked as the 

fourth and fifth leading causes of 

death, respectively, among this age 

group. As with adolescents, about 

half of suicides and most homicides 

involved a firearm (CDC 2004).

n In 2003, nearly 13.6 million adults 

ages 20 to 49 were nonfatally injured 

(CDC 2004). 

n The most common cause of nonfatal 

injury was falls (17%), followed by 

overexertion (15%) (CDC 2004).

Many of CDC’s injury and violence 

prevention efforts address injuries 

among this group. For example, 

programs to prevent intimate partner 

violence, reduce alcohol-impaired 

driving, increase smoke alarm use, and 

improve trauma care systems all benefit 

this age group. 
34 Injury—A Risk at Any Stage of Life

Older Adults (50 and older)

n In 2002, nearly 64,000 adults ages 

50 and older died as a result of 

injuries (CDC 2004).

n Falls were the most common cause 

of injury death in this age group, 

accounting for more than 14,000 

deaths in 2002 (CDC 2004). 

n Falls are the most common cause of 

nonfatal injuries in this age group. In 

2003, 2.7 million older adults were 

injured from falls, comprising 46% 

of all nonfatal injuries in this group.

n Drivers ages 65 and older have 

higher crash death rates per mile 

driven than all but teen drivers 

(NHTSA 2004b). 

n People ages 75 years and older have 

the highest rates of traumatic brain 

injury-related hospitalization and 

death (CDC 2004).

n In 2002, more than 12,000 

Americans ages 50 and older died 

from suicide (CDC 2004).

Several CDC activities address the 

problem of injury among older 

Americans. These include a fire and 

fall prevention program for older 

adults and a study which examines 

reasons why older drivers decide to 

stop driving. Additionally, CDC 

is developing a research agenda to 

prevent older adult maltreatment 

and is funding research on ways to 

improve acute injury care among this 

population.

References

Brenner RA, Trumble AC, Smith GS, 

Kessler EP, Overpeck MD. Where children 

drown, United States, 1995. Pediatrics

2001;108(1):85–89.

Centers for Disease Control and 

Prevention, National Center for Injury 

Prevention and Control. Web-based Injury 

Statistics Query and Reporting System 

(WISQARS) [online]. (2004) [cited 2005 

Feb 28]. Available from: URL: 

www.cdc.gov/ncipc/wisqars. 

Cody BE, Mickalide AD, Paul HP, 

Coleila JM. Child Passengers at Risk in 

America: A national study of restraint use. 

Washington (DC): Matopma; SAFE KIDS 

campaign, February 2002.

Committee on Child Abuse and Neglect. 

Shaken-baby syndrome: rotational 

cranial injuries technical report. Pediatrics

2001;108:206–210.

Durbin DR, Kallan NJ, Winston FK. 

Trends in booster seat use among young 

children in crashes. Pediatrics 2001;108(6):

E109. 

Gotsch K, Annest JL, Holmgreen P, 

Gilchrist J. Non-fatal sports and recreationrelated injuries treated in emergency 

departments—United States, July 2000–

June 2001. Morbidity and Mortality Weekly 

Report 2002;51(33):736–740.

Grunbaum JA, Kann L, Kinchen S, Ross 

JG, Lowry R, Harris WA, et al. Youth 

risk behavior surveillance—United States, 

2003. Morbidity and Mortality Weekly 

Report 2004;53(SS-2):1–100. Available 

from: URL: www.cdc.gov/mmwr/preview/

mmwrhtml/ss5302a1.htm.

Insurance Institute for Highway Safety 

(IIHS). Fatality Facts: Teenagers 2002. 

Arlington (VA): The Institute; 2004.

National Highway Traffic Safety 

Administration (NHTSA), Department 

of Transportation (US). Traffic Safety Facts 

2003: Pedestrians. Washington (DC): 

NHTSA; 2004a. [cited 2005 Feb 23]. 

Available from: URL: www-nrd.nhtsa.dot.

gov/pdf/nrd-30/NCSA/TSF2003/809769.

pdf. 

———. Traffic Safety Facts 2003: Older 

Population. Washington (DC): NHTSA; 

2004b. [cited 2005 Feb 23]. Available 

from: URL: www-nrd.nhtsa.dot.gov/pdf/

nrd-30NCSA/TSF2003/809766.pdf. 

———. Traffic Safety Facts 2003. 

Washington (DC): NHTSA; 2005. [cited 

4 Mar 2005]. Available from: URL: wwwnrd.nhtsa.dot.gov/pdf/nrd-30/NCSA/

TSFAnn/2003HTMLTSF/TSF2003.htm.

Powell JW, Barber-Foss KD. Traumatic 

brain injury in high school athletes. Journal 

of the American Medical Association 1999; 

282(10):958–963.
The problem of injury in America is complex. 

Many types of injury exist—both unintentional 

and violence-related. For each type of injury, 

CDC’s Injury Center has a key role in translating 

research into effective prevention strategies.

This part of the CDC Injury Fact Book contains 

detailed information about a range of injuries, 

from acute injury care to youth violence. Each 

section includes data that describe the extent of 

the injury problem, provide an overview of CDC’s 

accomplishments in research and prevention 

efforts, and present future steps the Injury Center 

and its partners must take to reduce injuries and 

resulting deaths and disabilities.

Preventing Injuries in 

America: Public Health 

in Action
36 Preventing Injuries in America: Public Health in Action 

The Problem

Injuries have physical, emotional, and 

financial consequences that can impact 

the lives of individuals, families, and 

society. Some injuries can result in 

temporary or long-term disability. 

Injuries also place an enormous burden 

on emergency departments (EDs) and 

trauma care systems. 

n In 2002, there were 110.2 million 

visits to EDs in the United States, 

representing a 23% increase from 

the 89.8 million ED visits in 

1992. During the same period, the 

number of EDs in the United States 

decreased by about 15% (McCaig 

and Burt 2004).

n The overall rate of ED use in 2002 

was 38.9 visits per 100 persons 

(McCaig and Burt 2004).

n In 2002, fewer than 1 of every 

100 ED visits required immediate 

attention (McCaig and Burt 2004).

n Falls, being struck, or striking 

against something or someone, and 

motor vehicle traffic crashes were 

the leading causes of injuries seen in 

EDs, accounting for about 40% of 

ED visits (McCaig and Burt 2004). 

CDC’s Accomplishments

CDC Acute Injury Care 

Research Agenda

In 2003, CDC’s Injury Center reviewed 

its current CDC Injury Research Agenda 

chapter on acute care, disability, and 

rehabilitation. Of the thirteen priority 

areas for research, only three areas 

addressed acute injury care, and none 

dealt with acute injury care in the 

context of terrorism preparedness and 

response. Recognizing these gaps, the 

Injury Center and its partners revised 

the CDC Injury Research Agenda’s 

chapter about acute injury care. This 

two-year revision process engaged 

experts from the continuum of injury 

care and public health. The Acute Injury 

Care Research Agenda was released at the 

2005 National Injury Prevention and 

Control Conference. Representatives 

of government agencies and national 

organizations involved in acute injury 

care have already begun to identify 

available resources to fully implement 

the revised research agenda.

Revision of field triage criteria

CDC convened several meetings 

of emergency care professionals to 

discuss the status, direction, and next 

steps for standardizing care of acutely 

injured people. Participants, including 

emergency physicians, first responders, 

and other emergency service providers, 

Acute Injury Care and Treatment

agreed to revise the 20-year-old 

national field triage guidelines. The 

group also will help develop a tool kit 

to serve as an information resource for 

emergency medical service providers. 

Prehospital care 

around the world

In 2004, prior to the 7th Annual 

World Injury Conference, CDC 

convened a meeting in Vienna, Austria, 

of individuals and organizations 

active in providing prehospital care 

to discuss its role in the developing 

world. Participants reviewed current 

evidence, examined affordable and 

effective prehospital interventions, 

established research priorities, and 

discussed the role of prehospital care 

in the larger health system. They 

also identified future initiatives and 

directions for the development of 

prehospital care systems in low-income 

countries. In 2005, the World Health 

Organization published a report and 

recommendations from this meeting, 

representing more than five years work 

in worldwide prehospital care. 

National Trauma Data Bank, 

National Sample Project

In 2004, CDC supported the American 

College of Surgeons (ACS) to develop a 

nationally-representative sample of U.S. 

trauma centers that provides data on 

treated trauma patients. This National 

Sample Project (NSP) will enhance 

the ACS’s National Trauma Data Bank 

(NTDB) by providing data to meet the 

broad range of trauma care assessment, 

clinical outcomes research, and injury 

surveillance needs. The NTDB is 

the largest compilation of traumatic 

injury data ever assembled, with farreaching implications for areas such as 

epidemiology, injury control, research, 

education, acute care, and resource 

allocation. Using a representative 

sample of 100 hospital trauma centers, 

NSP researchers can make statistically 

valid inferences about patient care in 

Level 1 and 2 trauma centers in the 

United States. 

Atrauma care system is an organized effort, coordinated by a state or local agency, to deliver the full spectrum of care (from acute injury care 

to rehabilitation) to injured persons in a defined geographic area. 

Such a system requires specially trained practitioners and adequate 

resources, equipment, and support personnel. 

Our nation’s trauma care systems are in various stages of development, 

implementation, and evaluation (American College of Emergency Physicians 

1999). Although 80% of Americans can access a trauma center within an 

hour, about 46.7 million Americans cannot (Branas et al. 2005). Some areas 

lack adequate trauma care—despite evidence that trauma care reduces 

death and disability rates (Bass et al. 1999).
Preventing Injuries in America: Public Health in Action 37

Conference to discuss 

alcohol and drug 

problems among trauma 

patients

In 2003, CDC convened 

a conference entitled 

“Alcohol and Other 

Drug Problems Among 

Hospitalized Trauma 

Patients: Controlling 

Complications, Mortality, 

and Trauma Recidivism.” 

The goal of this conference 

was to develop a set 

of research and policy 

recommendations to 

improve clinical 

alcohol and drug 

prevention and 

intervention services 

for trauma patients. 

Participants 

included 

government 

representatives, 

trauma surgeons, 

and substanceabuse treatment 

researchers. Conference proceedings 

include recommendations, papers, 

and detailed summaries of discussion 

sessions. The proceedings were 

published as a special supplement to 

the Journal of Trauma in December 

2005.

Beginning in fall 2006 and, in part, 

because of these recommendations, 

the American College of Surgeons 

Committee on Trauma (ACS-COT) 

will require Levels 1 and 2 trauma 

centers to have a mechanism to identify 

patients who are problem drinkers. 

Level 1 centers must also have the 

capability to provide an intervention 

for patients identified as problem 

drinkers. This requirement will be 

included in the revised 2006 version of 

Resources for Optimal Care of the Injured 

Patient, published by the ACS-COT.

Research and literature on 

alcohol and drug problems 

among college students

CDC-authored research was 

published in the Journal of 

American College Health’s article 

“Screening and Brief Intervention 

for Alcohol Problems Among College 

Students Treated in a University 

Hospital Emergency Department.”

This research suggests that EDs can 

serve as appropriate venues in which to 

screen patients for alcohol problems.

CDC-funded research grants

CDC provides grant funding to 

researchers at universities, medical 

institutions, and community-based 

organizations to study various factors 

related to acute injury care. Examples 

of extramural research projects follow. 

For more information about these and 

other projects, visit www.cdc.gov/ncipc/

res-opps/extra.htm. 

n Brief interventions in the ED to 

reduce risky driving. University of 

Cincinnati researchers are testing 

the effectiveness of administering 

screening and brief intervention in 

the ED to limit drivers’ problem 

drinking and risky driving behaviors 

(i.e., lack of seat belt use). This 

prospective, randomized controlled 

trial will result in a cost-benefit 

analysis from the perspectives 

of society overall and hospitals 

specifically.

n Health-related quality of life 

in trauma. The Johns Hopkins 

Bloomberg School of Public 

Health examined approaches 

for incorporating deaths into an 

analysis of trauma outcomes. The 

resulting approaches can be used 

to estimate the burden of injury in 

years of healthy life lost. The chief 

aim of the study was to develop a 

method for calculating populationbased estimates of the burden of 

major trauma overall and for specific 

subgroups of people who sustain 

traumatic injuries (i.e., traumatic 

brain injury, motor vehicle-related 

trauma). This research was published 

in a 2003 Epidemiologic Review

article titled “Measuring the Public 

Health Impact of Injuries.” The study 

supplements the ongoing National 

Study on the Costs and Outcomes 

of Trauma Care (NSCOT), which 

compares the costs and outcomes of 

care provided in hospitals with and 

without trauma centers. 

n Outcomes of elderly patients 

hospitalized with injuries. Rates 

of mortality from injury increase 

with age, and older adults constitute 

a disproportionate fraction of 

patients hospitalized with injuries. 

Researchers at Harvard University’s 

School of Public Health are 

examining measures to ensure 

quality care for this increasingly large 

segment of the population. Using 

Medicare data, researchers will study 

how factors such as patient’s age and 

sex, region of the country, hospital 

volume, and physician experience 

may affect quality of care. Findings 

may help improve or standardize 

care for patients of all ages, and 

particularly older adults.
38 Preventing Injuries in America: Public Health in Action 

Future Steps

During the next several years, CDC 

will focus on three overarching goals to 

improve acute injury care: 

n Enhance the medical and public 

health systems’ ability to reduce 

morbidity, mortality, and disabilities 

among people injured in a mass 

casualty event. 

n Increase the survival and improve 

the quality of life for injured people 

through advances in emergency medical 

response systems and injury care.

n Enhance the ability of state health 

departments to monitor injuries and 

to develop and implement injury 

prevention programs.

CDC will accomplish these goals by 

completing new and existing initiatives 

such as those listed below. 

Continued development of a 

national resource for 

trauma care data

CDC will continue working with the 

American Trauma Society to enhance 

the Trauma Information and Exchange 

Program (TIEP) as a national resource 

for trauma center and trauma system 

information. This effort involves 

maintaining and expanding inventory 

data and the scope of these data. 

Surveys will continue to be distributed 

among trauma centers and systems 

affiliated with TIEP to identify key 

issues in trauma care and to provide 

meaningful feedback on how TIEP 

can better serve agencies within its 

network. TIEP has also developed 

measures of access to trauma care, 

using these measures to assess the 

availability of trauma care across 

the country and to identify gaps in 

coverage. Ongoing evaluation and 

maintenance enable TIEP to provide 

current information to policy makers, 

the trauma community, and the public 

about the status, contributions, and 

needs of trauma care systems.

Insurance laws and 

substance abuse screening

CDC is collaborating with four 

other federal agencies to evaluate the 

impact of insurance laws on screening 

and interventions for substance-use 

problems among acute injury care 

patients. This project will examine the 

impact that current state insurance 

laws have on the detection and 

treatment of acute injury care patients 

with substance-use problems; identify 

and evaluate barriers to improving the 

standard of care for acute injury care 

patients with substance-use problems; 

and explore alternate legal, policy, and 

economic scenarios to pave the way for 

improved practice. 

Interface between emergency 

medical system and public health 

professionals

Emergency service providers and 

public health professionals share a 

mutual commitment to saving lives, 

although strategies to achieve this 

goal are fundamentally different. 

Discussions between emergency service 

providers and public health workers 

have revealed that the two disciplines 

are not mutually exclusive. Because 

each discipline can benefit by using the 

relevant knowledge and practices of the 

other, CDC supported the American 

Public Health Association (APHA) 

in 2004 to develop a curriculum 

outline on the interface between the 

emergency medical system and public 

health. The outline is being developed 

into a full curriculum that identifies 

opportunities and methods to integrate 

public health and emergency service 

practices that will enhance day-to-day 

operations and increase readiness in 

disaster situations. 

Interventions that address 

acute injury care

CDC is funding three extramural 

research grants that address priorities 

in the Acute Injury Care Research 

Agenda: Guiding Research for the 

Future. The grants include a study on a 

randomized effectiveness trial to reduce 

the impact of acute pediatric injury; 

a patient-centered study to improve 

trauma outcomes; and a prospective, 

multicenter, observational study of 

children with blunt abdominal trauma.

References

American College of Emergency 

Physicians. American College of 

Emergency Physicians Board of Directors 

policy statement: trauma care systems 

development, evaluation and funding. 

Journal of Trauma-Injury Infection & 

Critical Care 1999;47(3):S110.

Bass R, Gainer PS, Carlini AR. An update 

on trauma system development in the 

United States. Journal of Trauma 1999;47:

S15–S21.

Branas CC, MacKenzie EJ, Williams JC, 

Schwab CW, Teter HM, Flanigan MC, et 

al. Access to trauma centers in the United 

States. Journal of the American Medical 

Association 2005;293:2626–2633. 

McCaig LF, Burt CW. National hospital 

ambulatory medical care survey: 2002 

emergency department summary. Advance 

Data from Vital and Health Statistics

2004;340:2.
Preventing Injuries in America: Public Health in Action 39

The Problem

An alcohol-related motor vehicle crash 

kills someone every 31 minutes and 

nonfatally injures someone every 2 

minutes (NHTSA 2004).

n In 2003, 17,013 people died in 

alcohol-related motor vehicle 

crashes, representing 40% of the 

year’s total traffic deaths (NHTSA 

2004).

n More than 1.4 million drivers were 

arrested in 2001 for driving under 

the influence of alcohol or narcotics 

(DOJ 2002). This number is slightly 

more than 1% of the estimated 120 

million or more episodes of impaired 

driving that occur among U.S. adults 

each year (Dellinger, Bolen, and 

Sacks 1999; Liu et al. 1997).

n About 3 in 10 Americans are 

involved in an alcohol-related crash 

in their lifetimes (NHTSA 2001).

n After more than a decade of 

declining rates in alcohol-related 

fatal crashes in the United States, 

rates have begun to climb. Since 

1999, rates have increased between 

4% and 10% for all age groups, 

except ages 16 to 17 years (Elder 

and Shults 2002).

n Each year, alcohol-related motor 

vehicle crashes in the United States 

cost approximately $51 billion 

(Blincoe et al. 2002).

CDC’s Accomplishments

State DUI prevention activities to 

reduce alcohol-impaired driving

CDC scientists found that in states 

actively working to prevent DUI, 

fewer drivers report drinking and 

driving. The researchers examined 

the association between states’ grades 

on the 1999 Mothers Against Drunk 

Driving (MADD) Rating the States 

survey, which graded states on their 

DUI countermeasures from 1996 to 

1999, and on 1997 Behavioral Risk 

Factor Surveillance System (BRFSS) 

data on residents’ self-reported 

drinking and driving. They found that 

residents of states with a MADD grade 

of “D” were 60% more likely to report 

alcohol-impaired driving than were 

residents from states with a MADD 

grade of “A.”

Identifying effective interventions 

against alcohol-impaired driving

In systematic reviews of published 

research studies, a team of researchers 

led by CDC found strong evidence 

for the effectiveness of 0.08% blood 

alcohol concentration (BAC) laws, 

minimum legal drinking age laws, 

sobriety checkpoints, and mass 

media campaigns that meet certain 

conditions (i.e., careful audience 

research, adequate audience exposure, 

and presence of other alcohol-impaired 

driving prevention activities). They 

also found sufficient evidence of the 

effectiveness for lower BAC laws for 

young or inexperienced drivers (zero 

tolerance laws), and intervention 

training programs for alcohol servers. 

Finally, they found sufficient evidence 

that school-based education programs 

decrease riding with alcohol-impaired 

drivers (though there was insufficient 

evidence about the effects on alcoholimpaired driving). These interventions 

Alcohol-related Motor Vehicle Injuries

were effective in reducing fatal and 

nonfatal, alcohol-related motor vehicle 

crashes. These reviews, published in 

The Guide to Community Preventive 

Services in 2005, are available online. 

Please visit www.thecommunityguide.org. 

Mass media campaigns to reduce 

alcohol-related crashes

Under certain conditions, mass media 

campaigns are effective in preventing 

alcohol-impaired driving, according to 

a CDC report published in July 2004 

in the American Journal of Preventive 

Medicine. Based on these findings, the 

Task Force on Community Preventive 

Services—a 15-member, nonfederal 

group with expertise in public health 

policy and behavioral and social 

sciences—issued a recommendation 

for mass media campaigns that are 

carefully planned and well executed, 

attain adequate audience exposure, and 

are implemented in conjunction with 

other ongoing alcohol-impaired driving 

prevention activities. The systematic 

review found that under these 

conditions, mass media campaigns 

generally reduced alcohol-related 

crashes by about 14%. Economic 

analyses indicated that such campaigns 

also result in societal benefits that 

exceed their costs.
Protecting children from 

drinking drivers

CDC’s research found that about 68% 

of the children killed in alcohol-related 

crashes were riding in cars driven 

by drinking drivers. After these data 

were released, legislators in several 

states introduced bills to help protect 

children from drinking drivers. Such 

legislation creates special penalties 

under state child abuse laws for people 

who transport children while driving 

drunk. 

Future Steps

Based on data from the National 

Highway Traffic Safety Administration 

and the U.S. Census Bureau, the rate 

of fatalities in alcohol-related motor 

vehicle crashes decreased 13% from 

1993 to 2002, from 6.9 to 6.0 per 

100,000 persons. However, this rate 

will need to decline substantially 

to meet the Healthy People 2010 

objective of 4.0 per 100,000 persons. 

Additionally, while alcohol-related fatal 

crash rates have decreased over the 

past two decades by 60% for drivers 

Just the Facts . . . 

Children and Drinking 

Drivers

A CDC study of traffic crashes 

from 1997 to 2002 found that 

approximately 390 children 

ages 14 years and younger died 

each of those years in alcoholrelated crashes in the United 

States. More than two thirds of 

the children killed were riding 

with the drinking driver at the 

time of the crash. The study 

also found that child passenger 

restraint use decreased as the 

blood alcohol concentration of the 

child’s driver increased. In cases 

where restraint use was recorded, 

only 32% of fatally injured child 

passengers of drinking drivers 

were restrained at the time of the 

crash (Shults 2004). 

ages 16 to 17 and by 55% for drivers 

ages 18 to 20, progress has stalled in 

the past few years. To further decrease 

fatal alcohol-related crashes among 

young drivers, communities need to 

implement and enforce strategies that 

are known to be effective, such as 

minimum legal drinking age laws and 

“zero tolerance” laws for drivers under 

21 years of age. 

CDC is involved in the following 

activities to help reduce alcohol-related 

motor vehicle crashes among drivers of 

all ages.

Guide to Community 

Preventive Services

In addition to evaluating and 

sharing information about what

works to prevent impaired driving, 

CDC must support communities in 

implementing proven interventions. 

Efforts are currently underway to link 

recommendations in the Community 

Guide with detailed information about 

how to implement them and to provide 

examples of model programs when 

possible.

40 Preventing Injuries in America: Public Health in Action
Preventing Injuries in America: Public Health in Action 41

Cooperative agreements with 

Native American tribes

To help address the serious problems 

with motor vehicle-related injuries 

and fatalities in Native American 

communities, the Injury Center has 

funded four tribes to implement 

recommended interventions from 

the Community Guide. Two of 

the communities will implement 

recommended interventions to prevent 

alcohol-impaired driving. With the 

assistance of Injury Center staff, our 

partners will adapt these interventions 

and evaluate their effectiveness in tribal 

communities.

References

Blincoe L, Seay A, Zaloshnja E, Miller T, 

Romano E, Luchter S, et al. The 

Economic Impact of Motor Vehicle Crashes, 

2000. Washington (DC): National 

Highway Traffic Safety Administration, 

Department of Transportation (US); 

2002. Available from: URL: www.nhtsa.

dot.gov/people/economic/econimpact2000/

index.htm.

Dellinger AM, Bolen J, Sacks JJ. A 

comparison of driver- and passenger-based 

estimates of alcohol-impaired driving. 

American Journal of Preventive Medicine

1999;16(4):283–288. 

Department of Justice (US), Federal Bureau 

of Investigation. Crime in the United States 

2001. Uniform Crime Reports. Washington 

(DC): Government Printing Office; 2002. 

Available from: URL: www.fbi.gov/ucr/

cius_01/01crime.pdf.

Elder RW, Shults RA. Trends in alcohol 

involvement in fatal motor vehicle crashes 

among young drivers—1982–2001. 

Morbidity and Mortality Weekly Report

2002;51:1089–1091.

Liu S, Siegel PZ, Brewer RD, Mokdad AH, 

Sleet DA, Serdula M. Prevalence of alcoholimpaired driving: results from a national 

self-reported survey of health behaviors. 

JAMA 1997;277(2):122–125.

National Highway Traffic Safety 

Administration (NHTSA), Department 

of Transportation (US). Traffic Safety Facts 

2003. Washington (DC): NHTSA; 2004 

[cited 2005 Feb 14]. Available from: URL: 

www-nrd.nhtsa.dot.gov/pdf/nrd-30/NCSA/

TSFAnn/2003HTMLTSF/tbl13.htm.

———. Traffic Safety Facts 2000: Alcohol. 

Washington (DC): NHTSA; 2001 [cited 

2004 Aug 9]. Available from: URL: wwwnrd.nhtsa.dot.gov/pdf/nrd-30/NCSA/

TSF2000/2000alcfacts.pdf.

Shults RA. Child passenger deaths 

involving drinking drivers—United States, 

1997–2002 [published erratum appears 

in Morbidity and Mortality Weekly Report

2004;53(5):109]. Morbidity and Mortality 

Weekly Report 2004;53(4):77–79.
42 Preventing Injuries in America: Public Health in Action 

The Problem

n The true number of children who 

are victims of child maltreatment 

in the United States is unknown. 

Information about child abuse 

and neglect cases that came to the 

attention of Child Protective Services 

(CPS) agencies in 2002 indicates that: 

• Nearly 900,000 

children were 

confirmed to be 

victims of child abuse 

or neglect (ACF 2004).

• More than 60% of 

these victims suffered 

neglect (including 

medical neglect); 

almost 20% were 

physically abused; 

10% were sexually 

abused; and 7% 

were emotionally or 

psychologically abused 

(ACF 2004). 

• An estimated 1,400 

children died from 

maltreatment. One 

third of these deaths 

were from neglect. 

Physical and sexual 

abuse were also 

major contributors to 

fatalities (ACF 2004).

n Infants are at greatest risk of homicide 

during the first week of infancy, with 

the risk being highest on the first day 

of life (Paulozzi 2002).

n Child maltreatment through blunt 

trauma to the head or violent 

shaking is a leading cause of head 

injury among infants and young 

children (Committee on Child 

Abuse and Neglect 2001).

n The perpetrators of child 

maltreatment are most often parents. 

In 2002, one or both parents were 

involved in 79% of child abuse 

or neglect fatalities (National 

Clearinghouse 2004).

n Children who experience 

maltreatment are at increased risk 

for experiencing adverse health 

effects and behaviors as adults, 

including smoking, alcoholism, drug 

abuse, physical inactivity, severe 

obesity, depression, suicide, sexual 

promiscuity, and certain chronic 

diseases (Felitti et al. 1998). 

n Victims of child maltreatment are 

also at increased risk of experiencing 

violence as adults. A national 

survey found that victims who were 

physically assaulted by caregivers 

were twice as likely to be physically 

assaulted as adults (Tjaden and 

Thoennes 2000).

n As many as one third of parents 

who experienced maltreatment in 

childhood may victimize their own 

children (Fromm 2001).

CDC’s Accomplishments

Sociocultural and community risk 

and protective factors for child 

maltreatment and youth violence

CDC is funding researchers at the 

University of Georgia in Athens to 

examine the sociocultural and community 

risk and protective factors associated 

with child maltreatment and early risk 

for youth violence. Previous 

research has described 

the importance of such 

factors as access to social 

capital, community social 

organization, economic and 

family resources, residential 

instability, and community 

and family violence.However, 

limited information exists 

about how these and other risk 

and protective factors might 

affect child maltreatment and 

youth violence. The results 

from this research will inform 

the development of violence 

prevention strategies for 

communities.

Addressing state 

surveillance 

of child maltreatment

Five state health departments 

are implementing mortality 

and morbidity surveillance 

for child maltreatment. California, 

Michigan, Minnesota, Missouri, 

and Rhode Island are comparing 

alternative approaches to state-level 

surveillance for fatal and nonfatal child 

maltreatment and are testing methods 

that may be used for the surveillance 

of violence at all ages. This program 

addresses the pressing need for a 

practical surveillance system for child 

maltreatment that can be implemented 

at the state level. It will also help 

determine the utility of various 

data sources, including data from 

hospitals, Child Protective Services, law 

enforcement, child fatality reviews, and 

medical examiner and coroner reports.

Child Maltreatment
Preventing Injuries in America: Public Health in Action 43

SafeCare program. Project SafeCare 

provides home-based parenting and 

family preservation services to about 

1,000 families in Oklahoma each 

year.

Review of parenting programs

CDC is reviewing the literature on 

the scope and efficacy of programs for 

parents with children from birth to 7 

years of age. These programs provide 

parenting skills that enhance a child’s 

well-being and adjustment. The review 

will identify common and specific 

components of parenting program 

content, mode of program delivery, 

dosage effect, strategies used for 

recruitment and retention, evaluation 

methodology, and results of outcome 

evaluations. When completed, results 

from the review will inform CDC’s 

efforts to develop parenting approaches 

for child maltreatment prevention. 

Parenting program attrition and 

compliance efficacy trial 

Difficulties in engaging and retaining 

parents at risk for child maltreatment 

in prevention programs have been well 

documented. Even the most effective 

parenting programs have limited 

impact on child maltreatment if 

parents do not attend sessions or learn 

and apply alternative parenting skills. 

CDC is funding Purdue University 

in Indiana and the University of 

Oklahoma Health Sciences Center to 

test the role of different enhancements 

or service delivery methods for 

reducing attrition and improving 

emotional and cognitive engagement 

and behavioral compliance in an 

existing efficacious parenting program. 

Researchers are examining the impact 

of the strategies on parental attendance, 

attrition rates, compliance, behavior 

change, parent and child outcomes, 

and incidence of child maltreatment. 

Information about the cost of 

enhancements is being collected for 

later analyses.

Consequences of 

child sexual abuse

Research links child sexual abuse to a 

range of physical, sexual, reproductive, 

and psychological problems. Despite 

this evidence, efforts to prevent 

child sexual abuse are very limited. A 

systematic review of the consequences 

of child sexual abuse is underway to 

summarize findings from the scientific 

literature published since 1975. This 

review will show the links between 

sexual abuse and consequences, discuss 

how health care providers can respond, 

and introduce prevention concepts.

Practices to improve training 

skills of home visitors

CDC is funding the University of 

Colorado Health Sciences Center 

in Denver and the Johns Hopkins 

School of Medicine in Baltimore 

to examine two widely used home 

visiting programs. Home visiting has 

been reported as an effective strategy 

for preventing child maltreatment 

and other adverse child outcomes. 

However, the relative effectiveness 

of home visiting varies widely across 

different programs. Researchers will 

determine the impact of home visitor 

training and implementation factors on 

outcomes of child maltreatment and 

risk behaviors for youth violence.

Intervention for high-risk families

CDC is working on two projects with 

the University of Oklahoma’s Center 

on Child Abuse and Neglect and the 

Oklahoma Department of Human 

Services. Researchers are:

n Evaluating a pilot program serving 

families and children at high risk of 

abuse and neglect, including, but 

not limited to, parents with drugor alcohol-abuse problems, mental 

illness, mental or physical disability, 

or a history of intimate partner 

violence. 

n Conducting a large-scale 

effectiveness trial of the Project 

Developing uniform definitions and 

recommended data elements 

CDC is developing uniform definitions 

and recommended data elements to 

improve and standardize data collected 

for child maltreatment surveillance. 

Without uniform definitions, different 

terms are used to describe acts of child 

maltreatment. These inconsistencies 

contribute to confusion and a lack 

of consensus about the magnitude 

of the problem. Consistent data 

allow researchers to better gauge 

the scope of the problem, identify 

high-risk groups, and monitor the 

effects of prevention programs. CDC 

is working with a diverse group of 

child maltreatment experts and five 

state health departments currently 

funded to conduct child maltreatment 

surveillance to develop uniform 

definitions. The definitions will be 

completed in fall 2006.

National Violent Death 

Reporting System 

State and local agencies have detailed 

information from medical examiners, 

coroners, police, crime labs, and 

death certificates that could answer 

important, fundamental questions 

about trends and patterns of 

violence. However, the information 

is fragmented and difficult to access. 

CDC has funded 17 states to establish 

the National Violent Death Reporting 

System (NVDRS) to gather, share, and 

link state-level data about violence. 

Once implemented, NVDRS will 

enable CDC to compile vital, statelevel information to better understand 

violence. NVDRS will help policy 

makers and community leaders make 

informed decisions about violence 

prevention strategies and programs, 

including those that address violence 

against children. NVDRS will also 

help gather more accurate and indepth information about victims of 

child maltreatment and will establish 

standards for identifying abuse-related 

deaths.
Multilevel parent training 

effectiveness trial

CDC is funding the University 

of South Carolina to examine 

the effectiveness of a multilevel 

intervention program. The Triple 

P–Positive Parenting Program is a 

parenting and family support strategy 

to prevent severe behavioral, emotional, 

and developmental problems among 

children by enhancing parents’ 

knowledge, skills, and confidence. The 

project tests broad strategies aimed 

at preventing and reducing the risk 

of child maltreatment and promotes 

positive parenting to reduce stress and 

child behavior problems. 

Assessment of cultural attitudes 

and beliefs about parenting 

practices

CDC has researched attitudes, 

beliefs, and behaviors among parents 

to identify regional, ethnic, and 

socioeconomic factors that influence 

parenting practices. Information was 

gathered via a literature review; focus 

groups; and individual interviews in 

Hispanic, Asian, African-American, 

Native-American, and Caucasian 

populations. The information gathered 

from this research could be used to 

inform the development of culturally 

appropriate messages for diverse 

audiences.

Collaborations to prevent 

child sexual assault

CDC is funding three state 

organizations—Prevent Child Abuse 

Georgia; Project Pathfinder, Inc., 

in Minnesota; and Massachusetts 

Citizens for Children—to develop and 

implement statewide child sexual abuse 

prevention programs. The programs 

will focus on adult or community 

responsibility in preventing the 

perpetration of child sexual assault. 

The funding supports projects using 

existing infrastructures to broaden 

prevention efforts.

Just the Facts . . .

Child Maltreatment

The Child Abuse Prevention and 

Treatment Act identifies four major 

types of maltreatment: physical 

abuse, neglect, sexual abuse, and 

emotional abuse. 

n Physical abuse is to inflict a 

nonaccidental physical injury 

upon a child. This may include 

burning, hitting, punching, 

shaking, kicking, beating, or 

otherwise harming a child. 

n Neglect is the failure to provide 

for a child’s basic needs. Neglect 

can be physical or emotional.

n Sexual abuse is inappropriate 

adolescent or adult sexual 

behavior with a child.

n Other types of child abuse and 

neglect include emotional abuse 

and verbal abuse.

Preventing Violence Through 

Education, Networking, and 

Technical Assistance 

CDC is funding the University of North 

Carolina Injury Prevention Research 

Center to develop a national training 

program for violence prevention 

practitioners. PREVENT (Preventing 

Violence through Education, 

Networking, and Technical Assistance) 

is an outgrowth of the National Injury 

and Violence Prevention Training 

Initiative. It is supported by the Society 

for Advancement of Violence and 

Injury Research (formerly the National 

Association of Injury Control Research 

Centers) and the State and Territorial 

Injury Prevention Directors Association. 

PREVENT helps individuals and 

organizations build skills in identifying 

community needs and assets, creating 

and mobilizing partnerships, developing 

and implementing prevention programs, 

measuring success, and funding 

and sustaining programs. A variety 

of educational methods are used, 

including distance-learning modules, 

regional workshops, an intensive 

institute, action learning projects, and 

coaching.

BECAUSE Kids Count! 

(Building and Enhancing 

Community Alliances United for 

Safety and Empowerment)

CDC’s BECAUSE Kids Count! 

program expands the capacity of 

national organizations and their 

state, local, and regional affiliates to 

effectively address the prevention of 

child maltreatment. CDC is funding 

the National Alliance of Children’s 

Trust and Prevention Funds, Parents 

Anonymous, and Prevent Child Abuse 

America to expand their leadership 

roles in addressing the prevention of 

child maltreatment before it occurs; to 

foster collaborations that respond to 

emerging policy and program issues; 

to conduct assessments to determine 

organizational readiness; and to 

develop a plan to guide prevention 

activities. 

44 Preventing Injuries in America: Public Health in Action
Preventing Injuries in America: Public Health in Action 45

Many communities have implemented 

programs to prevent child maltreatment, 

but few programs have been evaluated 

for effectiveness. CDC’s Injury Center is 

systematically reviewing these programs 

and creating a database of those that work. 

The database will include information 

about target populations, location, 

activities, evaluation methods, outcomes, 

and other details to help communities 

replicate successful programs.

References

Administration for Children and Families 

(ACF), Department of Health and Human 

Services. Child Maltreatment 2002. 

Washington (DC): Government Printing 

Office; 2004. [cited 2004 Aug 3]. Available 

from: URL: www.acf.hhs.gov/programs/cb/

publications/cm02/summary.htm. 

Committee on Child Abuse and Neglect. 

Shaken-baby syndrome: rotational 

cranial injuries technical report. Pediatrics

2001;108:206–210.

Felitti V, Anda R, Nordenberg D, 

Williamson D, Spitz A, Edwards V, 

et al. Relationship of childhood abuse 

and household dysfunction to many of 

the leading causes of death in adults. 

American Journal of Preventive Medicine

1998;14(4):245–258.

Fromm S. Total estimated cost of child abuse 

and neglect in the United States—statistical 

evidence. Chicago (IL): Prevent Child 

Abuse America (PCAA); 2001. [cited 

2005 Jan 1]. Available from: URL: www.

preventchildabuse.org/learn_more/

research_docs/cost_analysis.pdf.

National Clearinghouse on Child Abuse 

and Neglect. Child Abuse and Neglect 

Fatalities: Statistics and Interventions 2004

[cited 2004 Aug 3]. Available from: URL: 

http://nccanch.acf.hhs.gov/pubs/factsheets/

fatality.cfm.

Paulozzi LJ, Sells M. Variation in homicide 

risk during infancy—United States, 

1989–1998. Morbidity and Mortality Weekly 

Report 2002;51(9):187–189.

Tjaden P, Thoennes N. Full Report of the 

Prevalence, Incidence, and Consequences of 

Violence Against Women: Findings from the 

National Violence Against Women Survey. 

Washington (DC): National Institute 

of Justice; 2000 Nov. Report No.: NCJ 

183721.

Enhancing State Capacity to 

Address Child and Adolescent 

Health Through Violence Prevention 

CDC’s ESCAPe program is designed 

to develop capacity and leadership in 

preventing all types of violence toward 

or among children and adolescents, 

including child maltreatment. The 

planning and implementation phases 

of this project will address shared 

risk and protective factors for these 

forms of violence. Colorado, Iowa, 

Massachusetts, Michigan, Minnesota, 

New Mexico, Rhode Island, and 

Virginia have received funding.

Recommendations to help 

communities better serve the abused 

CDC is partnering with other federal 

agencies to fund six community projects 

to implement recommendations from the 

National Council of Juvenile and Family 

Court Judges. These recommendations, 

published in Effective Intervention in 

Domestic Violence and Child Maltreatment 

Cases: Guidelines for Policy and Practice 

(called the “Green Book”), are designed 

to improve how the court system handles 

cases of abused women and children, 

to increase the effectiveness of the child 

protective system, and to enhance 

services for victims of domestic violence. 

Project goals include holding batterers 

accountable for their actions, increasing 

protection for victims of abuse, and 

decreasing the number of children who 

are removed from their non-abusive 

mothers. 

CDC extramural research grants

CDC provides grant funding to 

researchers at universities, medical 

institutions, and community-based 

organizations to study various factors 

related to child maltreatment. Examples 

of extramural research projects follow: 

n Evaluation of a program to prevent 

abusive head trauma. Researchers at 

the University of Maryland School of 

Medicine are evaluating the effectiveness 

of a hospital-based program to reduce 

the incidence of abusive head trauma in 

young children. The program educates 

postpartum parents about abusive 

head trauma and recommends ways to 

manage a crying infant and their own 

possible frustration. The researchers will 

also examine how maternal risk factors 

affect the risk for abusive head trauma. 

n Social support to enhance home 

visitation. Researchers at the 

Columbia University School of Social 

Work are examining the effectiveness 

of an enhancement to home visitation 

services. Evidence suggests that social 

contextual factors, especially the 

social networks of parents, may play 

a substantial role in the effectiveness 

of home visiting programs to prevent 

maltreatment. Initial pilot work has 

yielded a promising intervention, 

which will be tested with 100 families. 

Data on physical child abuse and 

neglect risk, social networks, parents’ 

sense of control, participation in home 

visitation, and other associated factors 

will be collected at baseline and at 3 

and 9 months of age.

For more information about these and 

other projects, please visit www.cdc.

gov/ncipc/res-opps/extra.htm. 

Future Steps

The full extent of the child 

maltreatment problem in this country 

is not known. Current data systems 

only capture information about child 

maltreatment that is severe enough 

to come to the attention of the Child 

Protective Services system. As a result, 

many cases of child abuse go unreported 

and unnoticed. We must develop data 

collection and tracking systems at 

the local, state, and national levels to 

accurately document the scope of the 

problem and identify changes over time.

CDC is interested in preventing child 

maltreatment through programs 

that promote positive parent-child 

interactions and improve parenting skills. 

Such programs and policies may provide 

parents with skills to better manage 

behavior before violence can occur.
46 Preventing Injuries in America: Public Health in Action 

The Problem

Motor vehicle injuries are among the 

greatest public health problem facing 

U.S. children today. Motor vehicle 

injuries are the leading cause of death 

among children at every age after their 

first birthday (CDC 2005). 

n In the United States during 2003, 

a total of 1,591 children ages 14 

years and younger died as occupants 

in motor vehicle crashes, and 

approximately 220,000 were injured. 

That is an average of 4 deaths and 

602 injuries each day (NHTSA 

2004a).

n In 2002, more than half the children 

ages 14 and younger killed in 

motor vehicle crashes were riding 

unrestrained. Many of these injuries 

could have been prevented. Placing 

children in age-appropriate restraint 

systems reduces serious and fatal 

injuries by more than half (NHTSA 

2004a).

n Children ages 12 years and younger 

should ride in the back seat, the 

safest place in a vehicle in the 

event of a crash. This is especially 

important for vehicles with front 

passenger airbags. Passengers riding 

in the back seat are at least 30% less 

likely to be injured (Braver et al. 

1998). 

n Drinking and driving are injury risk 

factors for child passengers. One 

in four occupant deaths among 

children ages 0 to 14 years involves 

a drinking driver. More than two 

thirds of these fatally injured 

children ride with the drinking 

drivers (Shults 2004). 

These research findings were published 

in 2001 in CDC’s Morbidity and 

Mortality Weekly Report and in a 

supplement of the American Journal 

of Preventive Medicine. In 2005, the 

findings were published in The Guide 

to Community Preventive Services, a 

publication of an independent task 

force. Also known as the Community 

Guide, it provides public health 

decision makers with recommendations 

about interventions to promote health 

and safety and to prevent disease, 

injury, disability, and premature death.

Drinking, driving, and 

child passenger safety 

In a recent study, CDC scientists 

found that one in four occupant 

deaths among children ages 0 to 14 

years involves a drinking driver. More 

than two thirds of these fatally injured 

children were riding with the drinking 

driver, and only 32% were restrained 

(Shults 2004).

CDC’s Accomplishments

Interventions to increase 

child safety seat use

Over several years, scientists conducted 

a rigorous, systematic review of 

literature about community efforts to 

increase the use of child safety seats. 

They analyzed evaluations of those 

efforts and identified four interventions 

that were proven effective:

n Laws mandating the use of child 

safety seats (all 50 states currently 

have such laws);

n Stricter enforcement of those laws;

n Programs that distribute child safety 

seats and educate parents about 

proper use; and

n Programs that provide education 

about and incentives for child safety 

seat use.

Child Passenger Safety
A boost for children ages 4 to 8

CDC’s Injury Center funded state 

health departments in Colorado, 

Kentucky, and New York to develop, 

implement, and evaluate communitybased programs to increase booster 

seat use among children ages 4 

to 8. Between 2000 and 2003, 

grantees implemented and evaluated 

community awareness campaigns 

and school-based programs, aired 

public service announcements, 

posted billboards, and conducted 

booster seat distribution events and 

car seat checkpoints. Evaluation data 

from Colorado showed a significant 

increase in booster seat use in target 

communities when compared with 

control communities. Results from 

these intervention evaluations will help 

guide future efforts to increase booster 

seat use.

Kids in the back for a safer ride

CDC’s Injury Center funded the 

Center for Risk Analysis at the Harvard 

School of Public Health to develop, 

implement, and evaluate the “Kids 

in the Back/Niños Atrás” program in 

a low-income Hispanic community. 

This three-year, community-based 

intervention was designed to increase 

the number of children 12 and younger 

who ride properly restrained in the 

back seat of motor vehicles, the safest 

place for them. Project investigators 

organized a community task force, 

developed educational materials for 

parents and children in English and 

Spanish, implemented an incentive 

program to further motivate parents 

and children to adopt this behavior, 

coordinated 25 community events and 

safety seat checkpoints, and conducted 

a public information campaign 

targeting parents and caregivers of 

children. Researchers conducted preand post-intervention observational 

surveys of restraint use and seating 

position among children ages 12 years 

and younger in the intervention group 

and two control communities. During 

the intervention period, the 

percentage of children in 

the intervention community 

who were observed riding in 

the back seat increased from 

33% to 49%. 

CDC extramural 

research grants

CDC provides grant 

funding to researchers 

at universities, medical 

institutions, and 

community-based 

organizations to study 

various factors related to 

child passenger safety. A 

sample of those extramural 

research projects follows. 

For more information about 

these and other projects, visit 

www.cdc.gov/ncipc/res-opps/extra.htm.

n Dissemination of booster seat 

community intervention. 

Researchers at Harborview Injury 

Prevention and Research Center 

at the University of Washington 

are using interviews and focus 

group studies to better understand 

behavioral barriers to booster seat 

use in high-risk Latino communities. 

Their findings will be used to 

develop a tailored community 

intervention. The effectiveness of 

the intervention will be assessed in a 

controlled community trial. Booster 

seat use and child passenger safety 

practices will be assessed through 

direct observation. 

n Boost ’em in the Back Seat: 

A Safe Ride Program. Using 

risk communication guidelines, 

researchers at the Eastern Virginia 

Medical School are developing a 

five-minute video that includes crash 

test footage, portraying the power 

of crash forces and evoking high 

emotion by means of vivid imaging. 

The effectiveness of the video-based 

program in increasing booster seat 

use and rear seating will be tested at 

Just the Facts . . .

Proper Restraint Using

Booster Seats

Having outgrown child safety seats 

designed for younger passengers, 

children 4 to 8 years old frequently 

ride unrestrained or strapped 

in adult seat belts. Children in 

this age group should use beltpositioning booster seats until they 

are 4 feet, 9 inches tall (NHTSA 

2004b, 2005). Belt-positioning 

booster seats raise a child’s 

sitting height to fit a standard lap 

and shoulder belt. Public health 

and traffic safety organizations 

recommend that children in this 

age group be restrained properly 

in belt-positioning booster seats. 

However, among children in this 

age group who are restrained, only 

37% ride in age-appropriate beltpositioning booster seats (Cody et 

al. 2002). 

 Preventing Injuries in America: Public Health in Action 47
48 Preventing Injuries in America: Public Health in Action 

two large, representative preschool/

daycare programs, using two similar 

control sites for comparison. 

n Childhood rear seating among 

the hard-to-reach. The Education 

Development Center, Inc. and the 

Harvard Injury Control Research 

Center will disseminate a successful 

prevention strategy to increase 

child rear seating in a low-income, 

ethnically diverse community 

(Brockton, MA) with a substantial 

Cape Verdean (African) population. 

This project builds on the successful 

CDC-funded, community-based 

Niños Atrás program for Latino 

communities and will be led by 

the same research team. Using 

focus groups and key informant 

interviews, researchers will develop 

culturally appropriate materials 

and activities to be disseminated in 

collaboration with a community 

coalition. The dissemination strategy 

will place particular emphasis on 

ensuring that educational materials 

and strategies target populations 

hardest to reach, such as males; 

minority racial or ethnic groups 

(i.e., Cape Verdean, Haitian, and 

Hispanic); and low-income, lowliteracy families. The primary 

outcome, child rear seating, will be 

assessed by observational study.

Future Steps

Although about 86% of children 14 

years and younger use restraints, nearly 

one third use the wrong restraint for 

their size and age (Cody et al. 2002). 

CDC and its partners will work to 

get more communities to implement 

proven strategies that increase restraint 

use among children and to emphasize 

the importance of using the correct 

restraint for age and size. CDC has 

funded the state health departments of 

Colorado and Michigan to implement 

evidence-based interventions to 

increase booster seat use among 

children ages 4 to 8 years. 

References

Braver ER, Whitfield R, Ferguson SA. 

Seating position and children’s risk of dying 

in motor vehicle crashes. Injury Prevention

1998;4:181–187.

Centers for Disease Control and 

Prevention, National Center for Injury 

Prevention and Control. Web-based Injury 

Statistics Query and Reporting System 

(WISQARS) [online]. (2005) [cited 2005 

Feb 23]. Available from: URL: www.cdc.

gov/ncipc/wisqars. 

Cody BE, Mickalide AD, Paul HP, Coleila 

JM. Child Passengers at Risk in America: A 

National Study of Restraint Use. Washington 

(DC): Matopma; SAFE KIDS Campaign, 

February 2002.

National Highway Traffic Safety 

Administration (NHTSA), Department 

of Transportation (US). Traffic Safety Facts 

2003: Children. Washington: NHTSA; 

2004a [cited 2004 Dec 13]. Available from: 

URL: www-nrd.nhtsa.dot.gov/pdf/nrd-30/

NCSA/TSF2003/809762.pdf.

_________ . Traffic Safety Facts, Traffic 

Tech—Technology Transfer Series. 

Washington (DC): NHTSA; 2004b. 

[cited 2004 Aug 5]. Available from: URL: 

www.nhtsa.dot.gov/people/outreach/

TrafficTech/2004/trafficTech290/.

_________ . General Child Seat Use

Information. Washington (DC): NHTSA; 

2005.

Shults RA. Child passenger deaths 

involving drinking drivers—United States, 

1997–2002 [published erratum appears 

in Morbidity and Mortality Weekly Report

2004;53(5):109]. Morbidity and Mortality 

Weekly Report 2004;53(4):77–79.
The Problem

In less than a decade, the United States 

has seen large-scale domestic terrorist 

attacks, coordinated violence against 

Americans abroad, increases in school 

shootings, and many catastrophic 

man-made and natural disasters. Such 

events have heightened awareness of 

child, family, and community mental 

health issues and the importance of 

resilient communities with resources to 

address the needs of residents during a 

crisis. Proactive leaders and concerned 

citizens in many locations have 

collaborated to develop emergency 

response plans; in some locations, 

exercises have been held to practice 

implementing these plans. Most plans 

focus on tangible issues like obtaining 

clean drinking water and food, 

providing shelter and clothing, and 

ensuring continuity of medical care 

and communication systems.

Disasters also have an emotional 

impact on communities. This 

includes feelings of anger, anxiety, 

confusion, depression, fear, grief, 

guilt, helplessness, and hopelessness; 

increased sense of insecurity; 

stigmatization; suspicion or mistrust 

of authority figures and organizations; 

and a greater perception of individual, 

community, and societal vulnerability.

In the absence of proper preparation, 

treatment, and follow-up, these 

psychosocial issues can lead to 

behavioral consequences such as 

increased alcohol and drug abuse; 

absenteeism and decreased job 

performance; higher rates of child 

maltreatment, youth violence, and 

speeding or erratic driving; avoidance 

of mass transportation; sexually 

transmitted health problems; intimate 

partner violence; and divorce. 

Although less common, some people 

also might experience anxiety attacks, 

stress-related disorders, and clinical 

depression. 

CDC’s Accomplishments

CDC is defining the science basis for a 

new field—community resilience—to 

address health protection strategies at 

the community level.

Summit explores 

community resilience

In 2004, CDC and the Terrorism and 

Disaster Branch of the National Center 

for Child Traumatic Stress sponsored a 

“Community Resilience Mini-Summit” 

in Oklahoma City. Professionals from 

key community service sectors such as 

schools, business, primary care, and 

families contributed papers. An executive 

summary has been created that defines 

and explores the concept of community 

resilience, recommends ways to develop 

resilience across different sectors of a 

community (e.g., public health, mental 

health, government, business), and 

describes how to sustain resilience. A 

guidebook for civic leaders is being 

developed to illustrate these findings.

Emotional consequences following 

traumatic events are not limited to 

the actual victims. Such events also 

affect families and friends of victims; 

public safety and health responders 

(police, firefighters, emergency 

medical technicians, doctors, nurses) 

and their families and friends; 

people who directly witnessed what 

happened or who watched detailed 

media coverage; people who narrowly 

missed being involved in the disaster; 

special populations (e.g., people with 

impaired mobility, people dependent 

on ventilators, frail elderly, people with 

physical or mental disabilities), and 

children.

Community Resilience

Shovels: Photo by Andrea Booher/FEMA

Flag: Photo by Lauren Hobart/FEMA

Preventing Injuries in America: Public Health in Action 49
50 Preventing Injuries in America: Public Health in Action 

Habitat for Humanity: Photo by Kim MacDonald/Habitat for Humanity

Increasing agency training 

on resilience 

CDC routinely trains agency 

professionals who respond to crises, 

including Epidemic Intelligence 

Service officers and Public Health 

Readiness team members. To increase 

the emphasis on psychosocial issues—

enhancing the resilience not only 

of disaster victims but also of those 

deployed in response and recovery 

efforts—CDC has incorporated into 

this curriculum specific mental health 

competencies related to resilience.

CDC extramural research grants

CDC provides grant funding to 

researchers at universities, medical 

institutions, and community-based 

organizations to study various factors 

related to community resilience. A sample 

of those extramural research projects 

follows. For more information about these 

and other projects, please visit www.cdc.

gov/ncipc/res-opps/extra.htm.

n Psychological treatment of acute 

stress disorder following traumatic 

injury. The Medical College of 

Wisconsin’s Injury Research Center 

is examining the influence of 

subject, trauma, and injury variables 

on psychological well-being after 

injury. Their study focuses on 

causal attributions; self-efficacy; 

spiritual and religious values; and 

perceived level of social support, 

anger, and personal coping resources. 

Outcome data include measures of 

the intensity of posttraumatic stress 

disorder (PTSD) and depression 

symptoms. Changes in pre- and 

post-injury alcohol use will also be 

examined. Study results will inform 

early psychological intervention 

with trauma patients to prevent the 

development of long-term PTSD 

and depression symptoms.

n Behavioral health effects of 

September 11, 2001. Columbia 

University researchers are working 

to identify opportunities for 

primary and secondary prevention 

of terrorist- and disaster-related 

behavioral health disturbances 

by assessing the effects of the 

September 11, 2001, terrorist 

attacks on the health of New York 

City’s communities. The study 

will determine whether there was 

an increase among vulnerable 

populations in emergency 

department and outpatient visits 

for stress-related conditions. The 

study will also examine whether 

such increases are associated with an 

adverse effect on the overall health of 

the community.

Future Steps

While resilience among children has 

been studied for years, integrating and 

analyzing relevant thoughts, attitudes, 

and behaviors that contribute to and 

sustain resilience at the community 

level is a new endeavor. CDC is 

working with academic researchers 

and practitioners to develop tools to 

measure processes associated with 

community resilience. Such tools 

will help identify best practices across 

communities and enable the efficacy 

of interventions to be evaluated 

within the same community. CDC is 

collaborating with the National Center 

for Child Traumatic Stress to publish a 

special journal edition and a textbook 

devoted to community resilience with 

an emphasis on children and families.

CDC is researching community-related 

factors that contribute to the successful 

implementation of and adherence to 

movement restrictions mandated by 

public health (e.g., quarantine and 

isolation) for emerging infectious 

diseases. Findings from research about 

community resilience could enhance 

the effectiveness and efficiency of those 

projects.

Efforts are underway to identify 

common links between risk and 

protective factors related to community 

resilience and those of other key areas of 

activity for CDC’s Injury Center such 

as reducing child maltreatment, youth 

violence, intimate partner and sexual 

violence, and suicidal behavior.
Preventing Injuries in America: Public Health in Action 51

The Problem

Despite the best efforts to protect 

the public, many Americans may 

be seriously injured in future mass 

casualty events such as large-scale 

natural disasters, disease outbreaks, 

or explosions. Survivors of these 

events may sustain unique types or 

combinations of injuries, such as blast 

lung (see page 52) or burns, which 

pose great challenges for medical 

management. The ability to effectively 

minimize the impact of such injuries 

will depend on all levels of the 

emergency medical response system 

to act appropriately, from individual 

providers and single treatment centers 

to regional networks of medical 

institutions. State and local public 

health systems also must be fully 

prepared and capable of responding 

to the public in the event of a mass 

casualty event.

More information is needed about 

the psychological, social, and 

behavioral ramifications of mass 

casualty events—especially terrorist 

attacks. Initiatives in these areas will 

provide vital information toward 

improving response preparedness at 

the community level. Community 

preparedness requires creative linkages 

between existing programs and 

initiatives (e.g., injury and violence 

prevention programs, victim assistance 

programs, and urban renewal projects). 

Improving collaboration among 

existing systems employed by social, 

civic, and faith-based organizations will 

help increase community preparedness 

and strengthen the public to manage 

the psychological and societal effects of 

mass casualty events.

also developed a standardized national 

surveillance module to assess trends in 

attitudes, preparedness behaviors, and 

reactions to terrorism. 

To increase community resilience, the 

Injury Center works with the American 

Red Cross (ARC) to develop materials 

about psychosocial issues presented 

by post-disaster situations. Facilitated 

by a CDC cooperative agreement, 

ARC developed “Preparedness Today” 

at www.redcross.org/preparedness/

cdc_english/CDC.asp. This website 

provides fact sheets and other materials 

that guide individual preparedness before 

an emergency, including emergency 

sheltering and quarantine. The site links 

to CDC’s home page and is accessible 

via CDC’s emergency preparedness Web 

pages: www.bt.cdc.gov.

Funding of TIIDE project to 

improve collaboration

In 2002, CDC began funding the 

Linkages cooperative agreement—now 

called Terrorism Injuries: Information, 

Dissemination and Exchange (TIIDE). 

The TIIDE project includes three 

interrelated areas: partnerships, 

CDC’s Accomplishments

Educating the public, clinicians, 

and public health professionals

CDC has developed an emergency 

preparedness and response website: 

www.bt.cdc.gov/masscasualties/. This 

site provides information and tools 

to help the public, clinicians, and 

public health professionals prepare for 

and respond to mass casualty events. 

CDC has developed hospital capacity 

and injury severity predictor tools, 

an explosion primer for physicians, 

and fact sheets about the types of 

injuries one can expect during a mass 

casualty event. Additionally, this site 

includes response tools, fact sheets, 

and education messages about mental 

health needs and behavioral reactions, 

including those of children, following 

mass casualty events. 

Partnerships to address 

psychosocial and behavioral 

aspects of mass casualty events

CDC’s Injury Center has forged 

partnerships to address the 

psychosocial and behavioral effects 

of mass casualty events. Partners 

include other U.S. Department of 

Health and Human Services agencies 

(National Institute of Mental Health, 

the Substance Abuse and Mental 

Health Services Administration, and 

the Health Resources and Services 

Administration); the Department of 

Veterans Affairs’ National Center for 

Posttraumatic Stress Disorder; the 

American Red Cross, the Department 

of Defense’s Uniformed Services 

University of the Health Sciences; 

and university-based networks of 

public health and traumatic stress 

researchers and practitioners. To date, 

these partnerships have resulted in 

the development of a standardized 

needs-assessment module to identify 

informational, social service, medical, 

and mental health needs in affected 

communities. The partnerships have 

Emergency Preparedness and Response
52 Preventing Injuries in America: Public Health in Action 

World Trade Center Evacuation 

Study yields strategies for risk 

reduction 

CDC supports research at the 

Columbia University Mailman 

School of Public Health to identify 

the individual, organizational, and 

environmental (building) factors 

that affected evacuation of the World 

Trade Center (WTC) on September 

11, 2001. During focus groups and 

qualitative interviews (phase I), WTC 

evacuees were asked about individual, 

organizational, and environmental 

factors that facilitated or posed barriers 

to evacuation or influenced their 

decisions to evacuate. Their decision 

process to evacuate included: perceived 

ability to walk down multiple 

flights of stairs; previous experience 

evacuating a WTC tower; concern 

over leaving the workplace; workplace 

preparedness planning and training; 

structural damage; heavy congestion on 

certain stairways; and lack of back-up 

communication. These data provide 

insights into preparedness planning 

for evacuating multistory buildings. 

Results from the qualitative research 

were published in the September 10, 

2004, issue of Morbidity and Mortality 

Weekly Report. Detailed quantitative 

information on how these factors 

affected evacuation behaviors, and how 

these behaviors affected evacuation 

time, was collected from more than 

1,400 evacuees. Findings of this study 

will provide information for groups 

such as builders, developers, insurance 

companies, employee organizations, 

fire prevention specialists, and 

emergency planners about risk 

reduction strategies related to the 

evacuation of high-rise buildings. 

information dissemination, and lessons 

learned from terrorist events outside 

the United States. TIIDE partners 

are national nonprofit or for-profit 

professional organizations, with at 

least 25 members, that address acute 

care, trauma, or emergency medical 

services. The partnership establishes a 

foundation for effective collaboration 

and the exchange of information with 

the larger community of stakeholders.

In July 2003, the National Association 

of Emergency Medicine Physicians, 

in partnership with CDC and other 

Linkages organizations, met in 

Washington, D.C., to determine how 

interactive information can be used 

to care for victims of a mass casualty 

event through an all-hazards approach. 

A summary of this meeting, “The Role 

of Interactive Information Systems 

for Responding to Events Resulting in 

Mass Injury,” was published in the July 

2004 issue of the Journal of Prehospital 

Emergency Care. CDC and its TIIDE 

partners have also developed a contact 

list to facilitate rapid communication 

among partners after a mass casualty 

event.

Studying the psychological 

aftermath of terrorist attacks

CDC has conducted research on the 

psychological and behavioral reactions 

to the 2001 terrorist attacks on the 

World Trade Center and the 2002 

sniper attacks in the Washington, 

D.C., metropolitan area. Women 

who reported living within five miles 

of either incident were more likely to 

experience elevated traumatic stress 

symptoms than women living farther 

from the incidents. Among men, 

no significant association between 

residential proximity and elevated 

traumatic stress symptoms was 

reported. The study outcomes can 

help to inform future public health 

interventions for terrorist events. 

Additionally, CDC personnel have 

served on the National Advisory 

Committee on Children and 

Terrorism.

Blast lung injury (BLI) is a direct consequence of pressure upon the 

body from high-explosive detonations. 

Because lungs are fragile and sensitive to 

overpressure, the force from an explosion can 

cause tearing, hemorrhage, contusion, and 

edema due to the inappropriate distribution 

of fluids and oxygen. BLI, a clinical diagnosis 

characterized by respiratory difficulty and 

hypoxia, can occur without obvious external 

injury to the chest. BLI presents unique triage, diagnostic, and management 

challenges and is a major cause of morbidity and mortality for blast victims at 

the scene—particularly the initial survivors. 

Photo courtesy of Chest, 1999
Just the Facts . . .

How Mass Casualty Events 

Affect Health

During a mass casualty event, 

people can be physically injured and 

may have limited access to medical 

care and vital services. People can 

also suffer emotional and physical 

stress after a mass casualty event, 

even if they are not near the scene. 

This additional stress can worsen 

existing health conditions (e.g., 

diabetes) or trigger a new health 

problem (e.g., heart attack or 

depression). 

If a mass casualty event occurs, 

anyone who is injured or suspects 

injury should seek medical 

care immediately. Everyone is 

encouraged to resume personal 

care:

n Maintain healthy eating, exercise, 

and sleeping habits;

n Continue to take medicine as 

prescribed by physicians;

n Maintain daily routines; and

n Talk to others about their feelings 

and concerns.

Fire evacuation data 

collection tools

CDC has developed protocols and 

data collection instruments for an 

epidemiologic field investigation 

for a large-scale fire and evacuation 

that could occur in a crowded public 

building. These materials may be 

adapted for similar incidents that occur 

in the future. 

CDC extramural research grants

CDC provides grant funding to 

researchers at universities, medical 

institutions, and community-based 

organizations to study various factors 

related to emergency preparedness 

and response. Some examples of these 

extramural research projects follow. 

For more information about these 

and other projects, visit www.cdc.gov/

ncipc/res-opps/extra.htm.

n Needs assessment of emergency 

preparedness and response 

activities in California schools.

The Southern California Injury 

Prevention Research Center, part of 

UCLA’s School of Public Health, is 

conducting a pilot study of public 

schools’ emergency preparedness in 

12 school districts in Los Angeles 

County. The pilot study will 

inform a larger needs assessment of 

emergency preparedness for schools 

in the state’s 100 school districts. 

The study will describe the types of 

emergencies that occur in schools; 

describe the intended (written) 

and actual emergency preparedness 

activities that exist in schools; 

identify the types, methods, and 

perceived adequacy and inadequacy 

of training provided to school staff; 

and examine differences in perceived 

and actual preparedness across school 

districts.

n Identifying and treating posttraumatic stress disorder symptoms 

resulting from traumatic injuries 

among children. This project, 

conducted by the University of 

California, San Francisco, will clarify 

the relationship between childhood 

posttraumatic stress disorder (PTSD) 

and potential impairment in 

social, academic, and psychological 

functioning. The project will also 

evaluate a novel combination of 

treatment interventions, which 

researchers hypothesize could 

effectively reduce PTSD symptoms 

for hospitalized children and for 

large numbers of children requiring 

immediate treatment after natural 

disasters, school shootings, or other 

catastrophic events.

Future Steps

TIIDE-funded partners are engaged 

in several CDC initiatives that address 

acute care and the health consequences 

of terrorism-related events. Future 

activities include developing a field 

triage protocol for mass casualty 

events, developing clinical primers 

and blast injury training for health 

care professionals, and translating 

injury care from the military to 

the civilian sector. The TIIDE 

project will enhance CDC’s ability 

to work with the emergency care 

 Preventing Injuries in America: Public Health in Action 53
54 Preventing Injuries in America: Public Health in Action 

community and will ensure that critical 

information is accessible and effectively 

communicated to a broad spectrum of 

health care providers and organizations 

before, during, and after a terrorist 

event.

Past mass casualty events indicate that 

medical resources could be depleted 

in the aftermath of an event. This 

depletion could be caused by a surge 

of persons seeking care during a brief 

period following the catastrophic 

event. Currently, limited strategies are 

in place to deal with a sudden surge 

of injuries at a ground zero hospital. 

These hospitals, although affected 

unequally, would be overrun. CDC 

is addressing this problem by seeking 

creative solutions to match resources 

to need and by identifying rapid, 

accurate triage methods for treating 

large numbers of patients with multiple 

injuries of varying severity. CDC will 

use a wide spectrum of communication 

channels to share its findings.

Equally important, CDC plans to 

develop a mechanism for conducting 

timely and rapid field epidemiological 

investigations on evacuation 

procedures. Incidents necessitating 

evacuation could include wildfires or 

fires in large public structures such as 

high-rise apartments or commercial 

buildings. Previously developed data 

collection instruments and protocols 

could easily be adapted to address 

hypotheses regarding psychological 

and behavioral effects. Study 

questions that can only be answered 

by rapid collection of field data may 

address pre- and post-evacuation 

expectations, preparedness, practice, 

prior experience, and decision-making 

strategies.

Much has yet to be learned about the 

effects of mass casualty events on one’s 

thoughts, behaviors, and emotions. 

To help increase awareness and 

understanding of these issues, CDC 

plans to complete the following tasks 

and initiatives:

n Conduct further research leading 

to a course of action that will help 

prevent or lessen the psychosocial 

and behavioral consequences 

of movement restrictions (e.g., 

quarantine and isolation) imposed 

to control the transmission of a 

communicable disease epidemic.

n Assist state health departments in 

addressing the psychosocial issues 

of the general public and special 

populations (e.g., children, disabled 

persons, persons with mental illness) 

to build more resilient communities.

n Develop data collection instruments 

for use during emergency events 

to evaluate fear as a contagion in 

emerging infectious diseases (such 

as SARS) and to identify the impact 

on critical workforce behavior and 

infrastructure during such outbreaks. 

n Develop demonstration projects and 

evaluate best practices for building 

community resilience, the ability of 

a community to adapt to unexpected 

events and stressful situations 

(e.g., natural disasters and terrorist 

attacks).
Preventing Injuries in America: Public Health in Action 55

The Problem

n Approximately 1.5 million women 

and 834,700 men are raped or 

physically assaulted by an intimate 

partner each year in the United 

States, according to the National 

Violence Against Women Survey 

(Tjaden and Thoennes 2000).

n Nearly two thirds of women who 

report being raped, physically 

assaulted, or stalked since age 

18 were victimized by a current 

or former husband, cohabiting 

partner, boyfriend, or date; in 8 of 

10 rape cases, the victim knew the 

perpetrator (Tjaden and Thoennes 

2000).

n More women than men experience 

intimate partner violence (IPV).

According to the National Violence 

Against Women Survey, 1 in 4 U.S. 

women has been physically assaulted 

or raped by an intimate partner; 1 

in 14 U.S. men reported such an 

experience (Tjaden and Thoennes 

2000).

n Among women who are physically 

assaulted or raped by an intimate 

partner, 1 in 3 is injured. Each year, 

more than 500,000 women injured 

as a result of IPV require medical 

treatment (Tjaden and Thoennes 

2000).

n Intimate partner violence is 

associated with both short- and longterm problems, including physical 

injury and illness, psychological 

symptoms, economic costs, and 

death (National Research Council 

1996).

n Each year, thousands of American 

children witness IPV within their 

families. Witnessing violence is a risk 

factor for long-term physical and 

mental health problems, including 

alcohol and substance abuse, being 

a victim of abuse, and perpetrating 

IPV (Felitti et al. 1998).

n The health care cost of intimate 

partner rape, physical assault, and 

stalking exceed $5.8 billion each 

year, nearly $4.1 billion of which is 

for direct medical and mental health 

care services (CDC 2003).

CDC’s Accomplishments

Developing uniform definitions and 

recommended data elements

In 1999, CDC published Intimate 

Partner Violence Surveillance: Uniform 

Definitions and Recommended Data 

Elements to improve and standardize 

data collected about intimate partner 

violence. Similar standards for sexual 

violence, Sexual Violence Surveillance: 

Uniform Definitions and Recommended 

Data Elements, were published in 

2002. Uniform definitions and 

recommended data elements for 

IPV and sexual violence provide 

consistency in the use of terminology 

and standardization in data collection. 

Without these standards, researchers 

have used varying terms to describe 

acts of violence. These inconsistencies 

have contributed to confusion and a 

lack of consensus about the magnitude 

of the problem. Consistent data allow 

researchers to better gauge the scope of 

the problem, identify high-risk groups, 

and monitor the effects of prevention 

programs.

Measuring the incidence and 

prevalence of intimate partner 

violence and sexual violence

With external partners, CDC has 

developed two surveys to help states 

better assess the problem of IPV, 

sexual violence, and resulting injuries. 

The surveys are available as optional 

modules in the CDC Behavioral Risk 

Factor Surveillance System. In addition 

to providing data on the incidence 

and prevalence of the problem, these 

surveys will provide knowledge of the 

related attitudes and norms that allow 

violence to occur. Data may also be 

used to compare statistics across states, 

assess the impact of programs, and 

guide policy development.

Intimate Partner Violence

I

ntimate partner violence (IPV) is actual or threatened physical or sexual 

violence or psychological and emotional abuse directed toward a spouse, 

ex-spouse, current or former boyfriend or girlfriend, or current or former 

dating partner. Intimate partners may be heterosexual or of the same sex.
56 Preventing Injuries in America: Public Health in Action 

Developing state-based 

surveillance systems

CDC funded activities in three states 

to help monitor and track IPV. These 

activities helped states identify existing 

data sources, recognize opportunities 

to link data sources, and develop 

and implement more comprehensive 

systems for monitoring and tracking 

the problem. Michigan, Minnesota, 

and Oregon are improving state injury 

surveillance capacity by implementing 

the Consensus Recommendations for 

Injury Surveillance in State Health 

Departments, issued in September 

1999. The states supported the 

integration of intimate partner violence 

surveillance systems into existing injury 

surveillance systems and are continuing 

to revise and test uniform definitions 

and data elements.

Reporting system to provide 

objective, timely violence data

State and local agencies have detailed 

information from medical examiners, 

coroners, police, crime labs, and 

death certificates that could answer 

important, fundamental questions 

about trends and patterns in 

violence. However, the information is 

fragmented and difficult to access. 

CDC has funded 17 states—

Alaska, California, Colorado, 

Georgia, Kentucky, Maryland, 

Massachusetts, New Jersey, 

New Mexico, North Carolina, 

Oklahoma, Oregon, Rhode 

Island, South Carolina, Utah, 

Virginia, and Wisconsin—to 

establish the National Violent 

Death Reporting System 

(NVDRS) to gather, share, 

and link state-level data 

about violence. When fully 

implemented, NVDRS 

will enable CDC to 

pull together vital statelevel information to 

gain a more accurate 

understanding of violence 

and will enable policy makers and 

community leaders to make informed 

decisions about violence prevention 

strategies and programs, including 

those that address IPV.

Assessing links between 

various forms of violence

CDC is conducting a study to 

identify the links between different 

forms of violent behaviors among 

adolescents. The findings will help 

scientists understand the prevalence 

and consequences of different types of 

aggressive behaviors; the association 

between dating violence and other 

forms of peer violence; and the manner 

in which these types of violent behavior 

vary by sex, developmental stage, and 

other factors.

Intimate partner violence 

perpetration behavior study

CDC is conducting a study to assess 

how issues of power and control 

contribute to the development of 

perpetrator behavior. Study results 

will help scientists determine the 

best way to address issues of power 

and control in prevention and 

intervention strategies. Information is 

being collected from court-mandated 

male perpetrators and controls from 

the same community to identify 

characteristics that lead to perpetration.

Culturally-competent 

demonstration projects

CDC funds 10 projects to prevent 

IPV and sexual violence among 

various racial and ethnic populations, 

including African Americans, 

American Indians and 
Preventing Injuries in America: Public Health in Action 57

Alaska Natives, Hispanic Americans, 

and Asian Americans and Pacific 

Islanders. These projects have developed 

and are evaluating programs for 

children, victims, and perpetrators; 

programs to prevent dating violence 

among school-aged youth; and programs 

that link victims with community-based 

service providers. The components and 

outcomes of interest vary by project.

Violence Against Women 

Evaluation Guide

CDC developed the Violence Against 

Women Evaluation Guide to help 

programs develop and implement 

outcome evaluations. The guide will 

assist programs in selecting useful, 

feasible, ethical, and accurate evaluation 

strategies. It clearly defines evaluation 

research based on CDC guidelines 

and provides an overview of issues to 

consider when evaluating programs 

that address violence against women. 

Information about data collection 

methodology and measures, data 

analyses, presentation of results, and 

selection of an external evaluator will 

be included. The guide is scheduled for 

release in 2006.

Using social networks to prevent 

violence against women

CDC is studying how friends, relatives, 

and acquaintances can influence the 

behavior of men and women in abusive 

situations and how social networks 

can be used to prevent violence against 

women. Researchers conducted 

interviews with women in shelters 

and support groups to identify who 

helped them make decisions or assisted 

them in leaving abusive situations. 

Men in batterer intervention programs 

were asked how friends, relatives, and 

acquaintances influenced their partner 

violence attitudes and behaviors. 

Results from the study will help direct 

prevention messages to people in the 

best position to assist women and 

men in preventing partner violence 

and changing the norms that lead to 

acceptance of violence.

CHOOSE RESPECT campaign 

aims to prevent intimate partner 

and sexual violence

CHOOSE RESPECT is 

a communications campaign that 

encourages adolescents to develop 

positive, respectful relationship 

behaviors. The campaign is designed 

to reach 11- to 14-year-olds and 

the caring adults in their lives with 

prevention messages about choosing 

respectful, positive relationship 

behaviors before norms and attitudes 

that support violence against women 

are firmly established. Campaign 

elements include a website, an 

interactive music video maker, an 

education video, brochures, posters, 

cinema slides, and radio and TV spots. 

The campaign was launched May 2006.

Domestic Violence Prevention 

Enhancement and Leadership 

Through Alliances 

CDC is funding 14 state domestic 

violence coalitions to develop and 

implement prevention activities that 

can be integrated into Coordinated 

Community Responses (CCRs) 

or similar community-based 

collaborations. The Domestic 

Violence Prevention Enhancement 

and Leadership Through Alliances 

(DELTA) program is adding a 

significant prevention focus to the 

existing CCR model by funding state 

domestic violence coalitions who 

provide prevention-focused technical 

assistance, training, and funding to 

local communities. 

Assessment tools for measuring 

intimate partner violence

CDC has developed Measuring Intimate

Partner Violence Victimization and 

Perpetration: A Compendium of Assessment 

Tools. The compendium will provide 

researchers and prevention specialists 

with a set of assessment tools with

demonstrated reliability and validity for

measuring the self-reported incidence and

prevalence of IPV and perpetration. The 

compendium will be available late 2006.

Recommendations to help 

communities better serve the 

abused 

CDC is partnering with other 

federal agencies to fund six 

community projects to implement 

recommendations from the National 

Council of Juvenile and Family Court 

Judges. These recommendations, 

published in Effective Intervention 

in Domestic Violence and Child 

Maltreatment Cases: Guidelines for 

Policy and Practice (called the “Green 

Book”), are designed to improve the 

way the court system handles cases 

of abused women and children. The 

recommendations are also designed to 

increase the effectiveness of the child 

protective system and to enhance 

services for victims of IPV. Project goals 

include holding batterers accountable 

for their actions, increasing protection 

for victims of abuse, and decreasing the 

number of children who are removed 

from their non-abusive mothers.
58 Preventing Injuries in America: Public Health in Action 

Evaluation assistance for projects 

to prevent first-time male 

perpetration of sexual violence

CDC has provided evaluation 

assistance to four projects designed 

to prevent first-time perpetration of 

sexual violence by males. Designed to 

help the programs build capacity to 

conduct their own evaluations, the key 

elements CDC provides are training 

and coaching on the use of evaluation 

concepts, techniques, and findings to 

foster program improvement.

Rape Prevention and 

Education program

CDC administers the Rape Prevention 

and Education (RPE) program and 

provides technical assistance to 

health departments, sexual assault 

coalitions, partner organizations, and 

other agencies. The RPE program 

supports educational seminars, hotline 

operations, training programs for 

professionals, informational materials, 

and other efforts to increase awareness 

of sexual violence, including that 

perpetrated by intimate partners. 

Through this program, states 

and territories have implemented 

prevention and education programs 

and developed a stronger infrastructure 

to address sexual violence. 

Rape Prevention and Education 

program evaluability assessment

To enhance the administration and use 

of the Rape Prevention and Education 

(RPE) funding, CDC assessed how 

states allocate funds and the types 

of activities the funds support. The 

primary objectives of this study were 

to document the goals and objectives 

of the RPE program as it relates to the 

activities of state health departments 

and sexual assault coalitions; to assess 

the allocation mechanisms, uses, and 

impact of the funds; and to assess the 

public health needs of states and local 

programs in terms of knowledge, skills, 

resources, and barriers to effective 

implementation.

Preventing Violence through 

Education, Networking, and 

Technical Assistance 

CDC is funding the University of 

North Carolina Injury Prevention 

Research Center to develop a national 

training program for violence 

prevention practitioners. The initiative, 

known as PREVENT (Preventing 

Violence through Education, 

Networking, and Technical Assistance), 

is an outgrowth of the National Injury 

and Violence Prevention Training 

Initiative and is supported by the 

Society for Advancement of Violence 

and Injury Research (formerly the 

National Association of Injury Control 

Research Centers) and the State and 

Territorial Injury Prevention Directors 

Association. PREVENT helps 

individuals and organizations build 

skills for identifying community needs 

and assets, creating and mobilizing 

partnerships, developing and 

implementing prevention programs, 

measuring success, and funding and 

sustaining programs. PREVENT uses 

various educational methods including 

distance-learning modules, regional 

workshops, an intensive institute, 

action learning projects, and coaching. 

National Sexual Violence 

Resource Center

The National Sexual Violence 

Resource Center (NSVRC) provides 

information, resources, and research 

on all aspects of sexual violence, 

including intimate partner sexual 

violence. The NSVRC collects, reviews, 

catalogs, and disseminates information 

about sexual violence prevention and 

intervention; coordinates efforts with 

other organizations; provides technical 

assistance and customized information; 

and maintains a website. The website 

links to sexual assault resources 

and information about upcoming 

conferences, funding opportunities, 

job announcements, research, and 

special events. The NSVRC also 

produces a biannual newsletter, 

recommends speakers for conferences, 

coordinates national sexual assault 

awareness activities, and identifies 

emerging policy issues and research 

needs. Further, the NSVRC serves 

coalitions, local rape crisis centers, 

government and tribal entities, colleges 

and universities, service providers, 

researchers, allied organizations, 

policy makers, and the general public. 

Additional information can be found 

online at www.nsvrc.org.

National online resources for 

violence against women

CDC has funded the Pennsylvania 

Coalition Against Domestic Violence 

(PCADV) and the California 

Coalition Against Sexual Assault’s 

(CALCASA) Prevention Connection 

to provide national, online resources 

for preventing violence against women. 

These resources will support local, 

state, national, and tribal agencies 

and organizations in developing, 

implementing, and evaluating 

prevention and intervention programs 

for violence against women. For more 

information, visit www.vawnet.org and 

www.preventconnect.org.

CDC-funded research grants

CDC provides grant funding to 

researchers at universities, medical 

institutions, and community-based 

organizations to study factors related 

to IPV. For information about CDC’s 

extramural research projects, visit www.

cdc.gov/ncipc/res-opps/extra.htm. 

Some examples of CDC-funded grants 

follow:

n Effects of formal danger assessment 

on actions to prevent women from 

partner violence. Researchers at the 

Johns Hopkins University School of 

Public Health are assessing whether 

using a standardized, empirically 

based tool to generate and 
Preventing Injuries in America: Public Health in Action 59

communicate scores reflecting the 

level of danger a victim of IPV faces 

will lead to more or less protective 

actions taken by the victim and the 

courts. In addition to educating IPV 

victims about the dangers they face 

and effective strategies for preventing 

further violence, legal advocates 

will use danger score information 

in communications with judges 

and prosecutors to influence legal 

decisions relevant to victim safety. 

n Piloting a family-based program 

for preventing adolescent dating 

violence. Researchers of the 

University of North Carolina at 

Chapel Hill are developing and 

pilot testing Families for Safe 

Dates, a family-based program to 

address multiple types of youth 

violence, including dating violence 

(psychological, physical, and sexual), 

victimization and perpetration, 

and violence directed at peers. The 

content of Families for Safe Dates 

will draw heavily from Safe Dates, 

an effective school-based program to 

prevent dating violence. The premise 

and structure will model the Family 

Matters program, a program that 

successfully reduced the prevalence 

of adolescent substance use. 

n Examining partner violence 

perpetration among men. Harvard 

School of Public Health researchers 

are conducting a mixed-methods 

retrospective cohort study of men 

ages 18 to 35 living within racially 

and ethically diverse neighborhoods 

in the Boston area. Men in this age 

group perpetrate IPV at the highest 

rates. The study will assess risk and 

protective factors for perpetration 

of IPV. Researchers also will assess 

interrelations of IPV perpetration 

and perpetration of other forms 

of violence (i.e., suicide, sexual 

violence, child maltreatment, general 

violence). Finally, researchers will 

assess the relevance of findings 

regarding risk and protective factors 

for IPV perpetration and compare 

with findings for the population of 

men enrolled in treatment programs 

from these same communities.

Future Steps

The full extent of nonfatal and fatal 

intimate partner violence (IPV) in the 

United States is not known. To better 

document the scope of the problem 

and identify trends in incidence 

and prevalence, the quality of data 

collection at national, state, and local 

levels must be improved.

Scientists, public health professionals, 

advocates, and others in the field 

must increase efforts to stop IPV from 

occurring. To this end, CDC will 

fulfill its public health responsibilities 

by evaluating interventions for IPV 

prevention and communicating sound, 

science-based recommendations about 

programs and practices that work. 

References

Centers for Disease Control and Prevention 

(CDC), National Center for Injury 

Prevention and Control. Costs of Intimate 

Partner Violence Against Women in the 

United States. Atlanta (GA): CDC; 2003.

Felitti V, Anda R, Nordenberg D, 

Williamson D, Spitz A, Edwards V, 

et al. Relationship of childhood abuse 

and household dysfunction to many of 

the leading causes of death in adults. 

American Journal of Preventive Medicine

1998;14(4):245–258.

National Research Council. Understanding 

Violence Against Women. Washington (DC): 

National Academy Press; 1996. p. 74–80.

Tjaden P, Thoennes N. Full Report of the 

Prevalence, Incidence, and Consequences of 

Intimate Partner Violence Against Women: 

Findings from the National Violence 

Against Women Survey. Washington (DC): 

Department of Justice (US); 2000. Report 

No.: NCJ183781. Available from: URL:

www.ncjrs.org/txtfiles1/nij/183781.txt. 
60 Preventing Injuries in America: Public Health in Action 

The Problem

In 2002, a total of 7,688 people ages 

65 and older died in motor vehicle 

crashes in the United States (CDC 

2005). 

n Drivers ages 65 and older have 

higher crash death rates per mile 

driven than all but teen drivers 

(NHTSA 2004). 

n Rates for motor vehicle-related 

injury are twice as high for older 

men as for older women (Stevens 

et al. 1999).

n Motor vehicle-related deaths and 

injuries among older adults are 

rising. During 1990–1997, the 

number of deaths rose 14%, and the 

number of nonfatal injuries climbed 

19% (Stevens et al. 1999).

n The 65-and-older age group is the 

fastest growing segment of the U.S. 

population. Estimates indicate that 

more than 40 million older adults 

will be licensed drivers by 2020 

(Dellinger et al. 2002).

CDC’s Accomplishments

Why older adults stop driving

Scientists at CDC’s Injury Center 

worked with the University of 

California, San Diego, to survey older 

drivers living in community settings 

about why they stop driving. The 

most common reasons for stopping 

were medical conditions—frequently, 

poor vision. This research provides 

useful insight into why older drivers 

decide that they are no longer fit to 

drive, which can help public health 

practitioners develop programs to 

reduce motor vehicle-related injuries 

in this population. These findings were 

published in 2001 in the Journal of the 

American Geriatrics Society.

Older drivers are less likely 

than younger drivers to 

kill others in a crash

CDC researchers analyzed fatality data 

to determine whether older drivers 

were more likely than younger drivers 

to be involved in crashes that killed 

someone else. They found that, in fact, 

older drivers were involved in fewer of 

these crashes than were drivers 16 to 

34 years old. This study helps dispel 

the myth that older drivers present an 

unacceptable threat to others on the 

road. Study findings were published 

in 2004 in the American Journal of 

Preventive Medicine.

Fatal crashes among older drivers

CDC researchers analyzed fatal crash 

involvement rates for drivers ages 65 

years and older. They assessed how 

the crash fatality rate (risk of death), 

incidence density (risk of crash), 

and exposure prevalence (amount of 

driving) contributed to the fatal crash 

involvement rates of older drivers. The 

crash fatality rates and the incidence 

densities increased with age, while the 

exposure prevalence decreased. In other 

words, although older drivers drove 

less, they were more likely to crash and 

to die in a crash. These findings suggest 

that older driver crash deaths can be 

reduced by decreasing their crash risk, 

their risk of injury when a crash occurs, 

or by decreasing the amount they 

drive. Research findings were published 

in 2002 in the American Journal of 

Epidemiology.

License renewal and crash risk 

among older drivers

With CDC funding, researchers at 

the University of Washington are 

investigating the relationship between 

older drivers’ crash risk and the time 

since their last license renewal. The 

interval between license renewals is 

an issue of public policy, and states 

must balance the crash risk caused by 

drivers who have become impaired 

against the cost and inconvenience of 

more frequent renewals. The results 

of this study will help decision makers 

determine the appropriate interval 

between license renewals for older 

drivers.

Older Adult Drivers
Preventing Injuries in America: Public Health in Action 61

Race and sex disparities 

in motor vehicle-related deaths 

among older adults

CDC researchers analyzed annual 

mortality data to identify differences 

in motor vehicle-related death rates 

among adults 65 and older by sex, 

race, and ethnicity. From 1990 to 

1998, motor vehicle-related death rates 

were highest among Native-American 

and African-American men, while 

women’s rates were highest among 

Native Americans and Asian/Pacific 

Islanders. These findings of racial- and 

sex-related disparities, published in 

the journal Injury Prevention in 2002, 

will be useful for identifying high-risk 

groups and for developing prevention 

strategies that target them (Stevens and 

Dellinger 2002). 

CDC extramural research grants

CDC provides grant funding to 

researchers at universities, medical 

institutions, and community-based 

organizations to study various factors 

related to older adult drivers. A sample 

of those extramural research projects 

follows. For more information about 

these and other projects, please visit 

www.cdc.gov/ncipc/res-opps/extra.htm. 

n Policies for older driver safety: 

evaluation of older driver policies 

and practices in other countries. 

Other countries, especially 

developed nations with high 

numbers of licensed drivers and 

advanced highway systems, face 

many of the same issues as the 

United States concerning older 

drivers. Researchers at the Johns 

Hopkins Bloomberg School of 

Public Health are systematically 

reviewing other nations’ policies, 

programs, and practices for older 

drivers to assess applicability in the 

United States. This research will 

examine whether a policy of staged 

licensing curtailment for older 

drivers—analogous to graduated 

licensing for younger drivers—would 

be appropriate and effective. Based 

on findings, researchers will develop 

and widely disseminate policy 

recommendations.

n Reducing older driver injuries 

at intersections. Data from 

other countries have shown that 

roundabouts dramatically improve 

traffic conflicts and overall safety 

at intersections. But in the United 

States, subjective data show that 

drivers, especially older drivers, fear 

what they perceive to be elevated 

demands and risks associated with 

roundabouts, and they may avoid 

their use. Researchers at the Texas 

A&M Research Foundation (part of 

Texas A&M University) explored the 

development of more elder-friendly 

designs for roundabouts. The results, 

reported in June 2005, informed 

recommendations for developing 

new guidelines for modern 

roundabouts, where the overall goal 

was to foster the use of these facilities 

by the groups most at risk of injury 

in intersection crashes, including 

older adults.

Future Steps 

Basic questions remain unanswered. 

CDC must work with a variety of 

partners—for example, clinicians, 

advocacy groups, transportation 

experts, and older drivers themselves—

to determine under what conditions 

older adults choose to stop driving and 

under what conditions they should stop 

driving. Issues to consider include:

n How medical conditions increase the 

risk of a crash;

n How much older adults drive and 

what their transportation needs are;

n Why older adults decide to stop 

driving;

n Whether they stop driving at the 

appropriate time and for the right 

reasons;

n Whether screening tests can 

successfully identify high-risk older 

drivers;

n How to practically measure older 

adults’ functional ability to drive; 

and

n Alternatives to driving that would 

be both practical and acceptable to 

older adults.

This information will enable policy 

makers and public health practitioners 

to make informed decisions and 

develop effective strategies to reduce 

the number of injuries and deaths 

among this age group.

References

Centers for Disease Control and 

Prevention, National Center for Injury 

Prevention and Control. Web-based Injury 

Statistics Query and Reporting System 

(WISQARS) [online]. (2005). [cited 2005 

Dec 23]. Available from: URL: www.cdc.

gov/ncipc/wisqars. 

Dellinger AM, Langlois JA, Li G. Fatal 

crashes among older drivers: decomposition 

of rates into contributing factors. American 

Journal of Epidemiology 2002;155(3):234–241. 

National Highway Traffic Safety 

Administration (NHTSA), Department of 

Transportation (US). Traffic Safety Facts 2003: 

Older Population. Washington: NHTSA; 

2004 [cited 2005 Feb 23]. Available from: 

URL: www-nrd.nhtsa.dot.gov/pdf/nrd-30/

NCSA/TSF2003/809766.pdf.

Stevens JA, Dellinger AM. Motor vehicle 

and fall related deaths among older 

Americans 1990–98: sex, race, and ethnic 

disparities. Injury Prevention 2002;8:272–275.

Stevens JA, Hasbrouck L, Durant TM, 

Dellinger AM, Batabyal PK, Crosby 

AE, et al. Surveillance for injuries and 

violence among older adults. Morbidity 

and Mortality Weekly Report Surveillance 

Summaries 1999;48(SS-8):27–50.
62 Preventing Injuries in America: Public Health in Action 

The Problem

n More than one third of adults 

65 years or older fall every year 

(Hornbrook et al. 1994; Hausdorff 

et al. 2001); both falls and fall injury 

rates increase sharply with age(CDC 

2001). 

n Among seniors, falls are the ninth 

leading cause of death and the 

leading cause of fatal and nonfatal 

injuries (CDC 2005).

n In 2002, 12,800 older adult deaths 

were caused by falls (CDC 2005). 

n Falls are the most common cause 

of nonfatal injuries and of hospital 

admissions for trauma (Alexander et 

al. 1992).

n Between 20% and 30% of falls cause 

moderate to severe injuries that 

reduce mobility and independence 

and increase the risk of premature 

death (Alexander et al. 1992; Sterling 

et al. 2001). 

n In 2002, 1.64 million persons visited 

hospital emergency departments for 

nonfatal injuries; 388,000 of those 

treated were hospitalized (CDC 

2005). 

n Most fractures are caused by falls 

(Bell et al. 2000), and the most 

serious type is hip fracture. Up 

to 20% of hip fracture patients 

die within a year (Liebson et al. 

2002), and those who survive often 

experience significant disability and 

reduced quality of life (Wolinsky et 

al. 1997; Hall et al. 2000). 

n In 2001, about 327,000 hospital 

admissions were for hip fracture; 

76% were among women (CDC 

2001). 

n In 1994, fall injuries totaled $27.3 

billion. By 2020, the cost of these 

injuries is projected to reach $43.8 

billion (figures adjusted for inflation; 

Englander et al. 1996).

CDC’s Accomplishments

Falls prevention materials

In 1999, CDC’s Injury Center 

published the Tool Kit to Prevent Senior 

Falls. It contained fact sheets and 

health education materials (brochure 

and home safety checklist) aimed 

at reducing falls and related injuries 

among older adults. In 2001, Spanish 

versions of the brochure and checklist 

were made available. More than 6,000 

organizations used the Tool Kit in fall 

prevention programs. Materials were 

distributed to senior centers, hospitals, 

and health departments. Materials were 

also incorporated into professional 

presentations and instruction for 

nursing and other health care students. 

Although the Tool Kit is no longer 

available as a complete package, 

individual pieces (available in English, 

Spanish, and Chinese) have been 

updated and can be ordered at no cost 

or downloaded from www.cdc.gov/

ncipc/pub-res/toolkit/brochures.htm.

Dane County Safety Assessment 

For Elders (SAFE) research study 

In October 2002, CDC funded 

the Wisconsin Department of 

Health, in collaboration with the 

University of Wisconsin, to conduct 

a randomized controlled trial to assess 

the effectiveness of a comprehensive 

approach to preventing falls among 

community-dwelling, higher-risk 

adults ages 65 and older. It uses 

two complementary strategies: a 

comprehensive at-home assessment 

followed by individualized risk 

reduction and a broad-based program 

to educate primary care physicians 

and other health practitioners. The 

study began in late October 2003; 352 

participants have been enrolled to date, 

and 62 have completed their one-year 

enrollment period.

Older Adult Falls
Preventing Injuries in America: Public Health in Action 63

No More Falls! study

In October 2001, CDC funded the 

California State Health Department 

to conduct a randomized controlled 

multicomponent fall-prevention 

study for older adults. The study 

integrates fall prevention into the 

Preventive Health Care for the Aging 

(PHCA) program, a communitybased public health program for older 

adults. The study, which had about 

500 participants, was implemented 

in PHCA clinics in San Diego and 

Humboldt counties. The intervention 

included four elements: education 

about fall risk factors, referrals 

to community exercise programs 

to increase strength and balance, 

medication review, and home 

modification to reduce home hazards. 

The study was completed in 2004 and 

these data are now being analyzed.

National Resource Center 

on Safe Aging

In 1998, CDC funded the San Diego 

State University Foundation and the 

University Center on Aging at San 

Diego State University to develop a 

national resource center. The Resource 

Center’s mission is to gather and share 

the best information and resources on 

injury prevention and senior safety, 

including pedestrian and motor vehicle 

safety and the prevention of falls 

and elder abuse. Information can be 

obtained at www.safeaging.org. 

Program to prevent fire- and fallrelated deaths among older adults

In October 2000, CDC began 

funding state health departments in 

Arkansas, Maryland, Minnesota, North 

Carolina, and Virginia to implement 

and evaluate a program to teach older 

adults how to prevent fires and falls. 

Remembering When: A Fire and Fall 

Prevention Program for Older Adults 

is a curriculum developed by the 

National Fire Protection Association, 

CDC, and other partners. It uses 

lesson plans, brochures, fact sheets, 

game cards, and other educational 

materials to present 16 life-saving 

lessons. This program is the first of 

its kind to combine education about 

fire- and fall-related injury prevention 

among older adults and is one of the 

few off-the-shelf programs of its type 

available to communities. To date, 

382 group presentations and 457 

individual presentations have been 

conducted; 3,245 smoke alarms have 

been installed.

In August 2002, CDC and Georgia 

State University began evaluating the 

effectiveness of the Remembering 

When program to assess the knowledge 

and skills needed to reduce falls and 

fires. Preliminary data show significant 

gains in knowledge on space heaters, 

safe clothing, and fall reduction 

in bathtubs. The home assessment 

showed an increase in the use of bath 

mats, night lights, and working smoke 

alarms. Manuscripts are currently being 

written, including recommendations 

for dissemination.

Estimating the health care costs of 

older adult fall-related injuries

In 2003, North Carolina’s Research 

Triangle Institute was awarded a 

contract to estimate the direct medical 

cost of fall-related injuries among 

U.S. adults ages 65 and older for 

2000. Estimates for fatal falls were 

derived from directly measured acute 

care costs plus nursing home costs for 

those who survived beyond hospital 

discharge. Nonfatal fall injuries were 

identified using claims data for about 

4 million Medicare enrollees. The 

claims contained detailed payment 

information for all covered services 

(hospital inpatient, outpatient, skilled 

nursing, home health, hospice, 

physicians/supplier services, and 

durable medical equipment). 

Falls Free: Promoting a national 

action plan to prevent falls 

among older adults

Because falls are recognized as a 

major public health problem, the 

National Council on Aging (NCOA), 

in collaboration with CDC and 

with funding from The Archstone 

Foundation and the Home Safety 

Council, spearheaded an initiative titled 

Falls Free: Promoting a National Falls 

Prevention Action Plan. The initiative, 

which provides strategic input into the 

development of a national blueprint to 

prevent older adult falls, was released at 

the American Society on Aging-NCOA 

Conference in March 2005 (visit 

www.healthyagingprograms.org). 

Healthy Aging Prevention 

of Falls project

In October 2001, CDC’s Injury 

Center and the National Center for 

Chronic Disease Prevention and 

Health Promotion funded the National 

Safety Council (NSC) to conduct a 

series of 8 to 10 focus groups in urban 

and rural settings. Information will 

be gathered from seniors, caregivers, 

and health care providers about their 

knowledge and attitudes about safety. 

The focus groups will also be asked 

about two Injury Center brochures on 

fall prevention. From these findings, 

the NSC will create and test three 

brochures for seniors, families and 

caregivers, and medical and other 

senior service providers. 
Just the Facts . . .

Falls and Prevention 

n The most effective fall intervention 

strategy is a comprehensive 

clinical assessment combined with 

individualized fall risk reduction and 

patient follow-up (Rand 2003).

n Environmental risk factors in and 

around the home (i.e., tripping 

hazards, lack of stair railings, or 

poor lighting) can increase fall risk 

(Northridge et al. 1995; Connell 

1996, Gill et al. 1999). Improve 

home safety by installing handrails 

on both sides of stairs; installing 

grab bars next to the toilet and in 

the tub or shower; removing tripping 

hazards such as throw rugs and 

clutter; and using nonslip mats in 

the bathtub and on shower floors. 

n Poor vision 

increases the 

risk of falling 

(Lord and 

Dayhew 2001). 

At least once 

a year, seniors 

should have an eye doctor check 

their vision and correct it as much 

as possible. 

n Psychoactive medications such 

as tranquilizers, sleeping pills, 

and antianxiety drugs can make 

a person more likely to fall (Ray 

and Griffin 1990). Having a doctor 

or pharmacist review prescription 

and over-the-counter medicines 

can reduce side effects and 

interactions. 

n Muscle weakness, 

gait, and balance 

problems increase 

the risk of falling 

(Graafmans et al. 

1996; American 

Geriatrics Society 

2001). Exercise is 

an effective prevention strategy to 

improve leg strength and balance 

(Rand 2003). Tai Chi is one 

example of this type of exercise 

(Wolf et al. 1996).

CDC extramural research grants

CDC provides grant funding to 

researchers at universities, medical 

institutions, and community-based 

organizations to study various factors 

related to falls among older adults. 

Examples of those extramural research 

projects follow. For more information 

about these and other projects, visit 

www.cdc.gov/ncipc/res-opps/extra.htm.

n Understanding factors that 

influence hip protector use among 

community-dwelling seniors. CDC 

funds researchers at the University 

of North Carolina Injury Prevention 

Research Center to evaluate the 

acceptability of hip protectors 

among community-dwelling 

seniors. Researchers seek to identify 

perceived barriers, promote 

acceptability, and encourage hip 

protector use.

The researchers will identify a 

sample of community-dwelling older 

adults and explore their reactions 

and attitudes to hip protectors using 

a combination of focus group and 

interview strategies. Another group 

of participants will be interviewed 

and then provided with three pairs 

of hip protectors, instructed in 

their use, and asked to wear them 

for one week. Participants will be 

interviewed again after one week 

to find out their attitudes toward 

various aspects of the hip protectors 

(i.e., ease of use, comfort 

and fit, ease of care) and 

their physical difficulties or 

illnesses. Follow-up data will 

be collected about adherence, 

falls that may have occurred, 

and whether hip protectors 

were being worn at the time 

of the fall. This process will 

be repeated four times with different 

types of hip protectors.

n Preventing falls through enhanced 

pharmaceutical care. Researchers 

at the University of North Carolina 

at Chapel Hill evaluated the 

effectiveness of a community-based 

fall-prevention program delivered by 

community pharmacists. The target 

population comprised communitydwelling older adults ages 65 and 

older who had fallen within the 

past year, had used four or more 

prescription medications, or had 

used at least one medication that 

acts on the central nervous system. 

A community pharmacist consulted 

the intervention group about their 

current medications. The control 

group was given a series of monthly 

informational materials about 

prevention and treatment of health 

problems associated with aging 

(e.g., osteoporosis, heart disease) 

and lifestyle behaviors important for 

health maintenance (e.g., exercise). 

All individuals were followed for one 

year. Data about falls were collected 

via monthly falls calendars.

Future Steps 

Fall injuries place an enormous 

burden on individuals, society, and 

the health care system. Because the 

U.S. population is aging, this problem 

will worsen unless we take preventive 

action. Even though much is known 

about effective fall prevention strategies, 

these strategies need to be refined, 

implemented, disseminated, and 

promoted—especially at the local level. 

Further research would also help tailor 

interventions for populations with 

differing characteristics and risk factors. 

The resulting data would indicate the 

underlying causes or circumstances of 

falls and how these differ between men 

and women. Clarifying these differences 

and obtaining information about the 

location and events preceding a fallrelated injury is vital to identifying highrisk behaviors and situations and to 

developing and implementing improved 

fall prevention strategies. 

64 Preventing Injuries in America: Public Health in Action
Preventing Injuries in America: Public Health in Action 65

References

Alexander BH, Rivara FP, Wolf ME. The 

cost and frequency of hospitalization 

for fall-related injuries in older adults. 

American Journal of Public Health

1992;82(7):1020–1023.

American Geriatrics Society, British 

Geriatrics Society, American Academy 

of Orthopaedic Surgeons Panel on 

Falls Prevention. Guideline for the 

prevention of falls in older persons. 

Journal of the American Geriatrics Society

2001;49(5):664–672. 

Bell AJ, Talbot-Stern JK, Hennessy A. 

Characteristics and outcomes of older 

patients presenting to the emergency 

department after a fall: a retrospective 

analysis. Medical Journal of Australia

2000;173(4):176–177.

Centers for Disease Control and 

Prevention, National Center for Health 

Statistics. National Hospital Discharge 

Survey, Hyattsville (MD): Public Health 

Service; 2001. 

Centers for Disease Control and 

Prevention, National Center for Injury 

Prevention and Control. Web-based Injury 

Statistics Query and Reporting System 

(WISQARS) [online]. (2005). [cited 2005 

Jan 28]. Available from: URL: 

www.cdc.gov/ncipc/wisqars. 

Connell BR. Role of the environment 

in falls prevention. Clinics in Geriatric 

Medicine 1996;12(4):859–880.

Englander F, Hodson TJ, Terregrossa 

RA. Economic dimensions of slip and 

fall injuries. Journal of Forensic Sciences

1996;41(5):733–746.

Gill TM, Williams CS, Robison JT, 

Tinetti ME. A population-based study of 

environmental hazards in the homes of 

older persons. American Journal of Public 

Health 1999;89(4):553–556.

Graafmans WC, Ooms ME, Hofstee HMA, 

Bezemer PD, Bouter LM, Lips P. Falls 

in the elderly: a prospective study of risk 

factors and risk profiles. American Journal of 

Epidemiology 1996;143:1129–1136.

Hall SE, Williams JA, Senior JA, 

Goldswain PR, Criddle RA. Hip fracture 

outcomes: quality of life and functional 

status in older adults living in the 

community. Australian & New Zealand 

Journal of Medicine 2000;30(3):327–332.

Hausdorff JM, Rios DA, Edelber HK. 

Gait variability and fall risk in communityliving older adults: a 1-year prospective 

study. Archives of Physical Medicine and 

Rehabilitation 2001;82(8):1050–1056. 

Hornbrook MC, Stevens VJ, Wingfield 

DJ, Hollis JF, Greenlick MR, Ory MG. 

Preventing falls among communitydwelling older persons: results from 

a randomized trial. The Gerontologist

1994:34(1):16–23. 

Leibson CL, Tosteson ANA, Gabriel SE, 

Ransom JE, Melton JL III. Mortality, 

disability, and nursing home use for persons 

with and without hip fracture: a populationbased study. Journal of the American 

Geriatrics Society 2002;50:1644–1650.

Lord SR, Dayhew J. Visual risk factors for 

falls in older people. Journal of the American 

Geriatrics Society 2001;49:508–515. 

Northridge ME, Nevitt MC, Kelsey JL, 

Link B. Home hazards and falls in the 

elderly—the role of health and functional 

status. American Journal of Public Health

1995;85(4):509–515.

Rand Report: Southern California 

Evidence-Based Practice Center. 

Evidence report and evidence-based 

recommendations: fall prevention 

interventions in the Medicare population; 

2003. Contract number 500-98-0281.

Ray W, Griffin MR. Prescribed medications 

and the risk of falling. Topics in Geriatric 

Rehabilitation 1990;5:12–20.

Sterling DA, O’Connor JA, Bonadies J. 

Geriatric falls: injury severity is high and 

disproportionate to mechanism. Journal of 

Trauma-Injury, Infection and Critical Care 

2001;50(1):116–119.

Wolf SL, Barnhart HX, Kutner NG, 

McNeely E, Coogler C, Xu T. Reducing 

frailty and falls in older persons: an 

investigation of Tai Chi and computerized 

balance training. Atlanta FICSIT 

Group. Frailty and injuries: cooperative 

studies of intervention techniques. 

Journal of the American Geriatrics Society

1996;44(5):489–497.

Wolinsky FD, Fitzgerald JF, Stump TE. 

The effect of hip fracture on mortality, 

hospitalization, and functional status: a 

prospective study. American Journal of 

Public Health 1997;87(3):398–403.
66 Preventing Injuries in America: Public Health in Action 

The Problem

In the United States, a total of 4,749 

pedestrians died from traffic-related 

injuries and another 70,000 sustained 

nonfatal injuries in 2003. On average, 

a pedestrian is killed in a traffic crash 

every 111 minutes and is injured every 

8 minutes (NHTSA 2004). 

n In 2003, almost one quarter (22%) 

of children ages 5 to 9 years killed 

in traffic crashes were pedestrians 

(NHTSA 2004).

n Pedestrians ages 75 and older 

accounted for 16% of all pedestrian 

deaths and about 6% of nonfatal 

pedestrian injuries in 2003. The 

pedestrian death rate for this age 

group is higher than for other age 

groups (NHTSA 2004).

n The pedestrian fatality rate is more 

than twice as high for men as for 

women (NHTSA 2004).

n In 2003, 34% of pedestrians killed 

by a motor vehicle and 13% of 

drivers who killed pedestrians were 

intoxicated, with blood alcohol 

concentrations of 0.08% or more 

(NHTSA 2004). 

Certain racial and ethnic groups are 

at increased risk for pedestrian deaths 

(CDC 2005).

n American Indians and Alaska 

Natives have rates 3 times higher 

than whites.

n African-Americans pedestrian deaths 

are 1.7 times that of whites.

n Hispanics die at a rate 1.8 times 

higher than non-Hispanics.

CDC’s Accomplishments

Understanding community 

characteristics

CDC-funded researchers at Johns 

Hopkins University studied community 

characteristics that may affect 

interventions to prevent child pedestrian 

injuries. Researchers compared four 

neighborhoods with varying risks of 

pedestrian injury and median household 

income. Their findings associated child 

pedestrian risk with wide roads and 

parking on both sides of the street. 

Although parents often allowed children 

younger than the recommended age 

of 10 years to cross streets alone, 

researchers found that parents were 

willing to become involved in child 

pedestrian safety initiatives.

CDC extramural research grants

CDC provides grant funding to 

researchers at universities, medical 

institutions, and community-based 

organizations to study various factors 

related to pedestrian safety. A sample 

of those extramural research projects 

follows. For more information about 

these and other projects, visit www.cdc.

gov/ncipc/res-opps/extra.htm. 

n Mapping risk and evaluating 

interventions. The Departments 

of Public Health and Parking 

and Traffic in the County of San 

Francisco have been funded to better 

understand pedestrian safety and to 

pursue intervention strategies. They 

will use geographic information 

systems (GIS) to analyze pedestrian 

Pedestrian Injuries
Preventing Injuries in America: Public Health in Action 67

Future Steps

To improve pedestrian safety 

and to identify the most effective 

interventions, rigorous evaluation of 

prevention programs must continue. 

Meanwhile, some evidence shows 

that environments can be modified 

to substantially reduce the risk of 

pedestrian injuries (Retting et al. 2003). 

Such modifications include 

separating pedestrians from vehicles 

by time or space (e.g., sidewalks), 

increasing pedestrian visibility (e.g., 

better lighting at crosswalks), and 

reducing vehicle speed (e.g., replacing 

conventional intersections with 

roundabouts). 

References

Centers for Disease Control and 

Prevention, National Center for Injury 

Prevention and Control. Web-based Injury 

Statistics Query and Reporting System 

(WISQARS) [online]. (2005). [cited 2005 

Feb 23]. Available from: URL: www.cdc.

gov/ncipc/wisqars. 

National Highway Traffic Safety 

Administration (NHTSA), Department of 

Transportation (US). Traffic Safety Facts 2003: 

Pedestrians. Washington (DC): NHTSA; 

2004. [cited 2005 Feb 23]. Available from: 

URL: www-nrd.nhtsa.dot.gov/pdf/nrd-30/

NCSA/TSF2003/809769.pdf.

Retting RA, Ferguson SA, McCartt AT. A 

review of evidence-based traffic engineering 

measures designed to reduce pedestrianmotor vehicle crashes. American Journal of 

Public Health 2003;93:1456–1463.

injury outcomes by location. This 

analysis will be used to identify 

intersections, neighborhoods, 

and traffic corridors that are most 

hazardous to pedestrians; to identify 

environmental risk factors that 

constitute those hazards; and to 

evaluate the effect of installing 

special pedestrian signals. 

n Pediatric pedestrian safety in 

virtual reality. Researchers at 

the University of Alabama at 

Birmingham are developing and 

validating virtual reality (VR) 

software as a tool for training 

children about pedestrian safety. 

VR software and hardware will be 

developed to simulate a street with 

realistic, computer-controlled traffic 

patterns. The virtual environment 

will allow participants to engage in 

(and investigators to measure) streetcrossing behavior in a laboratory or 

classroom setting. While engaging in 

the virtual environment, participants 

will stand on an artificial curb, view 

traffic on a five-monitor semicircular 

display in front of them, and hear 

traffic through surround-sound 

speakers. Stepping off the curb will 

activate a pressure sensor connected 

to the computer to record when 

participants begin crossing. After 

the software is developed, two 

validation studies will be conducted: 

one with adults and a second with 

children. Subsequent research phases 

will use the VR environment as an 

intervention tool to train children on 

pedestrian safety.
68 Preventing Injuries in America: Public Health in Action 

The Problem

Available statistics show the United 

States has the sixth highest fire death 

rate among 25 developed countries 

(International Association for the 

Study of Insurance Economics 2003). 

On average in the United States in 

2003, someone died in a fire every 

2 hours (every 134 minutes), and 

someone was injured every 29 minutes 

(Karter 2004). 

n In 2003, fire departments responded 

to 402,000 home fires in the United 

States which claimed the lives of 

an estimated 3,145 people (not 

including firefighters) and injured 

another 14,075 (Karter 2004).

n Cooking is the primary cause of 

residential fires; smoking is the 

leading cause of fire-related deaths 

(Ahrens 2003). Alcohol contributes 

to about 40% of residential fire 

deaths (Smith et al. 1999).

n In 2003, residential fires resulted in 

direct property damage totaling 

$6 billion (Karter 2004). 

Who is at the greatest risk for firerelated deaths?

n Children ages 4 and younger 

(CDC 2005) 

n Adults ages 65 and older 

(CDC 2005)

n The poorest Americans 

(Istre et al. 2001)

n African Americans and Native 

Americans (NCHS 1998)

n Persons living in rural areas 

(Ahrens 2003)

n Persons living in manufactured 

homes or substandard housing 

(Runyan et al. 1992; Parker et al. 

1993)

CDC’s Accomplishments

Preventing residential 

fire-related injuries

CDC works in partnership with the 

U.S. Fire Administration (USFA), 

the U.S. Consumer Product Safety 

Commission (CPSC), and several 

nongovernment organizations to 

coordinate a national effort that 

will help to eliminate residential fire 

deaths by 2020. To support this effort, 

Congress appropriated $5 million in 

fiscal year 2002 to the three agencies 

for a new fire safety campaign targeting 

high-risk populations—older adults, 

children, and firefighters. The partners 

have initiated activities related to 

surveillance, research, community 

programs, and marketing. Joint 

activities include research on the 

risk factors for residential fire-related 

injuries; data collection and analysis 

to track trends and progress; CDC’s 

community-based smoke alarm 

installation and fire safety education 

project; and a pilot project to examine 

a community-based Civilian Fire Safety 

Corps, whose primary purpose is to 

conduct fire safety education. Recently, 

CDC and USFA began to assess the 

effectiveness of fire safety programs 

and initiatives that their agencies have 

traditionally funded.

Funded partnership saves lives

Since 1998, CDC has funded smoke 

alarm installation and fire safety 

education programs in high-risk 

communities—those with fire death 

rates higher than state and national 

averages and median household 

incomes below the poverty level. An 

informal sample of program homes 

found that an estimated 1,071 lives 

may have been saved thus far. Program 

staff have canvassed more than 382,000 

homes and installed more than 

275,000 long-lasting smoke alarms in 

high-risk homes, targeting households 

with children ages 5 years and younger 

and adults ages 65 years and older. Fire 

safety messages have reached millions 

of people because of these programs. 

CDC funded 14 states from 1998 to 

2000. Based on the success of these 

programs, CDC awarded five-year 

cooperative agreements to 13 states in 

2001 to install long-lasting, lithiumResidential Fires
Preventing Injuries in America: Public Health in Action 69

powered smoke alarms and to provide 

fire-safety education for homes in 

high-risk communities. Those states 

are: Alabama, Alaska, Georgia, Kansas, 

Kentucky, Minnesota, Mississippi, 

New York, North Carolina, Oklahoma, 

South Carolina, Virginia, and 

Washington. In 2002, an additional 

3 states (Arkansas, Massachusetts, 

and Montana) were awarded funding 

for these activities, bringing the total 

number of CDC-funded states to 16. 

Three stories demonstrate how these 

programs helped save lives:

n A young boy awoke to the sound 

of the smoke alarm that had been 

installed in his home the year before 

through a CDC-funded program. 

A candle that had been left burning 

near a recliner had set the chair 

on fire. Upon hearing the alarm, 

the boy awakened his mother and 

they escaped without injury. The 

fire destroyed the house; the smoke 

alarm saved its residents. 

n Firefighters in a major city 

expressed concern for a particular 

neighborhood after repeatedly 

responding to fires in homes without 

smoke alarms. The firefighters went 

door-to-door in the community to 

install smoke alarms and distribute 

educational materials provided by 

the Injury Prevention Service at the 

State Department of Health. In one 

month, they canvassed a square mile 

and installed 50 smoke alarms. Not 

long after their campaign, a six-yearold child in one of the homes started 

a fire while playing with matches. 

The smoke alarm alerted the mother, 

and the residents of the home 

escaped without injury. 

n As part of a CDC-funded program, a 

firefighter installed a working smoke 

alarm for a family whose alarm had 

no battery. A few weeks later, the 

father woke early to light an oil 

space heater. Under medication for 

surgery at the time, he forgot to 

open the damper to the chimney. He 

returned to bed, and the heater soon 

began discharging soot throughout 

the home. Smoke from the heater 

quickly reached the next room, 

which contained the newly installed 

alarm. The alarm woke the family, 

and they immediately turned off 

the heater before opening doors and 

windows to ventilate the home. The 

father stated that if the alarm hadn’t 

sounded, the family would have 

suffered smoke inhalation, carbon 

monoxide poisoning, or worse. 

Program to prevent fire- and fallrelated deaths among older adults

In October 2000, CDC began 

funding state health departments in 

Arkansas, Maryland, Minnesota, North 

Carolina, and Virginia to implement 

and evaluate a program to teach older 

adults how to prevent fires and falls. 

Remembering When: A Fire and 

Fall Prevention Program for Older 

Adults is a curriculum developed 

by the National Fire Protection 

Association, CDC, and other partners. 

Remembering When uses lesson 

plans, brochures, fact sheets, game 

cards, and other educational materials 

to present 16 life-saving lessons. 

This program is the first of its kind 

to combine education about both 

fire- and fall-related injury prevention 

among older adults and is one of the 

few off-the-shelf programs available to 

communities for this purpose. To date, 

at least 382 group presentations and 

457 individual presentations have been 

conducted and 3,245 alarms have been 

installed.

In August 2002, CDC and Georgia 

State University began to evaluate 

the effectiveness of the Remembering 

When program. The evaluation 

included an examination of knowledge 

and skills needed to reduce falls and 

fires. Preliminary data show significant 

knowledge increases in areas such as 

space heater safety, safest clothing to 

wear, and bathtub falls. The home 

assessment shows gains in use of bath 

mats, night-lights, and workable 

smoke alarms. Manuscripts, including 

recommendations, are being developed.

Informing consumers about 

smoke alarm options

CDC has been working with the 

U.S. Consumer Product Safety 

Commission, National Institute 

of Standards and Technology, 

National Fire Protection Association, 

Underwriters Laboratories Inc., 

the U.S. Fire Administration, U.S. 

Department of Housing and Urban 

Development, and other partners to 

evaluate current and prototypic smoke 

alarm technologies. Researchers have 

tested the smoke alarm responses to 

serious residential fires and resistance 

to nuisance alarms. An official report 

documenting the findings is available 

at http://smokealarm.nist.gov.
70 Preventing Injuries in America: Public Health in Action 

Understanding human behaviors 

during a residential fire

CDC is directing development of 

the Human Behavior Fire Study 

(HBFS), in collaboration with the 

Battelle Centers for Public Health 

Research and Evaluation and the 

University of Maryland’s Department 

of Fire Protection Engineering. This 

research identifies behavioral factors in 

residential fires associated with injuries 

and fatalities. To develop effective 

public health interventions to reduce 

the number of fire-related casualties, 

people’s responses to a fire event 

must be identified and characterized. 

Researchers will gather detailed data on 

the sequence of events and behaviors of 

people involved in fires by interviewing 

those injured in residential fires or 

their surrogates. Data to be collected 

and analyzed include the cause of the 

fire, behaviors at each point in time 

following awareness of the fire, and 

injury outcomes.

CDC-funded research grants

CDC provides grant funding to 

researchers at universities, medical 

institutions, and community-based 

organizations to study various factors 

related to residential fires. An example 

of those extramural research projects 

follows. For more information about 

grants and other projects, visit www.

cdc.gov/ncipc/res-opps/extra.htm. 

n Rural smoke alarm trial. 

University of Iowa researchers are 

comparing the effectiveness of two 

alternative types of smoke alarms 

and two different life spans of 

battery. The primary study outcome 

is the presence of working smoke 

alarms. At the start of the study, 

researchers will install new, batterypowered photoelectric alarms in 

400 homes and ionizing alarms in 

400 homes. Half the alarms in each 

group will have alkaline batteries; in 

the other half, the alarms will have 

lithium batteries. After 18 months 

and 42 months, researchers will 

revisit the homes to determine which 

ones still have working alarms. 

Future Steps

Efforts to address residential fire-related 

injuries and deaths in this country 

must include the following activities:

n Across the country, track the number 

of homes with sprinkler systems and 

homes with an adequate number 

of correctly placed, working smoke 

alarms; identify communities with 

legislation and local ordinances 

related to fire-injury prevention (e.g., 

requirements for hard-wired smoke 

alarms and sprinkler systems).

n Expand existing smoke alarm 

installation and fire safety education 

programs.

n Apply lessons learned from an 

evaluation of current programs 

to increase the effectiveness and 

efficiency of community-based 

programs.

n Expand foundational research 

settings to include apartment 

buildings and high-rises.

n Research fire prevention technology 

(e.g., more effective, long-lasting 

smoke alarms; residential sprinkler 

systems; safer portable heaters; stoves 

with automatic shut-off features; and 

fire-retardant housing materials).

n Perform cost-benefit and costeffectiveness studies to better 

understand the economic impact of 

interventions.

References

Ahrens M. The U.S. Fire Problem Overview 

Report: leading causes and other patterns 

and trends. Quincy (MA): National Fire 

Protection Association; 2003.

Centers for Disease Control and 

Prevention, National Centers for Injury 

Prevention and Control. Web-based Injury 

Statistics Query and Reporting System 

(WISQARS) [online]. (2005) [cited 2005 

Mar 3]. Available from: URL: www.cdc.

gov/ncipc/wisqars. 

International Association for the Study 

of Insurance Economics. The world fire 

statistics: information bulletin of the world 

fire statistics. Geneva (Switzerland): The 

Geneva Association; 2003.

Istre GR, McCoy MA, Osborn L, 

Barnard JJ, Bolton A. Deaths and injuries 

from house fires. New England Journal of 

Medicine 2001;344:1911–1916.

Karter MJ. Fire loss in the United States 

during 2003. Quincy (MA): National Fire 

Protection Association, Fire Analysis and 

Research Division; 2004.

National Center for Health Statistics 

(NCHS). National Vital Statistics System. 

Hyattsville (MD): Department of Health 

and Human Services (US), Centers for 

Disease Control and Prevention, NCHS; 

1998.

Parker DJ, Sklar DP, Tandberg D, 

Hauswald M, Zumwalt RE. Fire fatalities 

among New Mexico children. Annals of 

Emergency Medicine 1993;22(3):517–522. 

Runyan CW, Bangdiwala SI, Linzer MA, 

Sacks JJ, Butts J. Risk factors for fatal 

residential fires. New England Journal of 

Medicine 1992;327(12):859–863. 

Smith GS, Branas C, Miller TR. Fatal 

nontraffic injuries involving alcohol: a 

meta-analysis. Annals of Emergency Medicine

1999;33(6):659–668.
Preventing Injuries in America: Public Health in Action 71

The Problem

In a report issued by the World Health 

Organization (WHO) in 2004, Peden 

et al. described the severity of the 

problem: 

n Road traffic crashes kill 1.2 million 

people a year worldwide—an average 

of 3,242 people every day.

n Road traffic crashes injure or disable 20 

million to 50 million people each year.

n Road traffic crashes rank as the 11th 

leading cause of death and account 

for 2% of all deaths globally.

n Most road traffic injuries affect 

people in low- and middle-income 

countries, especially young males 

and vulnerable road users such as 

pedestrians and cyclists.

n By 2020, road traffic injuries are 

predicted to become the third largest 

contributor to the global burden of 

disease.

n The economic cost of road traffic 

injuries is enormous; worldwide, the 

cost is an estimated $518 billion.

CDC’s Accomplishments

CDC partners with WHO to 

celebrate World Health Day 2004: 

Road Traffic Safety

CDC took an active role celebrating 

World Health Day 2004, the theme 

of which was “Road Safety is No 

Accident.” CDC Injury Center staff 

represented CDC and the Department 

of Health and Human Services at key 

events, including the official WHO 

launch of the World Report on Road 

Traffic Injury Prevention, held in Paris, 

and the U.S. launch of World Health 

Day. Staffers also observed World 

Health Day by coordinating related 

events addressing road safety. The 

theme for CDC’s U.S. World Health 

Day activities, “Family Road Safety: 

Protect the Ones You Love,” focused 

on occupant protection, impaired 

driving, pedestrian safety, and helmet 

use. CDC distributed more than 3,800 

World Health Day information kits, 

displayed World Health Day banners 

at injury conferences, and published 

information about World Health 

Day and the World Report in CDC’s 

Morbidity and Mortality Weekly Report, 

available at www.cdc.gov/mmwr/

preview/mmwrhtml/mm5312a1.htm.

World Report on Road Traffic 

Injury Prevention 

CDC researchers participated with 

WHO to plan, develop, and write the 

World Report on Road Traffic Injury 

Prevention—the first major report 

jointly issued by the WHO and the 

World Bank about road traffic injuries. 

The report underscores concerns that 

unsafe road traffic systems (drivers, 

roads, vehicles) seriously harm global 

public health and development. The 

authors contend that the level of 

road traffic injury is unacceptable 

and largely avoidable. The report 

was launched on April 7, 2004, in 

conjunction with World Health Day. 

Future Steps

CDC staff are members of the 

United Nations (UN) Road Safety 

Collaboration, a WHO-led initiative 

to coordinate road safety and health 

efforts worldwide as specified in the UN 

Road Traffic Safety

General Assembly resolution 58/289 

(improving global road safety) and the 

World Health Assembly resolution 

557.10 (road safety and public health). 

To support this effort, CDC helped 

design and field-test injury prevention 

training curricula for use in developing 

countries. In the next few years, staff 

members will work closely with WHO, 

the Pan American Health Organization 

(PAHO), and other international 

organizations to help package and 

disseminate these curricula (which 

include road traffic injury surveillance 

and program evaluation) to developing 

countries. CDC will continue to work 

closely with other UN organizations to 

develop strategies for implementing the 

recommendations from the 2004 World 

Report on Road Traffic Injury Prevention.

References

Greenspan A. Notice to readers: World 

Health Day−April 7, 2004. Morbidity and 

Mortality Weekly Report 2004;53(12):257. 

Available from: URL: www.cdc.gov/mmwr/

preview/mmwrhtml/mm5312a1.htm.

Peden M, Scurfield R, Sleet D, Mohan D, 

Hyder A, Jarawan E, et al. editors. World 

Report on Road Traffic Injury Prevention.

Geneva: World Health Organization; 2004. 

[cited 2005 Feb 23]. Available from: URL: 

www.who.int/world-health-day/2004/

infomaterials/world_report/en/.
72 Preventing Injuries in America: Public Health in Action 

The Problem

n Between 1994 and 1999, 172 

students ages 5 to 18 were killed on 

or near school grounds or at schoolrelated activities (Anderson et al. 

2001).

n More than 50% of school-associated 

violent deaths occur at the beginning 

or end of the school day or during 

lunch (Anderson et al. 2001). 

n School-associated homicide rates are 

highest near the start of each school 

semester; suicide rates are generally 

higher in the spring semester (CDC 

2001). 

n Overall, nonfatal violence-related 

behaviors among high school 

students in the United States have 

decreased since 1991 (CDC 2004). 

n In a nationwide survey, 12.8% of 

students had been in a physical fight 

on school property one or more 

times in the 12 months preceding 

the survey (Grunbaum et al. 2004).

• Among students nationwide, 6.1% 

reported carrying a weapon (e.g., 

gun, knife, or club) on school 

property in the 30 days preceding 

the survey.

• Nationwide, 9.2% of students had 

been threatened or injured with a 

weapon (e.g., gun, knife, or club) 

on school property one or more 

times in the 12 months preceding 

the survey. Overall, the prevalence 

of having been threatened or 

injured with a weapon on school 

property was higher among males 

(11.6%) than females (6.5%).

• Some students nationwide (5.4%) 

had not attended school at least 

one of the 30 days preceding the 

survey because they felt unsafe at 

school or while en route.

CDC’s Accomplishments

Tracking school-associated 

violent deaths

With the U.S. Department of 

Education and U.S. Department 

of Justice, CDC has conducted a 

national study of school-associated 

violent deaths since 1992. The latest 

findings, published in the Journal of the 

School Violence

School-related violent deathsare those that occur on school 

grounds, on the way to and from 

school, and on the way to and 

from school-sponsored activities 

(Anderson et al. 2001).

American Medical Association in 2001, 

show 220 incidents of school violence 

occurred between July 1, 1994, and 

June 30, 1999. Most incidents were 

homicides involving firearms. While 

the number of incidents has decreased 

steadily since 1992, the number of 

multiple-victim incidents has increased. 

This study plays an important role in 

monitoring school violence trends, 

identifying risk factors for school 

violence, and assessing the effects of 

prevention efforts.

Multisite project evaluates 

prevention effort

CDC is funding a multisite trial of a 

violence prevention program aimed 

at middle school students. Thirtyseven middle schools in four states 

are participating. The program being 
evaluated teaches students conflict 

resolution and problem-solving 

skills, trains teachers about violence 

prevention, and engages family 

members in program activities. The 

project––affiliated with Virginia 

Commonwealth University, the 

University of Illinois at Chicago, the 

University of Georgia, and Duke 

University––represents one of the 

largest efforts to date to assess the 

effectiveness of school-based violence 

prevention among middle school 

students.

National resource center 

offers wealth of information

The National Youth Violence 

Prevention Resource Center serves as 

a central source for information and 

materials gathered from institutions, 

community-based organizations, and 

federal agencies working to prevent 

violence among our nation’s youth. 

The Center’s website, toll-free hotline, 

and fax-on-demand service offer access 

to information about prevention 

programs, publications, research and 

statistics, and fact sheets. The website 

links parents, teens, and researchers 

to materials designed specifically for 

those audiences. Each month, the 

Center hosts more than 37,000 website 

visitors, fulfills more than 500 requests 

for publications and youth violence 

prevention materials, and responds 

to more than 100 public inquiries 

and requests for technical assistance. 

For more information, call 1-866-

SAFEYOUTH (1-866-723-3968) or 

visit www.safeyouth.org. 

Assessment tool for 

school environments

CDC is supporting the development 

of a tool to assess the physical 

characteristics of schools that can 

contribute to feelings of safety, 

increase prosocial behavior, and 

decrease aggressive behavior. The 

tool uses the Crime Prevention 

Through Environment Design 

(CPTED) framework. The core 

principles of CPTED include reducing 

opportunities for crime, enhancing 

natural surveillance of activities, 

and reinforcing a sense that the 

environment is cared for and that 

problems will be addressed. 

Enhancing State Capacity to 

Address Child and Adolescent 

Health Through Violence Prevention 

(ESCAPe)

CDC’s ESCAPe program is designed 

to develop capacity and leadership in 

preventing all types of violence toward 

or among children and adolescents, 

including school-associated violence. 

The planning and implementation 

phases of this project will address 

shared risk and protective factors for 

these forms of violence. Colorado, 

Iowa, Massachusetts, Michigan, 

Minnesota, New Mexico, Rhode 

Island, and Virginia have received 

funding.

Social and character 

development research program

CDC and the U.S. Department of 

Education have launched a social 

and character development research 

program. Researchers are evaluating 

the effectiveness of interventions 

designed to promote positive social 

and character development, increase 

positive behaviors, and reduce 

antisocial behaviors among elementary 

school children. 

Academic centers link researchers 

and communities

Eight colleges and universities have 

received CDC funding to establish 

National Academic Centers of 

Excellence (ACEs) on Youth Violence. 

These centers foster joint efforts 

between university researchers and 

communities to address the problem of 

youth violence, including violence at 

school. For information about specific 

Just the Facts . . .

Risk Behaviors Among 

High School Students 

Findings from students surveyed 

nationwide (Grunbaum 2004):

n 6.1% had carried a weapon 

(e.g., gun, knife, or club) on 

school property in the 30 days 

preceding the survey.

n 9.2% had been threatened or 

injured with a weapon (e.g., gun, 

knife, or club) on school property 

one or more times during the 12 

months preceding the survey.

n 12.8% had been in a physical 

fight on school property one 

or more times during the 12 

months preceding the survey.

n 5.4% had not gone to school 

on at least one of the 30 days 

preceding the survey because 

they felt unsafe at school or 

while en route.

Preventing Injuries in America: Public Health in Action 73
74 Preventing Injuries in America: Public Health in Action 

programs to prevent school violence 

conducted by the ACEs, visit www.cdc.

gov/ncipc/res-opps/ACE/ace.htm.

Collaboration with other 

parts of CDC

CDC’s Injury Center has worked with 

the Division of Adolescent and School 

Health, part of CDC’s National Center 

for Chronic Disease Prevention and 

Health Promotion, on a number of 

projects related to school violence. 

Examples of this collaboration follow:

n School Health Guidelines to 

Prevent Unintentional Injuries 

and Violence. These guidelines 

help state and local educational 

agencies and schools promote 

safety and teach students the skills 

needed to prevent injuries and 

violence. Guidance is provided for 

all components of a coordinated 

school health program encompassing 

all grade levels. Specialists from 

universities and from national, 

federal, state, and local agencies 

and organizations collaborated to 

develop the guidelines. Development 

was based on in-depth review of 

research, theory, and current practice 

in unintentional injury, violence, 

and suicide prevention; health 

education; and public health. The 

guidelines are available at www.cdc.

gov/HealthyYouth/injury/guidelines.

n Healthy Passages. Healthy Passages 

is a multiyear longitudinal study to 

help families, schools, communities, 

and health care providers understand 

how children grow to be healthy, 

educated, and productive members 

of society. The study will help 

explain why young people make 

healthy or risky behavior choices. 

Data collection, which began in 

fall 2004, will provide information 

about injury and violence issues, 

including individual and family 

factors associated with bullying and 

how behaviors change over time.

n Youth Risk Behavior Surveillance 

System. CDC’s Youth Risk Behavior 

Surveillance System (YRBSS) 

monitors priority health risk 

behaviors that contribute to the 

leading causes of death, disability, 

and social problems among youth 

and adults in the United States, 

including behaviors that contribute 

to unintentional injuries and 

violence. The YRBSS consists of 

national, state, and local schoolbased surveys of representative 

samples of 9th through 12th grade 

students. The surveys, conducted 

biennially, provide information on 

suicide- and interpersonal violencerelated behaviors both on school 

property and in the community.

n School Health Policies and 

Programs Study (SHPPS). This 

national survey is conducted 

periodically to assess school health 

policies and programs at state, 

district, school, and classroom 

levels. SHPPS was first conducted 

by CDC’s Division of Adolescent 

and School Health (DASH) in 1994 

and was repeated in 2000. SHPPS 

provides information on health 

education, programs, environmental 

strategies, and policies that states, 

districts, and schools use to address 

violence and suicide prevention.

n School Health Index. This selfassessment and planning tool enables 

a school to identify the strengths 

and weaknesses of its health and 

safety policies and programs; to 

develop an action plan for improving 

student health and safety; and to 

involve teachers, parents, students, 

and the community in improving 

school services. The third edition of 

the School Health Index, including 

unintentional injury and violence 

prevention items, is available at 

www.cdc.gov/nccdphp/dash/SHI/

index.htm.

Future Steps

CDC’s Injury Center works to 

improve the capacity of local and 

state authorities, community-based 

organizations, and private sector 

partners so they can better support 

services and policies proven to prevent 

school violence.

Steps to prevent school violence:

n Continue work with partners such as 

the U.S. Department of Education 

and U.S. Department of Justice to 

better track and monitor school 

violence.

n Identify factors that increase or 

decrease risk of school violence.

n Develop and test new strategies to 

prevent school violence.

References

Anderson MA, Kaufman J, Simon 

TR, Barrios L, Paulozzi L, Ryan G, et 

al. School-associated violent deaths in 

the United States, 1994–1999. Journal 

of the American Medical Association

2001;286:2695–2702.

Centers for Disease Control and 

Prevention. Temporal variations in schoolassociated student homicide and suicide 

events—United States, 1992–1999. 

Morbidity and Mortality Weekly Report

2001;50(31);657–660.

Centers for Disease Control and 

Prevention. Violence-related behaviors 

among high school students—United 

States, 1991–2003. Morbidity and Mortality 

Weekly Report 2004;53(29):651–655.

Grunbaum JA, Kann L, Kinchen S, Ross 

JG, Lowry R, Harris WA, et al. Youth 

risk behavior surveillance—United States, 

2003. Morbidity and Mortality Weekly 

Report 2004;53(SS-2):1–100. Available 

from: URL: www.cdc.gov/mmwr/preview/

mmwrhtml/ss5302a1.htm.
Preventing Injuries in America: Public Health in Action 75

The Problem

n According to the National Violence 

Against Women Survey, 1 in 6 

women and 1 in 33 men in the 

United States has experienced at least 

one attempted or completed rape in 

their lifetime (Tjaden and Thoennes 

2000).

n The National Violence Against 

Women Survey estimates that 

302,091 women and 92,748 men 

were raped in the 12 months prior to 

the survey. Victims often experience 

more than one rape. Of those 

raped in the 12 months preceding 

the survey, on average, women 

experienced 2.9 rapes and men 

experienced 1.9 rapes (Tjaden and 

Thoennes 2000).

n In 8 of 10 rape cases, the victim 

knew the perpetrator (Tjaden and 

Thoennes 2000).

n Fifty-four percent of female rapes 

occur before age 18; 22% of these 

rapes occur before age 12 (Tjaden 

and Thoennes 2000).

n According to the Youth Risk 

Behavior Survey, a national survey of 

high school students, about 9% of 

students report having been forced 

to have sexual intercourse at some 

time in their lives. More female 

students (11.9%) than male students 

(6.1%) reported having been 

sexually assaulted. Overall, 12.3% of 

black students, 10.4% of Hispanic 

students, and 7.3% of white students 

reported forced sexual intercourse 

(Grunbaum et al. 2004). 

n A review of state Child Protective 

Services (CPS) records for child 

abuse and neglect showed that 

88,656 children in the United States 

experienced sexual abuse in 2001 

(ACYF 2004).

n A number of long-lasting physical 

symptoms and illnesses are associated 

with sexual victimization including 

chronic pelvic pain; premenstrual 

Sexual Violence

Sexual violence includes a wide range of acts that occur in different settings. 

There are four types of sexual violence (Basile and Saltzman 2002):

n Attempted (but not completed) sex act without the victim’s consent, 

or involving a victim who is unable to provide consent or to refuse. 

n Abusive sexual contact including intentional touching, either directly or 

through the clothing, of the genitalia, anus, groin, breast, inner thigh, or 

buttocks of any person without his or her consent, or of a person who is 

unable to consent or to refuse.

n Completed sex act without the victim’s consent, or involving a victim 

who is unable to provide consent or to refuse. A sex act is defined as 

contact between the penis and the vulva or the penis and the anus 

involving penetration, however slight; contact between the mouth and 

penis, vulva, or anus; or penetration of the anal or genital opening of 

another person by a hand, finger, or other object.

n Non-contact sexual abuse including voyeurism; intentional exposure of 

an individual to exhibitionism; pornography; verbal or behavioral sexual 

harassment; threats of sexual violence to accomplish some other end; or 

taking nude photographs of a sexual nature of another person without his 

or her consent or knowledge, or of a person who is unable to consent or 

refuse.
76 Preventing Injuries in America: Public Health in Action 

syndrome; gastrointestinal disorders; 

and a variety of chronic pain 

disorders such as headache, back 

pain, and facial pain. Reproductive 

and mental health consequences 

are also associated with sexual 

victimization (Krug et al. 2002; 

Campbell and Soeken 1999; Koss 

and Heslet 1992).

CDC’s Accomplishments

Measuring the incidence and 

prevalence of intimate partner 

violence and sexual violence

With external partners, CDC has 

developed two surveys to help states 

better assess the problem of intimate 

partner violence, sexual violence, 

and resulting injuries. The surveys 

are available as optional modules 

in the CDC Behavioral Risk Factor 

Surveillance System. In addition to 

providing data on the incidence and 

prevalence of the problem, these 

surveys will provide knowledge of the 

related attitudes and norms that allow 

violence to occur. Data may also be 

used to compare statistics across states, 

assess the impact of programs, and 

guide policy development.

Uniform Definitions and 

Recommended Data Elements 

for Sexual Violence

In 2002, CDC published Sexual 

Violence Surveillance: Uniform 

Definitions and Recommended Data 

Elements to improve and standardize 

data collection. In the absence of 

standards, researchers have used 

varying terms to describe acts of sexual 

violence. These inconsistencies have 

contributed to confusion and a lack 

of consensus about the magnitude of 

the problem. Consistent data allow 

researchers to better gauge the scope of 

the problem, identify high-risk groups, 

and monitor the effects of prevention 

programs.

CHOOSE RESPECT campaign 

aims to prevent intimate partner 

and sexual violence

CHOOSE RESPECT, launched 

May 2006, is a communications 

campaign that encourages adolescents 

to develop positive, respectful 

relationship behaviors. The campaign 

is designed to reach 11- to 14-yearolds and the caring adults in their 

lives with prevention messages 

about choosing respectful, positive 

relationship behaviors before norms 

and attitudes that support violence 

against women are firmly established. 

Campaign elements include a website, 

an interactive music video maker, an 

education video, brochures, posters, 

cinema slides, and radio and TV spots. 

Collaborations to prevent 

child sexual assault

CDC is funding three state 

organizations (Prevent Child Abuse 

Georgia; Project Pathfinder, Inc., in 

Minnesota; and Massachusetts Citizens 

for Children) to develop and implement 

statewide child sexual abuse prevention 

programs. The programs focus on 

adult or community responsibility in 

preventing the perpetration of child 

sexual assault. The funding supports 

projects using existing infrastructures to 

broaden prevention efforts. 

Evaluation assistance for 

projects to prevent first-time male 

perpetration of sexual violence

CDC has provided evaluation assistance 

on four projects designed to prevent 

first-time perpetration of sexual 

violence by males. As these projects 

build capacity to conduct their own 

evaluations independently, CDC will 

foster project improvements through 

training and coaching on the use of 

evaluation concepts, techniques, and 

findings.

Rape Prevention and 

Education Program

CDC administers the Rape Prevention 

and Education (RPE) program and 

provides technical assistance to health 

departments, sexual assault coalitions, 

and other partner organizations or 

agencies. The RPE program supports 

educational seminars, hotline 

operations, training programs for 

professionals, informational materials, 

and other efforts to increase awareness 

of sexual violence, including that 

perpetrated by intimate partners. 

Through this program, all 50 states 

and U.S. territories have implemented 

prevention and education programs and 

have developed a stronger infrastructure 

to address sexual violence. 

Rape Prevention and Education 

program evaluability assessment

To enhance the administration and 

use of Rape Prevention and Education 

(RPE) funding, CDC assessed how 

states allocate RPE funds and the types 

of activities the funds support. The 

primary objectives of this study were 

to document the goals and objectives 

of the RPE program as it relates to the 

activities of state health departments 

and sexual assault coalitions; to assess 

the allocation mechanisms, uses, and 

impact of the funds; and to assess the 

public health needs of states and local 

programs in terms of knowledge, skills, 

resources, and barriers to effective 

implementation. The assessment 

provided CDC with recommendations 

which are currently being implemented 

to improve the administration and 

efficacy of the RPE program. 

Violence against women 

evaluation guide

CDC developed a Violence Against 

Women Evaluation Guide to help 

programs develop and implement 

outcome evaluations. The Guide will assist 

programs in selecting useful, feasible, 

ethical, and accurate evaluation strategies. 

It clearly defines evaluation research based 

on CDC guidelines and provides an 
overview of the issues to be considered in 

evaluating programs to prevent violence 

against women. Information about data 

collection methodology and measures, 

data analyses, presentation of results, and 

selection of an external evaluator will be 

included. The Guide is expected to be 

released in 2006.

National Sexual Violence 

Resource Center

The National Sexual Violence 

Resource Center (NSVRC) provides 

information, resources, and research 

on all aspects of sexual violence. 

Activities include collecting, reviewing, 

cataloging, and disseminating 

information about sexual violence 

prevention and intervention; 

coordinating efforts with other 

organizations; providing technical 

assistance and customized information; 

and maintaining a website. The website 

features links to sexual assault resources 

and information about upcoming 

conferences, funding opportunities, job 

announcements, research, and special 

events. The NSVRC also produces 

a biannual newsletter, recommends 

speakers for conferences, coordinates 

national sexual assault awareness 

activities, and identifies emerging 

policy issues and research needs. The 

NSVRC serves coalitions, local rape 

crisis centers, government and tribal 

entities, colleges and universities, 

service providers, researchers, allied 

organizations, policy makers, and the 

general public (see www.nsvrc.org).

National online resources for 

violence against women

CDC has funded the Pennsylvania 

Coalition Against Domestic Violence 

(PCADV) and the California Coalition 

Against Sexual Assault (CALCASA) 

Prevention Connection to provide 

national, online resources for preventing 

violence against women. These resources 

support local, state, national, and tribal 

agencies and organizations in developing, 

implementing, and evaluating 

prevention and intervention programs 

for violence against women. For more 

information, visit www.vawnet.org and 

www.preventconnect.org.

Assessing links between various 

forms of violence

CDC is conducting a study to 

identify the links between different 

forms of violent behaviors among 

adolescents. The findings will help 

scientists understand the prevalence 

and consequences of various aggressive 

behaviors; the association between 

dating violence and other forms of peer 

violence; and the manner in which these 

types of violent behavior vary by sex, 

developmental stage, and other factors.

Culturally-competent 

demonstration projects

CDC funds 10 projects to prevent 

intimate partner violence and sexual 

violence among various racial and 

ethnic populations, including African 

Americans, American Indians and 

Alaska Natives, Hispanics, Asians, and 

Pacific Islanders. These projects have 

developed and are evaluating programs 

for children, victims, and perpetrators; 

programs to prevent dating violence 

among school-aged youth; and programs 

that link victims with community-based 

service providers. The components and 

outcomes of interest vary by project.

Preventing Violence through 

Education, Networking, and 

Technical Assistance (PREVENT)

CDC is funding the University of 

North Carolina Injury Prevention 

Research Center to develop a national 

training program for violence 

prevention practitioners. The initiative, 

known as PREVENT (Preventing 

Violence through Education, 

Networking, and Technical Assistance), 

is an outgrowth of the National Injury 

and Violence Prevention Training 

Initiative. It is supported by the Society 

for Advancement of Violence and 

Injury Research (SAVIR), formerly 

the National Association of Injury 

Control Research Centers, and the 

Just the Facts . . .

Risk Factors for 

Perpetration of Rape

Some factors increase the risk that 

a man will commit rape (Jewkes et 

al. 2002):

Individual Factors

n Alcohol and drug use

n History of sexual abuse as 

a child

n Witnessed family violence 

as a child

Relationship Factors

n Association with sexually 

aggressive or delinquent peers

n Violent family environment and 

few resources

Community Factors

n Lack of employment opportunity

n General tolerance of sexual 

assault within the community

Societal Factors

n Societal norms supportive of 

sexual violence

n High levels of crime and other 

forms of violence

 Preventing Injuries in America: Public Health in Action 77
78 Preventing Injuries in America: Public Health in Action 

State and Territorial Injury Prevention 

Directors Association (STIPDA). 

Through PREVENT, individuals and 

organizations learn to identify community 

needs and assets; create and mobilize 

partnerships; develop and implement 

prevention programs; measure 

success; and secure funding to sustain 

programs. PREVENT uses a variety 

of educational methods including 

distance-learning modules, regional 

workshops, an intensive institute, 

action learning projects, and coaching.

CDC extramural research grants

CDC provides grant funding to 

researchers at universities, medical 

institutions, and community-based 

organizations to study various factors 

related to sexual violence. A sample 

of those extramural research projects 

follows. For more information about 

these and other projects, visit www.cdc.

gov/ncipc/res-opps/extra.htm.

n Primary prevention of child sexual 

abuse. The Medical University of 

South Carolina is conducting two 

complementary studies to increase 

understanding of the effects of a 

community-based media program 

aimed at raising awareness of the 

prevalence and consequences of 

child sexual abuse and educating 

the public about related prevention 

and response strategies. Results 

from these two studies will inform 

efforts to prevent child sexual abuse 

and identify possible strategies for 

refining prevention messages.

n Sexual violence prevention program 

for perpetrators. This project—a 

collaboration of the Southern Arizona 

Center Against Sexual Assault, the 

Pima County Attorney’s Office, and 

the University of Arizona College of 

Public Health—is implementing and 

evaluating a perpetrator-focused sexual 

violence prevention program. The 

RESTORE program (Responsibility 

and Equity for Sexual Transgressions 

Offering a Restorative Experience) 

is a restorative justice-based, nonadversarial, community-conferencing 

method to adjudicate first arrests for 

date or acquaintance rape and nonpenetration sexual offenses. 

n Risk for sexual abuse: a study of 

adolescent offenders. Researchers 

at the University of Minnesota are 

working to identify the unique and 

shared risk factors for child sexual 

abuse, sexual assault, and youth 

violence. The study includes 300 

adolescent males who have committed 

sexual abuse of children, peers, or 

adults; it also includes adolescent 

males who have committed other 

nonsexual types of delinquent 

behavior. Researchers are examining 

attitudes toward intimate relationships 

(attachment style) and involvement 

with peers, including consensual 

sexual experiences. Attitudes toward 

masculinity are also being examined 

(e.g., beliefs about the importance 

of competition, violence, and facesaving as an indication of masculinity; 

confidence in one’s own masculinity; 

and beliefs about sexuality, selfreported sexual behavior, and sexual 

interest and fantasies). Project results 

will be disseminated in collaboration 

with Stop It Now! Minnesota.

Future Steps

Like intimate partner violence, sexual 

violence often goes unreported because 

of embarrassment, denial, or fear of 

retaliation, especially when the perpetrator 

is someone known to the victim. This 

underreporting masks the magnitude of 

the problem of sexual assault in the United 

States. Even when incidents are reported, 

they may not be identified or recorded as 

sexual violence. Similarly, victims seeking 

medical care after rape or sexual assault 

may not disclose the true cause of their 

injuries. If they do, the information may 

not be recorded in the medical record. To 

better document the scope of the problem 

of sexual violence and identify trends 

in incidence and prevalence, we must 

improve the quality of data collection 

at national, state, and local levels. 

Scientists, public health professionals, 

advocates, and others must increase efforts 

to stop sexual violence from occurring. To 

this end, CDC is supporting the evaluation 

of interventions to prevent sexual violence 

so that science-based recommendations 

about programs and practices that work 

can be shared. 

References

Administration on Children, Youth, and 

Families (ACYF), Department of Health and 

Human Services (US). Child Maltreatment 

2002 [online]. Washington (DC): 

Government Printing Office; 2004. [cited 

2004 Aug 3]. Available from: URL: www.

acf.hhs.gov/programs/cb/publications/cm02. 

Basile KC, Saltzman LE. Sexual Violence 

Surveillance: Uniform Definitions and 

Recommended Data Elements Version 1.0. 

Atlanta (GA): National Center for Injury 

Prevention and Control, Centers for Disease 

Control and Prevention; 2002. Available 

from: URL: www.cdc.gov/ncipc/pub-res/

sv_surveillance/sv.htm.

Campbell JC, Soeken K. Forced sex and 

intimate partner violence: effects on 

women’s health. Violence Against Women

1999;5:1017–1035.

Grunbaum JA, Kann L, Kinchen S, Ross 

JG, Lowry R, Harris WA, et al. Youth risk 

behavior surveillance—United States, 2004 

[online]. Morbidity and Mortality Weekly Report

2004;53(SS-2):1–100. Available from: URL: 

www.cdc.gov/mmwr/PDF/SS/SS5302.pdf. 

Jewkes R, Sen P, Garcia-Moreno C. Sexual 

violence. In: Krug EG, Dahlberg LL, Mercy 

JA, Zwi AB, Lozano R, editors. World Report 

on Violence and Health. Geneva: World 

Health Organization; 2002. p. 149–181.

Koss MP, Heslet L. Somatic consequences of 

violence against women. Archives of Family 

Medicine 1992;1:53–59.

Krug EG, Dahlberg LL, Mercy JA, Zwi 

A, Lozano R, editors. World Report on 

Violence and Health. Geneva: World Health 

Organization; 2002. p. 162–164.

Tjaden P, Thoennes N. Full report of the 

prevalence, incidence, and consequences of 

intimate partner violence against women: 

findings from the National Violence Against 

Women Survey. Report for grant 93-IJ-CX0012, funded by the National Institute of 

Justice (NIJ) and the Centers for Disease 

Control and Prevention. Washington (DC): 

NIJ; 2000. NCJ Report No.: 183781.
Preventing Injuries in America: Public Health in Action 79

The Problem 

n An estimated 7 million Americans 

seek medical care annually for 

injuries sustained during sports or 

recreation (Conn et al. 2003). An 

estimated 4.3 million of them are 

treated in emergency departments 

(Gotsch et al. 2002). 

n Adolescents 10 to 14 years of age 

have the highest rates of sports- and 

recreation-related injury (Gotsch et 

al. 2002).

n About one quarter of people injured 

during sports or recreation miss one 

or more days of work or school due 

to the injury (Conn et al. 2003).

n An estimated 1.6 to 3.8 million 

sports- and recreation-related 

traumatic brain injuries occur in the 

United States each year (Langlois et 

al. 2006).

n Concussions can occur in any sport, 

including football, wrestling, soccer, 

basketball, softball, baseball, field 

hockey, and volleyball (Powell and 

Barber-Foss 1999).

n Collegiate and high school football 

players who have had at least one 

concussion are at an increased risk 

for another concussion (Guskiewicz 

et al. 2000; Zemper 2003).

CDC’s Accomplishments

Evaluation of an alternative 

warm-up program 

CDC, in collaboration with the 

National Collegiate Athletic 

Association, the American Academy 

of Orthopaedic Surgeons, the 

International Federation of Football 

Associations, and the Santa Monica 

Orthopaedic and Sports Medicine 

Research Foundation, conducted a 

randomized controlled trial of an 

alternative warm-up program to 

prevent anterior cruciate ligament 

(ACL) injuries in female soccer players. 

Women athletes are disproportionately 

affected by ACL injuries (Griffin 

2001). The research involved 

implementing and evaluating a physical 

training program specifically designed 

to reduce the risk of ligamentous 

knee injuries by incorporating proven 

neuromuscular and proprioceptive 

training concepts into a concise onfield warm-up activity. Results showed 

that this program reduced the risk of 

ACL injuries and noncontact ACL 

injury rates among female soccer 

players compared with athletes who did 

not receive the intervention.

Tool kit raises awareness about 

sports-related concussions

In 2004, CDC developed Heads Up: 

Concussion in High School Sports—a 

tool kit for high school athletic coaches 

containing materials about how to 

prevent, recognize, and manage sportsrelated concussions. The tool kit will 

also assist coaches in educating athletes, 

athletes’ parents, and school officials 

about sports-related concussions. 

In early 2005, CDC conducted a 

pilot study to evaluate the tool kit’s 

effectiveness. Of the nearly 500 

responses, most were positive—74% 

found the materials very easy to use, 

and 94% said the tool kit had just 

enough detail. More than two thirds 

of coaches reported being aware of 

incidents of sports-related concussions 

occurring at their schools; one third of 

the coaches had no access to education 

materials prior to receiving the tool 

kit. Also, 20% of coaches reported that 

their athletic department had no plan 

for dealing with concussions; however, 

most coaches (96%) thought the tool 

kit materials could be used to develop 

a plan. The revised tool kit, based on 

findings from the pilot study, now 

includes a DVD. The tool kit initiative, 

launched September 2005, distributed 

tool kits to more than 10,000 coaches, 

athletic directors, and principals in high 

schools nationwide. To order free of 

charge or download materials, visit www.

cdc.gov/ncipc/tbi/Coaches_Tool_Kit.

htm. 

Research illuminates impact of 

sports- and recreation-related 

injuries 

CDC researchers found that from 1997 

through 1999, an estimated 7 million 

Americans received medical attention 

for sports- and recreation-related 

injuries each year. Almost one third 

Sports- and Recreation-related Injuries
80 Preventing Injuries in America: Public Health in Action 

of these injuries occurred at sports 

facilities, and basketball ranked as the 

lead sport for injuries among organized 

and backyard or pickup games. More 

than two thirds of the people treated 

for sports- and recreation-related 

injuries were 5 to 24 years old (Conn 

et al. 2003).

CDC extramural research grants

CDC funds grants to researchers at 

universities, medical institutions, and 

community-based organizations to 

study various factors related to sports 

and recreation injuries. An example 

of those extramural research projects 

follows. For more information about 

grants and other projects, visit www.

cdc.gov/ncipc/res-opps/extra.htm. 

n Evaluation of existing sports injury 

interventions and countermeasures 

in high school varsity football.

Researchers at the UCLA-Southern 

California Injury Prevention 

Research Center are using a 

multilevel study design to identify 

primary, secondary, and tertiary 

prevention measures in place at local 

high schools; measure whether these 

interventions affect the frequency 

and severity of injury; compare 

treatment protocols across schools; 

and estimate costs of medically 

treated injuries in selected sports 

clinics. Investigators will focus on 

two samples of football teams: those 

that are under medical supervision 

by a local sports clinic and those that 

are not.

Future Steps

In 2004, CDC convened a panel 

of experts to explore potential 

collaborations for the development of 

public health surveillance, research, 

and programming which would 

promote physical activity while 

minimizing the risk of injury. This 

meeting was supported by the National 

Swimming Pool Foundation. CDC will 

use the outcomes from this meeting 

to shape collaborative research and 

program priorities. 

References

Conn JM, Annest JL, Gilchrist J. Sportsand recreation-related injury episodes in 

the U.S. population, 1997–1999. Injury 

Prevention 2003;9(2):117–123.

Gotsch K, Annest JL, 

Holmgreen P, Gilchrist J. 

Non-fatal sports and recreationrelated injuries treated in 

emergency departments—United 

States, July 2000–June 2001. 

Morbidity and Mortality Weekly Report

2002;51(33):736–740.

Griffin LY, editor. Prevention of Noncontact 

ACL Injuries. Rosemont (IL): American 

Academy of Orthopaedic Surgeons; 2001.

Guskiewicz KM, Weaver N, Padua DA, 

Garrett WE. Epidemiology of concussion 

in collegiate and high school football 

players. American Journal of Sports Medicine

2000;28(5):643–650.

Langlois JA, Rutland-Brown W, Wald 

M. The epidemiology and impact of 

traumatic brain injury: A brief overview. 

Journal of Head Trauma Rehabilitation

2006;21(5):375–378.

Powell JW, Barber-Foss KD. Traumatic 

brain injury in high school athletes. 

Journal of the American Medical Association

1999;282:958–963.

Zemper ED. Two-year prospective study of 

relative risk of a second cerebral concussion. 

American Journal of Physical Medicine and 

Rehabilitation 2003;82(9):653–659.
Preventing Injuries in America: Public Health in Action 81

The Problem

Each year in the United States, more 

people commit suicide than die from 

homicide.

n In 2002, 31,655 Americans took 

their own lives, an average of 87 

people each day (CDC 2004). 

n Completed suicides reflect only 

a small portion of the impact of 

suicidal behavior. In 2003, 176,707 

individuals were hospitalized 

following suicide attempts; 

130,004 were treated in emergency 

departments and released (CDC 

2004).

n Although females attempt suicide 

more often than males (DeLeo et al. 

2002), males are four times as likely 

to die from suicide. U.S. statistics 

for 2002 show that males account 

for 80% of suicides overall (CDC 

2004).

n Suicide is the third leading cause 

of death among young people ages 

15 to 24. In 2001, 4,010 suicides 

were reported in this age group 

(Kochanek et al. 2004).

n Suicide rates are highest among those 

65 years and older. In 2002, 5,548 

Americans over age 65 committed 

suicide, averaging one suicide every 

90 minutes (CDC 2004; DHHS 

2001). Men committed 85% of 

these suicides (CDC 2004). 

n In 2002, 56% of suicides were 

committed with a firearm (Kochanek 

et al. 2004).

CDC’s Accomplishments

Reporting system to provide 

objective, timely violence data

State and local agencies acquire 

detailed information from medical 

examiners, coroners, police, crime labs, 

and death certificates that could answer 

fundamental questions about violence 

trends and patterns. This information 

is fragmented and difficult to access. 

Consequently, CDC has funded 17 

states—Alaska, California, Colorado, 

Georgia, Kentucky, Maryland, 

Massachusetts, New Jersey, New 

Mexico, North Carolina, Oklahoma, 

Oregon, Rhode Island, South Carolina, 

Utah, Virginia, and Wisconsin—to 

establish the National Violent Death 

Reporting System (NVDRS) to gather, 

share, and link state-level data about 

violence-related deaths. When fully 

implemented, NVDRS will enable 

CDC to pull together vital state-level 

information to gain a more accurate 

understanding of the problem of 

violence, including suicide, and to 

enable policy makers and community 

leaders to make informed decisions 

about prevention strategies.

Study tracks school-associated 

violent deaths

With the U.S. Departments of 

Education and Justice, CDC is 

conducting an ongoing national study 

of school-associated violent deaths. 

Since 1992, this study has played an 

important role in monitoring trends 

related to school-associated violent 

deaths (including suicide), identifying 

risk factors, and assessing the effects of 

prevention efforts.

Integrating data for more 

accurate suicide measures

CDC has established a Suicide 

Prevention Research Center at the 

Trauma Institute of the University 

of Nevada School of Medicine. 

The Center has developed a pilot 

surveillance system to help states 

Suicide
integrate data from 

death certificates, 

emergency 

departments, and 

mental health 

departments. 

This new system 

provides a 

more accurate 

and complete 

measure of 

suicide rates than 

do surveillance 

systems that rely on mortality data 

alone.

Setting uniform definitions 

for suicide 

Standard definitions for suicide do 

not exist, and the definitions used 

in federal and state legislation vary 

dramatically. These inconsistencies 

contribute to confusion and a lack 

of consensus about the magnitude of 

the problem. CDC is convening an 

expert panel to review the existing 

state of suicide surveillance and to 

recommend definitions for use during 

data collection. Acquiring better data 

about suicide will shape prevention 

efforts and help policy makers 

and communities make informed 

public health decisions for allocating 

prevention resources.

Assessing links between various 

forms of violence 

CDC is conducting a study to 

identify the links between different 

forms of violent behaviors among 

adolescents, including suicide. The 

findings will help scientists understand 

the prevalence and consequences of 

different types of aggressive behaviors; 

the association between dating violence 

and other forms of peer violence; 

and the manner in which these types 

of violent behavior vary by sex, 

developmental stage, and other factors.

Just the Facts . . . 

Suicide Among 

High School Students

CDC’s 2003 nationwide 

study of high school 

students revealed 

alarming responses about 

suicide (Grunbaum et al. 

2004):

n 16.9% had seriously considered 

suicide during the 12 months 

preceding the survey; 

n 16.5% had made a plan to 

attempt suicide during the 12 

months preceding the survey; 

n 8.5% had attempted suicide 

one or more times during the 12 

months preceding the survey; 

and 

n 2.9% had attempted suicide 

during the 12 months preceding 

the survey that resulted in injury, 

poisoning, or overdose requiring 

medical treatment.

Understanding suicide risk 

among adolescents

CDC is funding Battelle Centers for 

Public Health Research and Evaluation 

to survey high school-aged adolescents 

from an urban school district. The 

research will enhance knowledge about 

youth suicidal behaviors and associated 

risk and protective factors; create a 

viable research and clinical instrument 

to evaluate suicide risk; and examine 

the utility of this instrument as a 

screening tool and outcome measure. 

The goal is to design better preventive 

interventions and thereby reduce 

suicide risk. 

Partnering in national suicide 

prevention strategy

CDC plays a key role in the Federal 

Steering Group for the Surgeon 

General’s National Strategy for Suicide 

Prevention. This group coordinates 

federal initiatives to prevent suicide, 

funds research, supports workshops, 

and shares information about suicide 

facts and prevention activities through 

such channels as public hearings 

and the Internet. In early 2001, the 

group published goals and objectives 

for the strategy, which include 

promoting awareness about suicide as 

a preventable public health problem; 

developing and evaluating prevention 

programs; improving the portrayal of 

suicide, mental health, and drug use 

in the entertainment and news media; 

promoting research about suicide and 

its prevention; and enhancing tracking 

systems for suicide.

Preventing Violence through 

Education, Networking, and 

Technical Assistance (PREVENT)

CDC is funding the University of 

North Carolina Injury Prevention 

Research Center to develop a national 

training program for violence 

prevention practitioners. The initiative, 

known as PREVENT (Preventing 

82 Preventing Injuries in America: Public Health in Action
National resource center offers 

wealth of information

The National Youth Violence 

Prevention Resource Center (www.

safeyouth.org, 1-866-SAFEYOUTH 

1-866-723-3968) is a central source 

for information and materials gathered 

from institutions, community-based 

organizations, and federal agencies 

working to prevent violence among 

our nation’s youth. The center’s 

website, toll-free hotline, and faxon-demand service offer access 

to information about prevention 

programs, publications, research and 

statistics, and fact sheets. The website 

links parents, teens, and researchers 

to materials designed specifically for 

those audiences. The Center responds 

to more than 100 public inquiries 

and requests for technical assistance, 

fulfills more than 500 requests for 

publications and youth violence 

prevention materials, and hosts more 

than 37,000 website visitors each 

month.

Collaboration with other 

parts of CDC

CDC’s Injury Center has worked with 

the Division of Adolescent and School 

Health, part of CDC’s National Center 

for Chronic Disease Prevention and 

Health Promotion, on a number of 

projects related to suicide prevention. 

Examples of these collaborations 

follow.

n School Health Guidelines to 

Prevent Unintentional Injuries and 

Violence. The guidelines help state 

and local educational agencies and 

schools promote safety and teach 

students the skills needed to prevent 

injuries and violence. Guidance is 

provided for all components of a 

coordinated school health program 

for all grade levels. The guidelines, 

developed in collaboration with 

specialists from universities and 

from national, federal, state, and 

Just the Facts . . .

Risk and Protective 

Factors for Suicide

(DHHS 1999)

A risk factor for suicide is anything 

that increases the likelihood that 

people will harm themselves. Risk 

factors for suicide include:

n Previous suicide attempt(s); 

n History of depression or feelings 

of hopelessness; 

n Precipitating events such as the 

breakup of a relationship; 

n Easy access to lethal methods; 

and 

n Isolation, or a feeling of being 

cut off from other people. 

Protective factors buffer people 

from the risks associated with 

suicide. Protective factors for 

suicide include:

n Effective 

clinical care 

for mental, 

physical, and 

substance 

abuse 

disorders;

n Family and 

community 

support; 

n Support from ongoing medical 

and mental health care 

relationships; 

n Skills in problem solving, conflict 

resolution, and nonviolent 

handling of disputes; and 

n Cultural and religious beliefs that 

discourage suicide and support 

self-preservation instincts.

Violence through Education, 

Networking, and Technical Assistance), 

is an outgrowth of the National Injury 

and Violence Prevention Training 

Initiative. It is supported by the Society 

for Advancement of Violence and 

Injury Research (SAVIR), formerly the 

National Association of Injury Control 

Research Centers, and the State and 

Territorial Injury Prevention Directors 

Association (STIPDA). PREVENT 

helps individuals and organizations 

build skills for identifying community 

needs and assets, creating and 

mobilizing partnerships, developing 

and implementing prevention 

programs, measuring success, and 

securing funds to sustain programs. 

PREVENT uses a variety of 

educational methods including 

distance-learning modules, regional 

workshops, an intensive institute, 

action learning projects, and coaching.

Multistate assessment of state 

suicide prevention planning

CDC is conducting an in-depth, 

multistate examination of the 

development and implementation of 

state suicide prevention plans. The 

findings will help other states develop 

suicide prevention plans and gain the 

support of stakeholders so that these 

plans can be implemented. Insights 

gleaned from this study will also help 

inform state-based prevention efforts in 

other public health problem areas such 

as violence against women and child 

maltreatment. 

State suicide prevention 

program implementation

CDC is funding state injury prevention 

experts in Maine and Virginia to 

develop evidence-based suicide 

prevention programs. These experts are 

designing and implementing a suicide 

prevention program tailored to the 

needs of their state.

 Preventing Injuries in America: Public Health in Action 83
84 Preventing Injuries in America: Public Health in Action 

local agencies and organizations, 

are based on an in-depth review of 

research, theory, and current practice 

in unintentional injury, violence, 

and suicide prevention; health 

education; and public health. The 

guidelines are available at www.cdc.

gov/HealthyYouth/injury/guidelines.

n Youth Risk Behavior Surveillance 

System. CDC’s Youth Risk Behavior 

Surveillance System (YRBSS) 

monitors priority health risk 

behaviors that contribute to the 

leading causes of death, disability, 

and social problems among youth 

and adults in the United States, 

including behaviors that contribute 

to unintentional injuries and 

violence. The YRBSS consists of 

national, state, and local schoolbased surveys of representative 

samples of 9th through 12th grade 

students. The surveys, conducted 

biennially, provide information on a 

variety of suicide- and interpersonal 

violence-related behaviors both 

on school property and in the 

community.

n School Health Policies and 

Programs Study. This national 

survey is conducted periodically 

to assess school health policies 

and programs at state, district, 

school, and classroom levels. School 

Health Policies and Programs Study 

(SHPPS) was first conducted by 

CDC’s Division of Adolescent and 

School Health (DASH) in 1994 

and was repeated in 2000. SHPPS 

provides information about health 

education, programs, environmental 

strategies, and policies that states, 

districts, and schools use to address 

violence and suicide prevention.

CDC extramural research grants

CDC provides grant funding to 

researchers at universities, medical 

institutions, and community-based 

organizations to study various factors 

related to suicide prevention. A sample 

of those extramural research projects 

follows. For information about these 

and other projects, please visit www.

cdc.gov/ncipc/res-opps/extra.htm.

n Help seeking by at-risk youth after 

suicide screenings. The Research 

Foundation for Mental Hygiene, Inc. 

is conducting a retrospective cohort 

study of youth identified through 

screening as at-risk for suicidal 

behavior. Each at-risk youth and his 

or her parent will be interviewed 

about two years after the screen to 

assess information about the use 

of services during the intervening 

period, barriers that may have 

interfered with seeking or receiving 

treatment, and the risk status of the 

youth at follow-up. Findings will 

guide efforts to develop optimal 

help-seeking strategies tailored to 

at-risk youth and their parents to 

establish effective screening programs 

to prevent suicidal behavior.

n Preventing youth suicide in 

primary care: a family model.

Researchers at Children’s Hospital 

of Philadelphia are testing the 

efficacy of brief family therapy for 

adolescents presenting with serious 

risk for suicide in a primary care 

setting. The intervention approach 

will be Attachment-based Family 

Therapy (ABFT), an efficacious 

and manualized family therapy 

model designed specifically for 

adolescent depression. ABFT has 

been successful in reducing suicidal 

ideation, hopelessness, depression, 

anxiety, and family conflict.

Future Steps

Accurate, timely, and accessible 

information about suicidal behaviors 

is crucial for prevention. To better 

document the scope of the problem, 

to identify high-risk groups, and to 

recognize trends in incidence and 

prevalence, CDC must refine and 

validate current definitions of suicide 

and develop systems to monitor and 

track the problem.

One of the greatest challenges in 

suicide prevention is to identify 

promising strategies and programs. 

CDC must continue research on 

effective prevention strategies for 

suicide and suicidal behavior. CDC 

must also continue to evaluate current 

interventions and develop and test new 

ones. As data become available about 

what works, we must communicate 

that information to practitioners. 

References

Centers for Disease Control and 

Prevention, National Center for Injury 

Prevention and Control. Web-based Injury 

Statistics Query and Reporting System 

(WISQARS) [online]. (2004) [cited 2004 

Dec 28]. Available from: URL: www.cdc.

gov/ncipc/wisqars. 

DeLeo D, Bertolote J, Lester D. Selfdirected violence. In: Krug EG, Dahlberg 

LL, Mercy JA, Zwi AB, Lozano R, editors. 

World Report on Violence and Health. 

Geneva: World Health Organization; 

2002:185–212.

Department of Health and Human Services 

(US). National Strategy for Suicide Prevention: 

at a glance—suicide among the elderly. 2001. 

Available from: URL: www.mentalhealth.

org/suicideprevention/elderly.asp.

Department of Health and Human 

Services (US). The Surgeon General’s Call 

to Action to Prevent Suicide. Washington 

(DC): Department of Health and Human 

Services; 1999.

Grunbaum JA, Kann L, Kinchen S, Ross 

JG, Lowry R, Harris WA, et al. Youth risk 

behavior surveillance—United States, 2003. 

Morbidity and Mortality Weekly Report

2004;53(SS-2):1–100.

Kochanek KD, Murphy SL, Anderson 

RN, Scott C. Deaths: leading causes 

for 2002. National Vital Statistics Report

2004;53(5):1–116. [cited 2004 Dec 28]. 

Available from: URL: www.cdc.gov/nchs/

data/nvsr/nvsr53/nvsr53_05.pdf.
Preventing Injuries in America: Public Health in Action 85

The Problem 

Unintentional injuries are the 

leading cause of death for children, 

and many of these injuries can be 

prevented through appropriate 

supervision. In 2002, 5,305 

children 14 years and younger died 

from unintentional injuries, and 

more than 6.5 million were seen 

in emergency departments. Many 

studies have described how lapses 

in supervision lead to injury such 

as drowning, burns, and poisonings 

(Pollack-Nelson and Drago 2002; 

Landen et al. 2003; Simon et al. 

2003). The key for preventing many 

unintentional injury deaths and 

disabling injuries among children 

is effective supervision, yet this 

behavioral component of injury 

prevention lacks conceptual and 

methodological clarity. Without 

this foundation, interventions are 

difficult to develop and test. CDC’s 

Injury Center is taking the lead in 

exploring the critical link between 

supervision and injury prevention. 

CDC’s Accomplishments

Supervision in injury 

prevention workshop

CDC sponsored an expert meeting 

in August 2003 to assess the 

role of supervision in preventing 

unintentional injuries among 

children and to identify areas where 

more research on supervision is 

needed. The meeting resulted in 

several suggestions for developing 

models of supervision. One priority 

area for future research is to enhance 

the evidence base for the role of 

supervision in injury outcomes.

Disseminating child safety 

products in urban communities 

With CDC support, the hospitalbased Children’s Safety Center at Johns 

Hopkins University has launched a 

traveling Mobile Safety Center. The 

Mobile Safety Center van travels to 

clinics and selected sites serving lowincome families to conduct safety 

interventions and to provide parents 

with the safety products (e.g., smoke 

alarms, cabinet latches, stair gates, car 

seats) they need to better supervise and 

protect their family. The project has 

developed training materials, educator 

protocols, and exhibits to be used 

by the Mobile Safety Center and the 

Safety Center clinic. Researchers are 

evaluating this dissemination strategy 

compared with others that are clinic 

based.

Safe Kids at Home

CDC funded SAFE KIDS Worldwide, 

a global public awareness and 

education campaign to help prevent 

unintentional injuries among 

children 14 and younger. SAFE KIDS 

Worldwide works with communities 

in 19 states to develop and disseminate 

culturally and ethnically diverse home 

safety educational materials addressing 

special risks in public housing. In 

addition to training health department 

staff and home visiting organizations 

about home safety and injury 

prevention, SAFE KIDS Worldwide 

developed task forces within each 

community to help sustain the Safe 

Kids at Home program. Working with 

their local coalitions, SAFE KIDS 

Worldwide conducted 26 home safety 

training workshops for nearly 600 

home visitors. During the project, 

home visitors went to 69,840 homes 

and installed nearly 57,000 home 

safety devices, including outlet covers 

and drawer and cabinet latches. CDC 

provided additional funding for the 

development of a low-literacy brochure 

on home safety and a multimedia 

train-the-trainer presentation that 

combines fundamental home safety 

knowledge with tips for implementing 

a home safety program. 

CDC extramural research grants

CDC provides grant funding to 

researchers at universities, medical 

institutions, and community-based 

organizations to study various factors 

related to supervision. A sample of 

those extramural research projects 

follows. For more information about 

these and other projects, visit www.cdc.

gov/ncipc/res-opps/extra.htm. 

Supervision of Children
86 Preventing Injuries in America: Public Health in Action 

n Concept mapping: an innovative 

method to measure supervision.

Researchers at the George 

Washington University School of 

Public Health and Health Services 

are using the concept mapping 

process of brainstorming groups, 

sorting and rating groups, and 

discussion and interpretation groups 

to conceptualize child supervision’s 

role in injury prevention. Concept 

mapping techniques will enable 

researchers to explore variations in 

sociodemographic and parenting 

style for identifying behaviors 

central to child supervision, to 

examine conceptualizations of child 

supervision with regard to injury 

mechanisms, and to identify styles 

and processes of child supervision 

that are perceived to be amendable 

to change.

n Injury risk management for young 

children. University of California 

researchers are developing a model 

of injury risk management for 

young children. Using an emergency 

department-based study about the 

circumstances of injury, researchers 

will explore the role of supervision in 

injury and injury risk management. 

They will follow a cohort of mothers 

from their children’s births to age 

30 months to identify individual 

factors and the interrelationship 

between those factors. The 

measurable components of the 

research model are management 

of the environment, supervision, 

use of resources, and adaptation to 

changing circumstances and child 

development. Researchers will use 

study findings to develop and test a 

clinical assessment tool to identify 

families who need help with injury 

risk management for their children.

n A dynamic model of supervision 

and injury among children.

Researchers at the University of 

Rochester are developing and 

validating a new, comprehensive, 

and developmentally sensitive 

measure of supervision. Researchers 

seek to expand the current focus on 

how adults structure supervision 

(through the creation of rules and 

the direct monitoring of their 

children). Researchers also want 

to learn how adults assess the risk 

inherent in a situation, how they 

perceive their role in reducing this 

risk, and how they implement their 

approach to supervision. Researchers 

will develop a self-report measure 

of this expanded conceptualization 

of supervision, an observational 

measure of supervision for parents of 

preschool children, and a child selfreport measure of risk-taking and 

rule compliance for older children.

Future Steps

Research continues to examine the 

varied supervisory patterns now in 

use with children of different ages 

and of different cultures. Behavioral 

scientists are collaborating to develop 

measurement tools to compare these 

various styles of supervision and to 

evaluate the relative effectiveness of 

each in preventing injuries. CDC’s 

Injury Center is taking the lead in this 

important area of research.

References

Landen MG, Bauer U, Kohn M. 

Inadequate supervision as a cause of injury 

deaths among young children in Alaska and 

Louisiana. Pediatrics 2003 Feb;111(2):328–

331.

Pollack-Nelson C, Drago DA. Supervision 

of children aged two through six years. 

Injury Control and Safety Promotion

2002;9(2):121–126.

Simon HK, Tamura T, Colton K. Reported 

level of supervision of young children while 

in the bathtub. Ambulatory Pediatrics 2003 

Mar–Apr;3(2):106–108.
Preventing Injuries in America: Public Health in Action 87

The Problem

Motor vehicle-related injuries are the 

biggest health threat to teenagers in the 

United States, accounting for two out 

of five deaths overall (CDC 2005).

n In 2002, more than 5,000 teens ages 

16 to 19 died of injuries caused by 

motor vehicle crashes (CDC 2005).

n The risk for motor vehicle crashes 

is higher among 16- to 19-year-olds 

than among any other age group. In 

fact, per mile driven, drivers in this 

age group are four times more likely 

than older drivers to crash (IIHS 

2004).

n In 2002, the estimated economic 

cost of police-reported crashes (both 

fatal and nonfatal) involving drivers 

ages 15 to 20 was $40.8 billion 

(NHTSA 2003). 

CDC’s Accomplishments

Young drivers and fatal alcoholrelated motor vehicle crashes, 

1982–2001

CDC researchers found that between 

1982 and 2001, alcohol-related fatal 

crash rates among drivers ages 16 to 

20 decreased almost 60%. Although 

crash rates decreased among drivers of 

all ages, the most dramatic decreases 

were among drivers under age 21. 

This strong downward trend suggests 

that prevention measures targeting 

this age group (national minimum 

legal drinking age and zero alcohol 

tolerance laws for young drivers) 

have been effective. However, despite 

the successes of the last two decades, 

progress has stalled in the past few 

years, and impaired driving remains 

a serious public health problem for 

drivers of all ages. In 2003 alone, 1 

in 4 drivers ages 15 to 20 who died 

in motor vehicle crashes had a blood 

alcohol concentration above the legal 

limit for adult drivers (NHTSA 2004).

Examining parental influence on 

teen driving behavior

CDC scientists collaborated with 

the National Institutes of Health to 

evaluate a brief intervention with 

parents and teens designed to increase 

parental restrictions of teen driving 

privileges. Results showed that the 

intervention parents reported more 

driving rules, restricted driving, limits 

for high-speed roads, weekend night 

restrictions, and overall driving limits 

for their teens than did parents in the 

control group. 

Graduated driver licensing

Graduated driver licensing (GDL) 

programs—which place restrictions 

on young drivers that are lifted as 

they gain driving experience—are an 

effective strategy for developing safe 

driving skills. CDC supported research 

at the UCLA Southern California 

Injury Prevention Research Center 

to examine the effectiveness of GDL 

in California. Results from this study 

showed a 17% to 18% decrease in crash 

rates for drivers ages 16 to 17 after GDL. 

CDC also supported and contributed 

to a special edition of the Journal 

of Safety Research documenting the 

current research evidence about GDL.

CDC helped fund and contributed to a 

series of five research papers, published 

in a September 2002 supplement of 

Injury Prevention. The articles, which 

reviewed the current status of research 

on young drivers, make a compelling 

case for GDL programs.

Effective interventions to prevent 

alcohol-impaired driving among 

teens

In systematic reviews of published research 

studies, a research team led by CDC 

found evidence that minimum legal 

drinking age laws and lower BAC laws 

for young or inexperienced drivers 

(zero tolerance laws) effectively reduce 

alcohol-impaired driving. A systematic 

review of school-based education 

programs found that such programs 

reduce the incidence of riding with 

alcohol-impaired drivers, though there 

was insufficient evidence that these 

programs reduced drinking and driving 

among teens. To learn more about this 

and other systematic reviews published 

in The Guide to Community Preventive 

Services, see www.thecommunityguide.org.

Teens Behind the Wheel
GDL effect on hospitalization rates 

and charges for 16-year-old drivers 

CDC is funding one of the first studies 

of the effect of GDL on serious, 

nonfatal injuries resulting from motor 

vehicle crashes among 16-year-old 

drivers. Researchers at the University 

of North Carolina will examine state 

crash data and the state’s Inpatient 

Discharge Database to document the 

rate of hospitalization and associated 

charges for 16-year-olds from 1996 

through 2001, encompassing data 

after the implementation of the North 

Carolina GDL program in December 

1997. Evidence of GDL’s impact on 

hospitalization rates and charges may 

assist policy makers and legislators in 

their efforts to increase the effectiveness 

of GDL programs. 

CDC extramural research grants

CDC provides grant funding to 

researchers at universities, medical 

institutions, and community-based 

organizations to study various factors 

related to teen drivers. One example of 

an extramural research project follows. 

For more information about this and 

other projects, visit www.cdc.gov/

ncipc/res-opps/extra.htm.

n Behavioral study to reduce youth 

DUI and risky driving. Researchers 

at the University of Alabama at 

Birmingham are working to better 

understand two factors associated 

with the underlying attitudes 

that lead to teen involvement in 

motor vehicle-related crashes: risky 

behavior and driving under the 

influence (DUI) of alcohol. In one 

study, researchers will evaluate social 

and attitudinal influences on DUI 

among college students before and 

after exposure to persuasion methods 

successfully used in antismoking 

interventions. In a second study, 

researchers will conduct focus 

Just the Facts . . .

Why Teens are at Risk 

Several factors increase a teen’s 

risk for vehicle-related injuries: 

n Inexperience—Teens often fail 

to recognize or underestimate 

the dangers in hazardous 

situations, and they also have 

less experience coping with such 

situations; teens are more likely 

than older drivers to speed, run 

red lights, make illegal turns, ride 

with an intoxicated driver, and 

drive after using alcohol or drugs 

(Jonah and Dawson 1987).

n Low rates of seat belt 

use—Compared with other age 

groups, teens have the lowest 

rate of seat belt use. In 2003, 

18% of high school students 

reported that they rarely or never 

wear seat belts when riding in a 

car as a passenger (CDC 2004). 

n Alcohol and driving—All 50 

states have “zero tolerance” 

laws that establish a blood 

alcohol concentration (BAC) 

limit of 0.02% or lower for 

drivers under the age of 21. 

In 2003, 25% of drivers ages 

15 to 20 who died in motor 

vehicle crashes had a BAC of 

0.08% or higher, which is above 

the legal BAC limit for adult 

drivers (NHTSA 2004). Among 

teen drivers who were killed 

in crashes after drinking and 

driving, 74% were not wearing 

seat belts (NHTSA 2004). 

88 Preventing Injuries in America: Public Health in Action
Preventing Injuries in America: Public Health in Action 89

groups and phone surveys of 16- to 

20-year-old drivers to assess their 

attitudes and normative beliefs 

that lead to risky driving. Based 

on this knowledge, researchers will 

develop interventions oriented 

toward exploiting group dynamics 

as opposed to relying on individual 

education. In both the DUI and 

risk-taking studies, the interventions 

will be pilot tested first in a 

laboratory and later in a real-world 

environment.

Future Steps

Driving is a complicated skill that 

takes time and practice to master. 

Graduated driver licensing, GDL, is 

one strategy that allows driving skills 

to be developed with minimum risk 

of injury. GDL addresses the high 

risks new drivers face by requiring 

an apprenticeship of planned and 

supervised practice, followed by 

provisional licensure that temporarily 

restricts unsupervised driving. 

Restrictions are lifted as new drivers 

gain experience and teenage drivers 

mature. Most states now have some 

form of GDL in place, but the strength 

of its components varies widely. In 

itself, GDL is not the final solution to 

the problem. More research is needed 

to identify how family, peers, and 

others influence teen driving behavior.

References

Centers for Disease Control and 

Prevention, National Center for Injury 

Prevention and Control. Web-based Injury 

Statistics Query and Reporting System 

(WISQARS) [online]. (2005) [cited 2005 

Feb 23]. Available from: URL: www.cdc.

gov/ncipc/wisqars. 

Insurance Institute for Highway Safety 

(IIHS). Fatality Facts: Teenagers 2002. 

Arlington (VA): The Institute; 2004 [cited 

2004 April 1]. Available from: URL: 

www.iihs.org/research/fatality_facts/pdf/

teenagers.pdf.

Jonah BA, Dawson NE. Youth and risk: age 

differences in risky driving, risk perception, 

and risk utility. Alcohol, Drugs, and Driving

1987;3:13–29.

National Center for Chronic Disease 

Prevention and Health Promotion, Centers 

for Disease Control and Prevention. Youth 

Risk Behavior Surveillance System—United 

States, 2003 [online]. (2004) [cited 2005 

Jan 14]. Available from: URL: http://apps.

nccd.cdc.gov/yrbss/CategoryQuestions.

asp?cat=1&desc=Unintentional%20Injuries

%20and%20Violence. 

National Highway Traffic Safety 

Administration (NHTSA), Department 

of Transportation (US). Traffic Safety Facts 

2002: Young Drivers [online]. Washington 

(DC): NHTSA; 2003 [cited 2005 Sep 

22]. Available from: URL: www-nrd.nhtsa.

dot.gov/pdf/nrd-30/NCSA/TSF2002/

2002ydrfacts.pdf.

———. Traffic Safety Facts 2003: Young 

Drivers [online]. Washington (DC): 

NHTSA; 2004 [cited 2004 Dec 13]. 

Available from: URL: www-nrd.nhtsa.dot.

gov/pdf/nrd-30/NCSA/TSF2003/809774.

pdf.
90 Preventing Injuries in America: Public Health in Action 

The Problem

Traumatic brain injuries (TBI) 

contribute to a substantial number 

of deaths and cases of permanent 

disability. Each year in the United 

States, an estimated: 

n 1.4 million people sustain a TBI. Of 

them, 235,000 are hospitalized and 

survive. These rates are more than 20 

times the number of hospitalizations 

for spinal cord injury, another key 

disabling injury (Langlois et al. 

2004; Johnson 2001); 

n 1.1 million people who sustain a 

TBI are treated and released from an 

emergency department (Langlois et 

al. 2004);

n 50,000 people die from a TBI 

(Langlois et al. 2004); and 

n 80,000 to 90,000 people experience 

the onset of long-term or lifelong 

disability associated with a TBI 

(Thurman et al. 1999).

Among children ages 0 to 14 years, 

TBI results in an estimated:

n 2,685 deaths; 

n 37,000 hospitalizations; and

n 435,000 emergency department 

visits (Langlois et al. 2004).

Falls are the leading cause of TBI; rates 

are highest among children ages 0 to 4 

and adults ages 75 or older 

(Langlois et al. 2004).

Motor vehicle trafficrelated causes result in 

the greatest number 

of TBI-related deaths 

and hospitalizations; 

rates are highest among 

adolescents ages 15 to 19 

(Langlois et al. 2004).

n In almost every age group, TBI rates 

are higher for men than for women 

(Langlois et al. 2004).

n People ages 75 years or older have 

the highest rates of TBI-related 

hospitalization and death (Langlois 

et al. 2004). 

n African Americans have the highest 

death rate from TBI (Langlois et al. 

2004).

n An estimated 5.3 million 

Americans—2% of the population—

currently live with disabilities 

resulting from TBI (Thurman et al. 

1999).

n About 75% of TBIs that occur each 

year are concussions or other forms 

of mild TBI (CDC 2003).

n Direct and indirect costs of TBI 

were an estimated $60 billion in the 

United States in 2000 (Finkelstein et 

al. 2006). 

CDC’s Accomplishments

The Children’s Health Act of 2000 

helps CDC provide continued 

leadership in the study of TBI. CDC 

supports multiple projects and 

programs, including those that 

monitor TBI, link people with TBI to 

information and services, and prevent 

TBI-related disabilities. 

Generating national estimates for 

TBI deaths, hospitalizations, and 

emergency department visits

CDC supported an analysis of 

TBI data from its National Center 

for Health Statistics. This analysis 

generated national estimates for TBI 

deaths, hospitalizations, and emergency 

department visits by sex, age, and 

geographic region; it also offered 

information about causes of TBI and 

average hospital stays for TBI patients. 

Results of this analysis are the subject 

of a CDC report, Traumatic Brain 

Injury in the United States: Emergency 

Department Visits, Hospitalizations, and 

Atraumatic brain injury(TBI) is caused by a blow or 

jolt to the head that disrupts the 

brain’s function. The severity of 

such an injury may range from 

“mild” (a brief change in mental 

status or consciousness) to 

“severe” (an extended period of 

unconsciousness or amnesia after 

the injury). Each year, about 75% 

of TBIs that occur in the United 

States are concussions or other 

forms of mild TBI (CDC 2003). 

Any TBI is considered serious.

Traumatic Brain Injury
Preventing Injuries in America: Public Health in Action 91

Deaths, published in 2004. (The report 

is available online at www.cdc.gov/ncipc/

pub-res/TBI_in_US_04/TBI_ED.htm.) 

This report is the first of its kind to 

include detailed national data about TBI 

in a single-reference document.

Identifying persons with TBI among 

World Trade Center survivors

CDC conducted a rapid assessment 

of injuries among survivors of the 

September 11, 2001, World Trade 

Center (WTC) attack who were seen in 

emergency departments; CDC found 

only a small percentage experienced 

head injury. Because other injured 

people may have had an undiagnosed 

TBI, CDC funded New York City’s 

Department of Health and Mental 

Hygiene to conduct a retrospective 

study to identify how many people 

hospitalized with injury after the 

WTC attack also may have had a TBI. 

Researchers reviewed inpatient hospital 

records that identify possible TBI 

and describe the cause and nature of 

injuries. Preliminary findings include 

a number of cases in which signs 

and symptoms of TBI were listed in 

patients’ medical records, suggesting a 

TBI even though it was not diagnosed. 

Researchers have found that some 

diagnosed TBIs were the result of 

falling debris or people being trampled. 

Planning the future of TBI 

registries and data systems

In July 2002, CDC convened an expert 

panel of TBI researchers, advocates, 

registry administrators, and other 

professionals to discuss the future of 

TBI registries and data systems and to 

obtain guidance in the development 

of a national program. The report, 

Traumatic Brain Injury in the United 

States: The Future of Registries and Data 

Systems, summarizes recommendations 

made to CDC by the expert panel and 

includes information about activities 

related to the TBI Reauthorization Act 

and the definition of a TBI registry. This 

report is available online at www.cdc.

gov/ncipc/tbi/RegistriesDataSys.htm.

Highlighting CDC-funded TBI 

research and programs

The May–June 2005 issue of the 

Journal of Head Trauma Rehabilitation,

“TBI in the US: Research and 

Programs of the CDC,” provides a 

comprehensive look at CDC-funded 

activities for TBI at national and 

state levels. This special issue also 

addresses public health principles and 

TBI legislation; TBI surveillance and 

education; TBI rates among children, 

older adults, and American Indians/

Alaska Natives; TBI-related outcomes, 

including the risk of death; and linkage 

to information and services for people 

with TBI. The publication is available 

online at the publisher’s website: www.

lww.com/product/?0885-9701.

Reporting to Congress 

about mild TBI

The Children’s Health Act of 2000 

required CDC to report to Congress 

on how best to measure the rate at 

which new cases of mild TBI occur and 

the proportion of the U.S. population 

that, at a point in time, experiences 

signs or symptoms of a mild TBI. To 

that end, CDC formed the Mild TBI 

Work Group, comprising experts in 

brain injury, to determine appropriate 

and feasible methods for assessing 

the incidence and prevalence of mild 

TBI in the United States. Report to 

Congress on Mild Traumatic Brain 

Injury in the United States: Steps to 

Prevent a Serious Public Health Problem, 

published in 2003, presents the Mild 

TBI Work Group’s findings and 

recommendations. 

Standardizing facts and 

information about TBI

CDC, in collaboration with 10 other 

TBI agencies and organizations such 

as the Brain Injury Association of 

America (BIAA) and the National 

Association of State Head Injury 

Administrators (NASHIA), developed 

a standard TBI fact sheet titled Facts 

about Traumatic Brain Injury. This fact 

sheet contains up-to-date information 

about the incidence, causes, risk 

factors, and costs associated with TBI. 

It is available online at www.cdc.gov/

ncipc/tbi/FactSheets/Facts_About_

TBI.pdf. 

Preventing and managing

sports-related concussions 

In 2004, CDC developed an 

educational tool kit, Heads Up: 

Concussion in High School Sports, for 

high school athletic coaches. It contains 

information about how to prevent, 

recognize, and manage sports-related 

concussions. It also contains materials 

to assist coaches in educating athletes, 

athletes’ parents, and school officials 

about sports-related concussions. 

A pilot study, conducted in 2005, 

evaluated the tool kit’s effectiveness. Of 

the nearly 500 responses, 74% found 

the materials very easy to use, and 

94% said the tool kit had just enough 

detail. More than two thirds of coaches 

reported being aware of incidents of 

sports-related concussions occurring at 
92 Preventing Injuries in America: Public Health in Action 

their schools, and a third had no access 

to the materials prior to receiving the 

tool kit. Also, 20% of coaches reported 

that their athletic department had no 

plan for dealing with concussions; 

however, most coaches (96%) thought 

the tool kit materials could be used to 

develop a plan. Most coaches said they 

would give the materials to parents, 

athletes, and other school officials. 

The revised tool kit, based on the pilot 

study, now includes an instructional 

DVD. 

The tool kit initiative, launched 

September 2005, distributed tool 

kits to more than 10,000 coaches, 

athletic directors, and principals in 

high schools nationwide. To order free 

of charge or download materials, visit 

CDC’s website: www.cdc.gov/ncipc/

tbi/Coaches_Tool_Kit.htm. 

Educating health care 

professionals about TBI 

In January 2003, CDC published 

and disseminated a TBI tool kit called 

Heads Up: Brain Injury in Your Practice. 

The tool kit contains practical, easyto-use clinical information, patient 

information in English and Spanish, 

scientific literature, and a CD-ROM. 

More than 150,000 tool kits have been 

distributed to health care professionals 

in the United States and internationally. 

Although the tool kit was originally 

developed for physicians, other 

health care providers such as nurse 

practitioners and physical therapists 

have requested the materials. CDC has 

received positive feedback from more 

than 2,000 recipients of the tool kit, 

indicating that it is well received and 

useful to the intended audience.

Funding researchers to address 

TBI among children and 

adolescents

CDC funds TBI research in academic 

institutions. Results of these projects 

will inform development of future 

programs and policies. Examples of 

research include the following:

n Measuring children’s health 

after a TBI. A TBI can significantly 

affect a child’s health and 

development. Yet no efficient, 

standardized method exists to 

monitor the health of children 

who sustain a TBI. In 2001, CDC 

funded Johns Hopkins University to 

conduct a 3-year study to evaluate 

different methods for measuring 

physical and psychosocial health 

outcomes of children with TBI. 

Initial findings from this study have 

been published in a peer-reviewed 

journal. Validating and adopting a 

standardized health status survey 

that is appropriate for large-scale, 

ongoing surveillance of children’s 

health following a TBI will improve 

understanding of how these injuries 

affect children. Such information 

will inform policy and research 

initiatives.

n Developing tools to measure the 

effects of mild TBI. CDC is funding 

a collaborative study between 

Children’s National Medical Center 

in Washington, D.C., the University 

of Pittsburgh Medical Center Sports 

Medicine Concussion Program, and 

researchers from Dartmouth College. 

This study seeks to develop and 

validate a series of tests for assessing 

health outcomes of mild TBI among 

children, adolescents, and teens. 

It will also document factors that 

influence the outcome of a mild TBI 

during the recovery period

Future Steps

TBIs are a major problem with 

devastating consequences to injured 

individuals and society at large. 

The impact of TBI in the United 

States indicates a need for ongoing 

monitoring and dedicated prevention 

efforts. In response to the Children’s 

Health Act of 2000, CDC is moving 

forward in the following areas:

Conducting a brain injury 

information center pilot study

CDC funded the Brain Injury 

Association of America (BIAA) in 

support of a pilot study to evaluate 

the development of a national brain 
Preventing Injuries in America: Public Health in Action 93

injury information center. The concept 

behind the information center was to 

provide persons with brain injury, their 

families, and agencies that serve them, 

with information on state-specific 

resources and available services. The 

“one-call” information center is being 

piloted in three states (Michigan, 

Minnesota, and Mississsippi). People in 

these states who call the BIAA’s toll-free 

number will be linked automatically 

to their local Brain Injury Association 

for confidential and individalized brain 

injury resources in their state. 

Conducting a TBI information and 

materials needs assessment 

CDC is supporting a TBI needs 

assessment to determine what materials 

are useful to varied audiences 

(e.g., health care professionals, educators, 

patients, families and caregivers, law 

and policy makers, community-based 

organizations, and state and local 

agencies). The project should also provide 

insight into which current materials reach 

diverse audiences; determine deficiencies 

in information, training, education, 

and available resources; and report on 

and develop ways to close information 

and resource gaps. 

Producing a concussion tool kit 

for youth sports

CDC’s tool kit on sports-related 

concussions, Heads Up: Concussion 

in High School Sports, was distributed 

to high school athletic coaches 

across the United States in 2005. 

Encouraged by positive feedback, 

CDC is expanding its prevention 

efforts by addressing another life stage: 

children who participate in youth 

sports. The tool kit materials will 

be revised for youth sports athletes, 

their parents, and coaches. CDC 

convened an expert meeting of youth 

sports leaders and TBI experts to 

discuss tool kit development and will 

develop partnerships to ensure effective 

distribution. CDC will also evaluate 

the effectiveness of the materials in 

raising awareness of sports-related 

concussion among the target audiences. 

Determining TBI prevalence in 

incarcerated populations 

CDC is funding cooperative 

agreements to develop methods to 

determine the prevalence of TBI 

history in an incarcerated population. 

Anecdotal reports suggest that a large 

proportion of the prison population 

may have experienced one or more 

TBIs. The cognitive deficits that 

may result often are not visible, and 

behavioral and emotional problems 

associated with TBI may be attributed 

to other causes. Thus, prisoners 

with TBI or prison officials may not 

recognize the symptoms and may not 

seek or provide appropriate treatment. 

Better methods for identifying 

incarcerated persons with a history of 

TBI and related problems could lead to 

improved management of TBI in this 

population.

Determining prevalence of TBIrelated disability among children 

and adolescents

CDC plans to support longitudinal 

research to assess disability and 

other outcomes, including physical, 

cognitive, social, emotional, behavioral, 

and educational, on a population or 

representative sample of children or 

adolescents from a geographically 

defined region or state. Currently, no 

such study results of TBI outcomes 

among these groups are available to 

estimate the prevalence of TBI-related 

disability nationwide. Estimates of 

children and adolescents with TBIassociated disability are necessary to 

document their need for services, help 

them return to school, and enable them 

to lead healthy and productive lives. 

References

Centers for Disease Control and Prevention 

(CDC), National Center for Injury 

Prevention and Control. Report to Congress 

on Mild Traumatic Brain Injury in the 

United States: Steps to Prevent a Serious 

Public Health Problem, Atlanta (GA): CDC; 

2003.

Finkelstein EA, Corso PS, Miller TR. 

Incidence and Economic Burden of Injuries in 

the United States. New York (NY): Oxford 

University Press; 2006. 

Johnson R. Traumatic Spinal Cord Injury 

Brief Overview of Impact [unpublished]. 

Atlanta (GA): Centers for Disease Control 

and Prevention; 2001.

Langlois JA, Rutland-Brown W, Thomas KE. 

Traumatic Brain Injury in the United States: 

Emergency Department Visits, Hospitalizations, 

and Deaths. Atlanta (GA): Centers for 

Disease Control and Prevention; 2004.

Thurman D, Alverson C, Dunn K, 

Guerrero J, Sniezek J. Traumatic brain 

injury in the United States: a public health 

perspective. Journal of Head Trauma and 

Rehabilitation 1999;14(6):602–615. 
94 Preventing Injuries in America: Public Health in Action 

The Problem

n In 2002, there were 3,447 

unintentional drownings in the 

United States, averaging nine people 

per day. This does not include 

drownings in boating-related 

incidents (CDC 2004a). 

n In 2002, males accounted for 80% 

of drownings in the United States 

(CDC 2004a).

n Alcohol use is involved in about 

25% to 50% of adolescent and 

adult deaths associated with 

water recreation (Howland et al. 

1995; Howland and Hingson 

1988). Alcohol influences balance, 

coordination, and judgment, and 

its effects are heightened by sun 

exposure and heat (Smith and Kraus 

1988).

n Nearly 50% of drowning victims 

treated in emergency departments 

need hospitalization or transfer 

for higher levels of care compared 

with 3% to 5% of people treated in 

emergency departments for other 

reasons (Gilchrist et al. 2004). 

n According to the U.S. Coast Guard, 

703 people died in recreational 

boating incidents in 2003 (USCG 

2003). 

n Up to 70% of boating-related deaths 

were the result of drowning; 86% 

of people who drowned were not 

wearing personal flotation devices 

(USCG 2003). 

CDC’s Accomplishments

Research on nonfatal drownings at 

recreational water sites

In 2004, CDC scientists published 

the first national estimate of nonfatal 

drowning injuries treated in emergency 

departments in the Morbidity and 

Mortality Weekly Report. In the United 

States in 2001 and 2002, more 

than 4,100 people sought care in an 

emergency department each year for 

nonfatal drowning injuries; more 

than half required hospital admission 

or transfer for higher levels of care. 

Children ages 4 and younger and males 

of all ages were at greatest risk. The 

most common locations of nonfatal 

injuries for very young children 

were residential pools. Among older 

children, more injuries occurred in 

natural water settings. The study also 

confirmed that injuries happen most 

often on weekends and during summer 

months, when people typically enjoy 

water-related activities.

Report assesses effectiveness of 

lifeguards for drowning prevention 

Most drownings occur at sites 

without lifeguards, according to an 

October 2001 CDC report. This 

report assessed lifeguard services as 

a strategy for preventing drowning 

and water-related injuries. Data for 

1988–1997 show more than three 

Water-related Injuries
inadvertent exposure. The National 

SAFE KIDS Campaign evaluated 

the Three Tragic Seconds program 

during the summer of 2003. Findings 

showed that at the end of the program, 

many participants demonstrated an 

increased awareness about home safety 

and the need for adult supervision of 

children. For many, the program also 

dispelled common myths surrounding 

water safety, including the inaccurate 

belief that air-filled toys are safety 

devices and the idea that swimming 

lessons are sufficient to prevent small 

children from drowning. These 

findings will guide development of 

future educational interventions for 

childhood drownings.

National Safe Boating Week 

CDC helped promote boating safety 

during National Safe Boating Week 

2004 (May 22–28) and 2005 (May 

21–27). Boating safety is an important 

public health issue because more 

than 70 million Americans enjoy 

recreational boating each year. Plus, 

annual boat registrations have increased 

steadily from just over 10 million in 

1988 to more than 12.8 million in 

2002. During this same time, boatingrelated fatalities decreased, due in part 

to increased use of personal flotation 

devices (life jackets). Still, in 2003, 

3,888 participants were reported 

injured and 703 killed in boating 

incidents. Among those who died from 

drowning, about 9 out of 10 were not 

wearing life jackets. The 2004 North 

American Safe Boating Campaign 

focused on raising awareness and 

ensuring that every person on a boat 

wears a life jacket. The campaign’s 

theme was “Boat smart. Boat safe. 

Wear it!” 

CDC extramural research grants

CDC provides grant funding to 

researchers at universities, medical 

institutions, and community-based 

organizations to study various factors 

Just the Facts . . . 

Children and Drowning

Drowning is the second leading 

cause of injury-related death for 

children ages 1 to 14 (CDC 2004b).

n In 2002, 904 children ages 0 to 

14 died from drowning (CDC 

2004b). 

n For every child 14 years and 

younger who drowns, three 

receive emergency department 

care for nonfatal submersion 

injuries. More than 40% of these 

children require hospitalization 

(CDC 2004b). Nonfatal incidents 

can cause brain damage that 

result in long-term disabilities 

ranging from memory problems 

and learning disabilities to 

the permanent loss of basic 

functioning (i.e., persistent 

vegetative state). 

n Children under age 1 most often 

drown in bathtubs, buckets, or 

toilets (Brenner et al. 2001).

n Among children ages 1 to 4 

years, most drownings occur 

in residential swimming pools 

(Brenner et al. 2001; Gilchrist et 

al. 2004). Most young children 

who drowned in pools were last 

seen in the home, had been out 

of sight less than five minutes, 

and were in the care of one or 

both parents at the time (Present 

1987).

n During 2001–2002, the overall 

age-adjusted drowning rate for 

African Americans was 1.4 times 

higher than for whites. However, 

these rates vary by age. AfricanAmerican infants under 1 year 

had a drowning rate only slightly 

higher than the rate of white 

infants. Among children 1 to 4 

years of age, African Americans 

had a lower drowning rate than 

whites. African-American children 

ages 5 to 19 drowned at 2.7 times 

the rate of white children in this 

age group (CDC 2004b). 

quarters of drownings at United States 

Lifesaving Association (USLA) sites 

(mostly ocean beaches) occurred when 

beaches were unguarded. In contrast, 

the chance of drowning at a beach 

where USLA-trained lifeguards are on 

duty is less than 1 in 18 million. These 

findings underscore the importance 

of having trained lifeguards at all 

beaches where people swim. This 

report will help communities, local 

government officials, and owners of 

private water recreational areas make 

informed decisions about whether 

to begin, retain, or discontinue 

lifeguard services. Additionally, the 

report describes some environmental 

modifications that can minimize injury 

risk. These modifications include 

creating slope gradients that gradually 

and smoothly lead to deeper water; 

prohibiting diving platforms and 

swim floats; using buoys and markers 

to delineate the swim area and keep 

boats out; and ensuring the availability 

of additional safety measures such as 

rings, buoy lines, and poles. Finally, 

comprehensive water safety 

information campaigns can educate 

recreational water enthusiasts about 

their risks and preventive measures. 

Three Tragic Seconds: A childhood 

drowning prevention program

CDC worked with the Children’s 

Hospital of Orange County, California, 

(CHOC) and the National SAFE 

KIDS Campaign to implement the 

Three Tragic Seconds program in two 

communities in Arizona and Florida. 

CHOC developed this multimedia 

educational program to teach parents 

about drowning prevention. In 

addition to highlighting appropriate 

supervision while children are in the 

water, the program stresses the need for 

multiple layers of protection (i.e., foursided isolation fencing, pool alarms, 

door and gate locks, and door alarms) 

between small children and residential 

pools, or other water sites, to prevent 

 Preventing Injuries in America: Public Health in Action 95
96 Preventing Injuries in America: Public Health in Action 

associated with water-related injuries. 

An example of those extramural 

research projects follows. For more 

information about this and other 

projects, please visit www.cdc.gov/

ncipc/res-opps/extra.htm.

n Oceanfront injury prevention.

Researchers at the Eastern Virginia 

Medical School are creating a 

community injury prevention model 

to reduce beach-related injury risk 

behavior (e.g., leaving children 

unsupervised, swimming during 

rough weather). They will develop a 

multifaceted education intervention 

by working with members of a 

coalition that have successfully 

changed behavior at the community 

level. Researchers will develop 

quantitative measures of injury risk 

that they will use in a pilot study 

conducted at a single oceanfront 

beach in Virginia Beach, Virginia. 

Future Steps 

Additional research, as demonstrated 

in the following examples, is needed to 

help answer many remaining questions 

about the risk factors for drowning and 

other water-related injuries. 

n Evaluate the effectiveness of 

legislation (e.g., four-sided pool 

fencing) and community-based 

programs to prevent drowning.

n Assess levels of water safety 

knowledge and swimming ability 

among drowning and near-drowning 

victims. 

n Assess levels of water safety 

knowledge and swimming skill 

among the general population and 

among high-risk groups.

n Describe the frequency and 

circumstances of water activities 

among the general population and 

among various groups.

n Assess the effectiveness of personal 

flotation devices.

References

Brenner RA, Trumble AC, Smith GS, 

Kessler EP, Overpeck MD. Where children 

drown, United States, 1995. Pediatrics

2001;108(1):85–89.

Centers for Disease Control and 

Prevention, National Center for Injury 

Prevention and Control. Web-based Injury 

Statistics Query and Reporting System 

(WISQARS) [online]. (2004a) [cited 2005 

Feb 24]. Available from: URL: www.cdc.

gov/ncipc/wisqars. 

———. (2004b) [cited 2005 Jan 14]. 

Available from: URL: www.cdc.gov/ncipc/

wisqars. 

Gilchrist J, Gotsch K, Ryan G. Nonfatal 

and fatal drownings in recreational water 

settings—United States, 2001–2002. 

Morbidity and Mortality Weekly Report

2004;53(21):447–452.

Howland J, Hingson R. Alcohol as a 

risk factor for drownings: a review of the 

literature (1950–1985). Accident Analysis 

and Prevention 1988;20(1):19–25. 

Howland J, Mangione T, Hingson R, 

Smith G, Bell N. Alcohol as a risk factor for 

drowning and other aquatic injuries. 

In: Watson RR, editor. Alcohol and 

accidents. Drug and Alcohol Abuse Reviews. 

Vol 7. Totowa (NJ): Humana Press, Inc.; 

1995. p. 85–104. 

Present P. Child Drowning Study. A 

report on the epidemiology of drowning in 

residential pools to children under age five. 

Washington (DC): Consumer Product 

Safety Commission (US); 1987.

Smith GS, Kraus JF. Alcohol and 

residential, recreational, and occupational 

injuries: A review of the epidemiologic 

evidence. Annual Review of Public Health

1988;9:99–121. 

U.S. Coast Guard (USCG), Department 

of Homeland Security. Boating Statistics

[online] 2003 [cited 2005 Mar 4]. Available 

from: URL: www.uscgboating.org/statistics/

accident_stats.htm.

Kids Don’t Float program: Photo by Ryan Hill/Alaska Native Tribal Health
Preventing Injuries in America: Public Health in Action 97

Youth violence involves the intentional use of physical force or 

power (threatened or actual) against 

another person, group, or community 

that either results in or will likely result 

in injury, death, psychological harm, 

maldevelopment, or deprivation.

The Problem

Although homicide rates have dropped 

in recent years, the rates remain 

unacceptably high. Homicide rates for 

young people are higher in the United 

States than in other developed nations.

n In 2003, 888,508 young people 

ages 10 to 24 were injured from 

violent acts. About 1 in 12 required 

hospitalization (CDC 2004).

n Homicide is the second leading 

cause of death among young people 

ages 10 to 24. In this age group, 

homicide is the third leading cause 

of death for American Indians/

Alaska Natives, the second leading 

cause of death for Hispanics and 

Asian/Pacific Islanders, and the 

leading cause of death for African 

Americans (CDC 2005).

n In 2002, 5,435 young people ages 10 

to 24 were murdered—an average of 

15 deaths each day (CDC 2004).

n In 2002, 82% of homicide victims 

ages 10 to 24 were killed with 

firearms (CDC 2004).

n Among students surveyed 

nationwide in a 2003 CDC study 

(Grunbaum et al. 2004):

• 17.1% had carried a weapon (e.g., 

a gun, knife, or club) in the 30 

days preceding the survey.

• 6.1% had carried a gun in the 30 

days preceding the survey.

• 33.0% had been in a physical fight 

one or more times during the 12 

months preceding the survey.

• 4.2% had been injured in a 

physical fight one or more times 

during the 12 months preceding 

the survey and sustained injuries 

requiring treatment by a doctor or 

nurse. 

CDC’s Accomplishments

Academic centers link 

researchers and communities

Eight colleges and universities have 

received CDC funding to establish 

National Academic Centers of 

Excellence (ACEs) on Youth Violence. 

These Centers foster joint efforts 

between university researchers and 

communities to address youth violence. 

The primary objectives of the Centers 

include monitoring and tracking 

the problem, researching risk and 

protective factors, testing prevention 

strategies, developing multidisciplinary 

collaborations, providing training, 

and formulating community-based 

plans for youth violence prevention. 

For more information about specific 

programs conducted by the ACEs, visit 

www.cdc.gov/ncipc/res-opps/ACE/ace.

htm.

National resource center offers 

wealth of information

The National Youth Violence 

Prevention Resource Center is a 

central source for information and 

materials gathered from institutions, 

community-based organizations, and 

federal agencies working to prevent 

violence among our nation’s youth. 

The Center’s website, toll-free hotline, 

and fax-on-demand service offer access 

to information about prevention 

programs, publications, research and 

statistics, and fact sheets. The website 

links parents, teens, and researchers 

to materials designed specifically for 

those audiences. Each month, the 

Center responds to more than 100 

public inquiries and requests for 

technical assistance, fulfills more than 

500 requests for publications and 

youth violence prevention materials, 

and hosts more than 37,000 website 

visitors. For more information, call 

1-866-SAFEYOUTH (1-866-723-

3968) or visit www.safeyouth.org. 

Youth Violence
98 Preventing Injuries in America: Public Health in Action 

Multisite project evaluates 

prevention effort

CDC is funding a multisite trial of a 

violence prevention program aimed 

at middle school students. Thirtyseven middle schools in four states 

are participating. The program being 

evaluated teaches students conflict 

resolution and problem-solving 

skills, trains teachers about violence 

prevention, and engages family 

members in program activities. The 

project––affiliated with Virginia 

Commonwealth University, the 

University of Illinois at Chicago, the 

University of Georgia, and Duke 

University––represents one of the 

largest efforts to date to assess the 

effectiveness of school-based violence 

prevention among middle school 

students.

Study tracks school-associated 

violent deaths

With the U.S. Department of 

Education and U.S. Department of 

Justice, CDC has conducted a national 

study of school-associated violent 

deaths since 1992. The latest findings, 

published in the Journal of the American 

Medical Association in 2001, show 220 

incidents of school violence occurred 

between July 1, 1994, and June 30, 

1999. Most incidents were homicides 

involving firearms. While the number 

of incidents has decreased steadily 

since 1992, multiple-victim incidents 

have increased. This study plays an 

important role in monitoring trends in 

school violence, identifying risk factors 

for school violence, and assessing the 

effects of prevention efforts.

Reporting system to provide 

objective, timely violence data

State and local agencies acquire 

detailed information from medical 

examiners, coroners, police, crime labs, 

and death certificates that could answer 

fundamental questions about violence 

trends and patterns. However, the 

information is fragmented and difficult 

to access. CDC has funded 17 states—

Alaska, California, Colorado, Georgia, 

Kentucky, Maryland, Massachusetts, 

New Jersey, New Mexico, North 

Carolina, Oklahoma, Oregon, Rhode 

Island, South Carolina, Utah, Virginia, 

and Wisconsin—to establish the 

National Violent Death Reporting 

System (NVDRS) to gather, share, and 

link state-level data about violence. 

When fully implemented, NVDRS 

will enable CDC to pull together vital 
Preventing Injuries in America: Public Health in Action 99

Compendium of assessment tools

CDC has updated Measuring 

Violence-related Attitudes, Behaviors, 

and Influences Among Youths: A 

Compendium of Assessment Tools. The 

compendium provides researchers and 

prevention specialists with measures to 

assess the factors associated with youth 

violence and to evaluate prevention 

programs. This publication may be 

ordered online at www.cdc.gov/injury. 

Preventing Violence through 

Education, Networking, and 

Technical Assistance (PREVENT) 

CDC is funding the University of 

North Carolina Injury Prevention 

Research Center to develop a 

national training program for 

violence prevention practitioners. 

The initiative, PREVENT, is an 

outgrowth of the National Injury 

and Violence Prevention Training 

Initiative. It is supported by the 

Society for Advancement of Violence 

and Injury Research (formerly the 

National Association of Injury 

Control Research Centers) and the 

State and Territorial Injury Prevention 

Directors Association. PREVENT 

helps individuals and organizations 

build skills to identify community 

needs and assets; to create and 

mobilize partnerships; to develop 

and implement prevention programs; 

to measure success; and to fund and 

sustain programs. PREVENT uses 

many educational methods including 

distance-learning modules, regional 

workshops, action learning projects, 

coaching, and an intensive institute.

Association between exposure to 

media violence and youth violence

CDC is funding Internet Solutions 

for Kids, Inc., in Irvine, California, 

and the University of Michigan to 

study how media violence, particularly 

violence in new media such as the 

Internet and video games, affects youth 

violence. Researchers are examining 

Assessing links between various 

forms of violence 

CDC is conducting a study to 

identify the links between different 

forms of violent behaviors among 

adolescents. The findings will help 

scientists understand the prevalence 

and consequences of different types of 

aggressive behaviors; the association 

between dating violence and other 

forms of peer violence; and the 

manner in which these types of violent 

behaviors vary by sex, developmental 

stage, and other factors.

Youth violence prevention through 

community-level change

CDC is funding the University of 

Michigan to evaluate the Youth 

Empowerment Solutions for Peaceful 

Communities (YES) project. The 

project aims to reduce rates of youth 

violence in communities through 

interventions designed to change 

community structures and social 

processes. The YES project provides 

opportunities for youth that will 

prevent or reduce youth violence and 

initiate positive community change. 

For example, YES helps neighborhood 

organizations engage youth in activities 

that focus on changing their social and 

physical environments. 

Assessment tool for school 

environments

CDC is supporting the development 

of a tool to assess the physical 

characteristics of schools that can 

contribute to feelings of safety, 

increase prosocial behavior, and 

decrease aggressive behavior. The tool 

uses the Crime Prevention Through 

Environment Design (CPTED) 

framework. The core principles of 

CPTED are to reduce opportunities for 

crime, to enhance natural surveillance 

of activities, and to reinforce a sense 

that the environment is cared for and 

that problems will be addressed. 

state-level information to gain a more 

accurate understanding of violence 

and to enable policy makers and 

community leaders to make informed 

decisions about violence prevention 

strategies and programs, including 

decisions that address youth violence.

Sourcebook guides community 

efforts to prevent youth violence

Best Practices of Youth Violence 

Prevention: A Sourcebook for 

Community Action was published in 

1999 to help communities develop and 

implement youth violence prevention 

programs. The sourcebook presents 

four key strategies for preventing youth 

violence: school-based programs, 

mentoring programs, parenting and 

family-based programs, and home 

visitation. The sourcebook builds on 

lessons learned from the first CDCfunded evaluation projects and draws 

on the expertise of more than 100 

of the nation’s leading scientists and 

practitioners. Best Practices is also 

available in Spanish.

Sociocultural and community risk 

and protective factors for child 

maltreatment and youth violence

CDC is funding researchers at the 

University of Georgia to examine the 

sociocultural and community risk 

and protective factors associated with 

child maltreatment and early risk 

factors for youth violence. Previous 

research has described the importance 

of such factors as access to social 

capital, community social organization, 

economic and family resources, 

residential instability, and community 

and family violence. However, limited 

information is available about how 

these and other risk and protective 

factors might affect child maltreatment 

and the early developmental risk 

factors for youth violence. The results 

from this research will inform the 

development of violence prevention 

strategies for communities.
The components for a coordinated 

school health program are addressed 

for all grade levels. Specialists from 

universities and from national, 

federal, state, and local agencies 

and organizations collaborated to 

develop the guide. Development 

was based on in-depth review of 

research, theory, and current practice 

in unintentional injury, violence, 

and suicide prevention; health 

education; and public health. The 

guidelines are available at www.cdc.

gov/healthyyouth/injury/guidelines.

n Healthy Passages. Healthy Passages 

is a multiyear longitudinal study to 

help families, schools, communities, 

and health care providers understand 

how children grow to be healthy, 

educated, and productive members 

of society. The study will help 

explain why young people make 

choices that lead to healthy or risky 

behaviors. Data collection, which 

began in fall 2004, will provide 

information about varied injury and 

violence issues including individual 

and family factors associated with 

bullying and how behaviors change 

over time.

n Youth Risk Behavior Surveillance 

System. CDC’s Youth Risk Behavior 

Surveillance System (YRBSS) 

monitors priority health risk 

behaviors that contribute to the 

leading causes of death, disability, and 

social problems among adolescents 

and adults in the United States, 

including behaviors that contribute to 

unintentional injuries and violence. 

The YRBSS consists of national, 

state, and local school-based surveys 

of representative samples of 9th 

through 12th grade students. The 

surveys, conducted biennially, 

provide information on varied 

suicide- and interpersonal violencerelated behaviors both on school 

property and in the community.

Just the Facts . . .

Key Risk Factors for 

Youth Violence

Using the public health approach, 

one of the first steps toward 

preventing violence is to identify 

and understand the factors 

that place young people at risk 

for violent victimization and 

perpetration. Research shows that 

some individual and social factors 

can increase the probability of 

violence during adolescence and 

young adulthood:

Individual

n History of early aggression

n Beliefs supportive of violence

n Social cognitive deficits

Family

n Poor monitoring or supervision 

of children

n Exposure to violence

n Parental drug or alcohol abuse

n Poor emotional attachment to 

parents or caregivers

Peer/School

n Association with peers engaged 

in high-risk or problem behavior

n Low commitment to school

n Academic failure

Neighborhood

n Poverty and diminished economic 

opportunity

n High levels of transience and 

family disruption 

n Low community participation

the association between exposure to 

media violence and serious violent 

behavior, assessing the aspects of media 

that contribute to the risk of violence, 

and identifying factors that mediate 

or moderate the association between 

media violence and violent behavior.

Enhancing State Capacity to 

Address Child and Adolescent 

Health Through Violence Prevention 

(ESCAPe)

CDC’s ESCAPe program is designed 

to develop capacity and leadership in 

preventing all types of youth violence. 

The planning and implementation 

phases of this project will address 

shared risk and protective factors. To 

date, Colorado, Iowa, Massachusetts, 

Michigan, Minnesota, New Mexico, 

Rhode Island, and Virginia have 

received funding.

Social and character development 

research program

CDC and the U.S. Department of 

Education have launched a social 

and character development research 

program. Researchers are evaluating 

the effectiveness of interventions 

designed to promote positive social 

and character development, increase 

positive behaviors, and reduce 

antisocial behaviors among elementary 

school children. 

Collaboration with other 

parts of CDC

CDC’s Injury Center has worked 

with the Division of Adolescent and 

School Health (DASH), part of CDC’s 

National Center for Chronic Disease 

Prevention and Health Promotion, 

on projects related to youth violence. 

Examples of this collaboration follow:

n School Health Guidelines to 

Prevent Unintentional Injuries and 

Violence. State and local educational 

agencies and schools use these 

guidelines to promote safety and 

to teach students the skills needed 

to prevent injuries and violence. 

100 Preventing Injuries in America: Public Health in Action
Preventing Injuries in America: Public Health in Action 101

twice during home-based sessions 

to determine the source, frequency, 

and severity of intentional injury 

and the consequences of such injury 

on their physical, psychological, 

social, and academic functioning. 

Participants will also be interviewed 

about gun ownership (self and 

family), gun carrying, and reasons 

for gun ownership. These data are 

being collected as part of an ongoing 

study of the neighborhoods, schools, 

families, and personal risk factors for 

violence.

n Youth employment and 

youth violence. Is work a viable 

intervention? Researchers at the 

University of North Carolina at 

Chapel Hill are examining whether 

youth employment has promise as 

a potential intervention to reduce 

youth violence. This project uses 

data collected from the National 

Longitudinal Study of Adolescent 

Health, based on a nationally 

representative sample of more 

than 10,000 adolescents who 

completed in-home interviews over 

a six-year period. Investigators are 

examining the relationship between 

employment during adolescence 

and violent (i.e., assault, fighting, 

threatening with weapons) and 

violence-related behaviors (i.e., drug 

and alcohol use, stealing, weapon 

carrying, gang membership).

Future Steps

CDC has identified promising 

interventions to prevent youth 

violence; however, more strategies 

are needed for community-level 

interventions. CDC must continue 

to build on the prevention knowledge 

base by identifying the best ways to 

disseminate and encourage adoption of 

effective strategies. 

CDC’s experience in studying suicide, 

family violence, and youth violence 

provides a unique environment for 

understanding the shared factors 

contributing to different forms of 

violence. CDC and its partners must 

examine these common links to 

develop broad prevention strategies. 

References

Centers for Disease Control and 

Prevention, National Center for Injury 

Prevention and Control. Web-based Injury 

Statistics Query and Reporting System 

(WISQARS) [online]. (2004) [cited 2004 

May 24]. Available from: URL: www.cdc.

gov/ncipc/wisqars. 

———. (2005) [cited 2005 Oct 2]. 

Available from: URL: www.cdc.gov/ncipc/

wisqars. 

Grunbaum JA, Kann L, Kinchen S, Ross 

JG, Lowry R, Harris WA, et al. Youth risk 

behavior surveillance—United States, 2003. 

Morbidity and Mortality Weekly Report

2004;53(SS-2):1–100.

n School Health Policies and 

Programs Study (SHPPS).

This national survey is conducted 

periodically to assess school health 

policies and programs at state, 

district, school, and classroom 

levels. SHPPS was first conducted 

by CDC’s Division of Adolescent 

and School Health (DASH) in 1994 

and was repeated in 2000. SHPPS 

provides information about health 

education, programs, environmental 

strategies, and policies that states, 

districts, and schools use to address 

violence and suicide prevention.

n School Health Index. This selfassessment and planning tool enables 

schools to identify the strengths and 

weaknesses of its health and safety 

policies and programs; develop an 

action plan for improving student 

health and safety; and involve 

teachers, parents, students, and the 

community in improving school 

services. The third edition of the 

School Health Index, including 

unintentional injury and violence 

prevention items, is available at 

www.cdc.gov/nccdphp/dash/SHI/

index.htm.

CDC extramural research grants

CDC provides grant funding to 

researchers at universities, medical 

institutions, and community-based 

organizations to study various factors 

related to youth violence. A sample 

of those extramural research projects 

follows. For information about these 

and other projects, please visit www.

cdc.gov/ncipc/res-opps/extra.htm.

n Intentional injury among urban 

youth. Harvard University 

researchers are studying 5,000 males 

and females, ages 2, 5, 8, 11, 14, and 

17, residing in 80 neighborhoods 

in Chicago. These children and 

their caregivers will be assessed 

Publications and Resources

Each year, CDC’s Injury Center staff contribute 

to publications for researchers and professional 

health practitioners and for the general public. 

The list of government publications, books, 

conference proceedings, and journal articles 

are extensive. Examples of publications follow 

and, unless otherwise noted, these resources are 

available by visiting the Injury Center’s website, 

www.cdc.gov/injury, or by calling 

1-800-CDC-INFO. 
104 Publications and Resources 

Activity Report 2004: CDC’s 

Unintentional Injury Prevention 

Program 

Unintentional injuries are a leading 

cause of death for all Americans, 

regardless of age, race, gender, or 

economic status. The Division of 

Unintentional Injury and Prevention, 

part of CDC’s Injury Center, has 

produced a report detailing its 

achievements to prevent such injuries. 

CDC’s Unintentional Injury Activities 

2004 highlights the agency’s research 

and programmatic accomplishments 

for 2002–2004 in the areas of motor 

vehicle and home and recreation injury. 

Atlas of Injury Mortality Among 

American Indian and Alaska Native 

Children and Youth, 1989–1998

Injuries, from both unintentional and 

intentional causes, are third behind 

heart disease and cancer as the leading 

cause of death among all American 

Indians and Alaska Natives (Native 

Americans). This Atlas presents injury 

mortality data from 1989 through 

1998 for Native American children 

and youth ages 0 to 19 years residing 

in the 12 Indian Health Service areas. 

Bibliography of Behavioral Science 

Research in Unintentional Injury 

Prevention 

The Bibliography of Behavioral Science 

Research in Unintentional Injury 

Prevention includes more than 900 

citations of journal articles, book 

chapters, government reports, and 

other publications. Designed as a 

tool for researchers, practitioners, and 

students, this bibliography documents 

the contributions of behavioral and 

social sciences to unintentional 

injury prevention and control from 

1980 through 2003. The publication 

includes the complete bibliography in 

two formats: alphabetical by author 

and by injury topic. Citations are also 

indexed by keyword. 

Brain Injury Association of 

America Family Helpline

www.biausa.org

1-800-444-6443 (toll free)

The Brain Injury Association of 

America’s Family Helpline receives 

about 15,000 calls each year from 

individuals with brain injury and from 

family members and providers seeking 

assistance, education, and support. For 

many, the Family Helpline is the first 

point of contact and support during the 

difficult times following a brain injury. 

CDC Injury Research Agenda 

The CDC Injury Research Agenda is 

a blueprint to prevent injuries and 

resulting disabilities, deaths, and costs. 

Initially published in 2002, the Agenda 

identifies CDC’s highest priorities 

for key areas of injury prevention 

and control—those research issues 

that CDC must address to fulfill 

its public health responsibilities. 

Research areas include transportation; 

sports, recreation, and exercise; youth 

violence; suicidal behavior; intimate 

partner violence, sexual violence, 

and child maltreatment; and acute 

care, disability, and rehabilitation. 

The Agenda was developed with 

extensive input 

from national 

nonprofit 

organizations, 

CDC’s 

academic 

research 

centers, and 

other federal 

agencies 

with a stake 

in injury 

prevention. 

In 2003, the Injury Center identified 

gaps in the area of acute injury care 

and updated the Agenda to clearly state 

CDC’s highest priorities for acute care 

research. By defining research needs, 

CDC expects to maximize efficient and 

effective use of resources and encourage 

collaboration among researchers and 

practitioners.

Publications and Resources
Publications and Resources 105

CDC School Health Index

The School Health Index (SHI) SelfAssessment & Planning Guides are 

self-assessment and planning tools that 

elementary and middle/high schools 

can use to improve health and safety 

policies and programs. CDC developed 

these guides in partnership with 

parents, school health experts, school 

administrators and staff, and national 

nongovernmental health and education 

agencies. Each SHI is structured around 

CDC’s research-based guidelines for 

school health programs, which identify 

the policies and practices most likely to 

be effective in improving youth health 

risk behaviors.

CDCynergy: Violence 

Prevention Edition

CDCynergy is a multimedia CDROM used for planning, managing, 

and evaluating public health 

communication programs tailored 

to the specific needs of an issue or 

audience. This edition of CDCynergy 

is ideal for those interested in 

developing prevention programs 

about child abuse, intimate partner 

violence, sexual violence, and youth 

violence. Included on the CD-ROM 

are guidelines on how to conduct 

focus groups; case examples of how 

other organizations have planned, 

implemented, and evaluated violenceprevention campaigns; and examples 

of existing media campaign materials 

(radio and television PSAs, posters, 

brochures) from across the violence 

prevention spectrum.

Central Nervous System Injury 

Surveillance Data Submission 

Standards 

This publication guides users in 

collecting, formatting, evaluating, and 

submitting data to CDC. It updates 

sections from the 2001 Annual Data 

Submission Standards Central Nervous 

System Injury, Guidelines for the 

Surveillance of Central Nervous System 

Injury (published in 1995); sections 

from the 1999 TBI Surveillance 

Grantees’ Meeting; and 

parts of the 1999 Technical 

Reference Document related 

to data processing and 

submission.

Costs of Intimate Partner 

Violence Against Women 

in the United States 

Recognizing the need to 

better measure both the scope 

of the problem of intimate 

partner violence (IPV) and 

resulting economic costs—in 

particular, those related to 

health care—Congress funded 

CDC to obtain national estimates of 

the occurrence of IPV-related injuries, 

to estimate the cost to our health care 

system, and to recommend strategies 

to prevent IPV and its consequences. 

The publication includes estimates 

of incidence, prevalence, and costs of 

nonfatal and fatal IPV; identifies future 

research needs; and highlights CDC’s 

research priorities for IPV prevention. 

Heads Up: Brain Injury in 

Your Practice Tool Kit 

At least 1.4 million people sustain 

traumatic brain injuries in this country 

every year. Of them, about 1.1 million, 

or 75%, sustain a mild traumatic 

brain injury (MTBI). Yet, many are 

not hospitalized or receive no medical 

care. CDC, working with a number 

of partners, has developed a physician 

tool kit to improve clinical diagnosis 

and management of MTBI. Physicians 

can play a key role in reducing the 

occurrence of MTBI by educating 

patients and the community about 

risks and injury prevention.

Heads Up: Concussion in High 

School Sports Tool Kit 

Concussions can happen to any athlete, 

male or female, in any sport. An 

estimated 1.6 to 3.8 million Americans 

sustain sports- and recreation-related 

traumatic brain injuries every year. 

Athletic directors, trainers, and coaches 

can learn to recognize, help prevent, 

and manage concussion properly when 

it occurs. Working with a number of 

notable partner organizations, CDC 

developed a tool kit on concussion 

for high school coaches, athletes, 

and parents. The kit contains a video 

featuring a young athlete disabled 

by concussion; practical, easy-to-use 

information for coaches; posters; 

facts sheets for parents and athletes in 

English and Spanish; and a CD-ROM 

with downloadable kit materials and 

additional concussion-related resources. 

Información Acerca de la 

Lesión Cerebral Leve

Facts About Concussion and Brain 

Injury: Where to Get Help is now 

translated for the Spanish-speaking 

population. This 18-page brochure 

is written for Spanish-speaking 

people with brain injuries and for the 

family members or caregivers of these 

individuals. The brochure provides 

information about brain injury, 

symptoms of brain injury, tips for 

healing, and resources. The brochure 

also highlights a Spanish-speaking 

helpline, managed by the Brain 

Injury Association of America, where 

individuals can access more information 

and resources. Members of the Latino 

community, comprised of varied ethnic 

origins and backgrounds, were involved 

in the development, design, and 

translation of this brochure.
106 Publications and Resources 

Measuring Violence-related 

Attitudes, Behaviors, and 

Influences Among Youths: A 

Compendium of Assessment Tools 

CDC has revised 

and updated 

Measuring Violencerelated Attitudes, 

Behaviors, and 

Influences Among 

Youths: A 

Compendium 

of Assessment 

Tools. The 

compendium 

provides 

researchers 

and prevention specialists with 

measures to assess the factors associated 

with youth violence and to evaluate 

prevention programs.

National Online Resource Center 

on Violence Against Women 

(VAWnet)

The National Online Resource 

Center on Violence Against Women 

(VAWnet) supports the development, 

implementation, and maintenance 

of effective violence against women 

intervention and prevention efforts at 

national, state, and local levels. VAWnet 

provides a collection of full-text, searchable 

electronic resources on domestic violence, 

sexual violence, and issues related to state 

domestic violence and sexual assault 

coalitions, allied organizations, and the 

general public. It provides useful links; 

monitors news coverage of violence 

against women issues; offers calendars 

of trainings, conferences, and grant 

deadlines; and presents information about 

Domestic Violence Awareness Month 

(DVAM) and Sexual Assault Awareness 

Month (SAAM). For more information, 

visit www.vawnet.org.

Injury Surveillance Training Manual

The Injury Surveillance Training Manual

is designed primarily for professionals 

who develop or operate surveillance 

systems and conduct prevention 

activities in less-resourced countries. It 

describes the steps needed to establish 

and maintain an injury surveillance 

system; provides information on 

designing and monitoring prevention 

activities; and offers guidance for 

making informed decisions about 

injury prevention. The curriculum 

emphasizes basic epidemiological skills 

needed to conduct surveillance and 

prevention activities; participation by 

different sectors and institutions in 

injury prevention efforts; and injury 

surveillance and prevention activities at 

the local level. The manual is available 

on CD-ROM in English and Spanish; 

the CD-ROM includes Instructor 

and Participant Guides, PowerPoint 

presentations for each session, and data 

for session exercises. 

Measuring Intimate Partner 

Violence Victimization and 

Perpetration: A Compendium of 

Assessment Tools

CDC’s Measuring Intimate Partner 

Violence Victimization and Perpetration: 

A Compendium of Assessment Tools will 

provide researchers and prevention 

specialists with a set of assessment 

tools that have already demonstrated 

reliability and validity for measuring the 

self-reported incidence and prevalence 

of intimate partner violence and 

perpetration. Though the compendium 

will include more than 20 scales, it is 

not intended to be an exhaustive listing 

of available measures. The information 

will help researchers and practitioners 

make informed decisions when 

choosing scales to use in their work. The 

compendium will be available in late 

2006. 
Publications and Resources 107

National Sexual Violence 

Resource Center

1-877-739-3895 (toll-free)

This resource center provides 

comprehensive information about 

sexual violence and emerging policy 

on sexual violence and prevention. It 

also provides technical assistance to 

sexual assault programs, state and local 

organizations, community volunteers, 

and the media. The resource center 

plays an important role in compiling, 

synthesizing, and distributing research 

and evaluation findings. For more 

information, access the center’s website 

at www.nsvrc.org.

National Youth Violence Prevention 

Resource Center

1-866-SAFEYOUTH (toll-free)

People interested in learning more 

about preventing youth violence and 

suicide can start with this resource 

center that combines information 

gathered from institutions, 

community-based organizations, and 

federal agencies. Its website, toll-free 

hotline, and fax-on-demand service 

offer access to prevention program 

information, publications, research 

and statistics, and fact sheets. Separate 

portals exist for parents, teens, and 

researchers. To view the website, go to 

www.safeyouth.org.

Poison emergency hotline

1-800-222-1222 (toll-free)

This nationwide toll-free poison 

hotline automatically connects callers 

to their local poison centers. Calls are 

routed by the area code and exchange 

of the caller’s phone number. The 

helpline is available 24 hours a day, 7 

days a week, and is staffed by poison 

experts such as nurses, pharmacists, 

and doctors. In most cases, a poison 

exposure problem can be resolved over 

the phone with the advice from the 

poison center specialist. If hands-on 

medical treatment is necessary, the 

poison center will call an ambulance 

and give treatment advice to the 

emergency care providers. Poison 

experts responding to hotline calls 

help prevent poisonings by answering 

a wide range of questions about drug 

interactions, household dangers, and 

insect bites. 

Preventing Violence Against 

Women: Program Activities Guide

About 1.5 million women are raped 

or physically assaulted by an intimate 

partner each year. This guide describes 

CDC’s public health activities and 

research to prevent violence against 

women. It outlines five categories 

of activities which are key to CDC’s 

prevention work: tracking the problem, 

developing and evaluating prevention 

strategies, supporting and enhancing 

prevention programs, providing 

prevention resources, and encouraging 

research and development. 

Preventing Violence Through 

Education, Networking and 

Technical Assistance 

PREVENT is a national training 

program for violence prevention 

practitioners that helps individuals and 

organizations build skills in identifying 

community needs and assets, create 

and mobilize partnerships, develop 

and implement prevention programs, 

measure success, and fund and 

sustain programs. Varied educational 

methods are used, including distancelearning modules, regional workshops, 

an intensive institute, action 

learning projects, and coaching. For 

information about PREVENT, visit 

www.prevent.unc.edu.

Prevention Connection: 

The Violence Against Women 

Prevention Partnership

Prevention Connection features a 

Listserv and bimonthly Web-based 

forums designed to build the capacity 

of local, state, national, and tribal 

agencies and organizations to develop, 

implement, and evaluate effective 

violence against women prevention 

initiatives. The Prevent-Connect 

Listserv provides a vehicle for ongoing 

analysis and discussion of domestic and 

sexual violence prevention efforts. The 

forums feature a variety of prevention 

experts exploring prevention 

approaches and comprehensive 

solutions to domestic and sexual 

violence. Prevention Connection is 

a project of the California Coalition 

Against Sexual Assault. For more 

information, visit www.calcasa.org.

Report to Congress on Mild 

Traumatic Brain Injury in the United 

States: Steps to Prevent a Serious 

Public Health Problem

CDC formed the Mild Traumatic 

Brain Injury (MTBI) Work Group, 

comprised of experts in the field of 

brain injury, to determine appropriate 

and feasible methods for assessing 

the incidence and prevalence of 

MTBI in the United States. After 

numerous discussions and thorough 

review of the scientific literature, the 

work group reported their findings 

and recommendations. Their report 

describes the public health significance 

of MTBI and recommends how to 

better measure the magnitude of the 

problem in this country.

Sexual Violence Surveillance: 

Uniform Definitions and 

Recommended Data Elements

Sexual violence is a significant public 

health problem in the United States. 

Measuring the problem can be difficult 

because of inconsistencies in terminology 

and data elements for sexual violence. 

Without consistency, trends cannot be 

monitored or tracked to determine the 

extent of the problem. To address this 

issue, CDC’s Injury Center consulted 

with researchers and practitioners to 

develop these recommendations for 

standardizing definitions and data 

elements for sexual violence surveillance. 

Policy makers, researchers, public health 

practitioners, victim advocates, service 

providers, media professionals, and others 

interested in better quality and timely 

incidence and prevalence estimates will 

find this publication useful.
108 Publications and Resources 

Tools to prevent older adult falls

For millions of older Americans, falls 

are a serious health threat. In the 

United States, 1 in 3 adults ages 65 

or older will fall each year. Among 

older adults, falls are the leading 

cause of injury deaths and the most 

common cause of injuries and hospital 

admissions for trauma. CDC has 

released new educational materials to 

help older adults prevent falls. Through 

a partnership with the CDC 

Foundation and the MetLife 

Foundation, two 

CDC brochures, 

What You Can 

Do to Prevent 

Falls and Check 

for Safety: A 

Home Fall 

Prevention 

Checklist for 

Older Adults, 

were updated, 

redesigned, 

and 

translated into Spanish 

and Chinese.

n What You Can Do to Prevent 

Falls focuses on four key messages 

that research shows are effective 

in preventing falls: begin a regular 

exercise program; have your health 

care provider review your medicines; 

have your vision checked; and 

make your home safer. Posters that 

promote these four fall prevention 

activities were created and are 

available in English, Spanish, and 

Chinese.

n Check for Safety: A Home Fall 

Prevention Checklist for Older 

Adults helps people identify possible 

fall hazards and suggests solutions. 

The brochure uses a question and 

answer format to guide people 

through each room of their home.

State Injury Indicators Report, 

2nd Edition—1999 Data 

CDC’s Injury Center, the Council of 

State and Territorial Epidemiologists, 

and the State and Territorial Injury 

Prevention Directors Association have 

published the second edition of the 

State Injury Indicators Report (SIIR) with 

1999 data. The SIIR compiles injury 

data voluntarily collected by 26 state 

health departments. It consolidates data 

from hospital records, death certificates, 

and several national surveillance systems 

to provide the rates of various injuries 

(such as traumatic brain injuries, fire 

and burn injuries, and suicide) and 

related factors (such as seat belt and 

smoke alarm use). Findings are also 

categorized by sex and age. SIIR findings 

can help states determine priorities 

for their injury prevention programs 

and identify prevention needs. These 

surveillance data can also be used to 

evaluate the effectiveness of program 

activities and to identify problems 

needing further investigation.

State Injury Profiles 

Gathering and sharing reliable data 

about the broad range of public health 

problems are among the many ways 

CDC protects the safety and health of 

Americans. Through maps and graphs, 

each Profile shows how a state compares 

with others in the nation, how its 

mortality rates compare with the United 

States as a whole, and what injury 

problems are most pressing. Each Profile

shows a state’s death rates from falls, 

poisoning, drowning, suffocation, fires 

and burns, suicide, homicide, traumatic 

brain injury, and injuries related to 

firearms. The ten leading causes of death 

in the United States are shown for each 

state along with county-by-county maps 

showing locations with higher death 

rates for each type of injury. The Profiles

include links to state and local health 

departments and descriptions of CDCsponsored injury prevention programs 

and research activities in each state. 
Publications and Resources 109

Traumatic Brain Injury in the United 

States: Emergency Department 

Visits, Hospitalizations, and Deaths 

This report addresses the incidence and 

prevalence of traumatic brain injury 

(TBI) in all age groups in the general 

population of the United States, 

providing detailed information about 

TBI-related deaths, hospitalizations, 

and emergency department visits from 

1995 through 2001. These data address 

the number of TBIs occurring each 

year, who is affected, and how TBIs 

occur.

Traumatic Brain Injury in the United 

States: The Future of Registries 

and Data Systems

In response to the Children’s Health 

Act of 2000, CDC convened an 

expert panel to discuss the future 

of TBI registries and data systems, 

providing guidance for CDC to 

develop a national 

program. This 

report summarizes 

the expert panel’s 

recommendations 

for funding states 

to collect, analyze, 

and report TBI 

surveillance data; 

using existing 

national data 

sets to estimate 

the impact of TBI; and enhancing 

systems to identify and contact people 

with TBI, linking them with needed 

services. This report will help policy 

makers, researchers, advocates, public 

health professionals, and health 

department officials further the 

development of systems to collect data 

about people with TBI.

Using Evidence-based Parenting 

Programs to Advance CDC Efforts 

in Child Maltreatment Prevention—

Research Brief 2004

This brief summarizes several CDC 

prevention initiatives aimed at 

encouraging and promoting positive 

parent-child 

interactions. 

By acquiring 

positive 

parenting 

skills, 

parents 

and 

caregivers 

can better 

manage 

children’s behavior and prevent 

violence before it occurs. The initiatives 

resulted from extensive strategic 

planning and consultation with child 

maltreatment prevention experts.

WISQARS

www.cdc.gov/

ncipc/wisqars

WISQARS 

(pronounced 

“whiskers”), 

the Web-based 

Injury Statistics 

Query and Reporting 

System, is an interactive database of 

injury morbidity and mortality data. 

Created by CDC’s Injury Center, 

WISQARS offers prompt, customized 

reports about both unintentional and 

violent injuries, including leading 

causes of death reports, leading causes 

of nonfatal injury reports, and years 

of potential life lost reports. Data are 

updated each year in the fall. Tutorials, 

frequently asked questions, and a help 

file ensure that users obtain the data 

they need. 

World Report on Road Traffic 

Injury Prevention 

To raise awareness that road traffic 

injuries kill more than one million 

people and injure tens of millions 

more every year, on World Health Day 

2004, the World Health Organization 

(WHO) and the 

World Bank 

released the World 

Report on Road 

Traffic Injury 

Prevention. 

CDC’s Injury 

Center staff 

collaborated 

with WHO 

to produce 

the World 

Report. More than 30,000 copies 

were distributed; it was translated 

into nine languages; and shortly after 

its release, a Congressional Caucus 

on global road safety was launched. 

In 2004, the World Report won the 

United Kingdom’s coveted HRH 

Prince Michael (of Kent) Premier 

International Road Safety Award. 
The websites listed below can be 

found in the CDC Injury Fact 

Book. For more valuable links that 

address injury and violence prevention, 

please visit CDC’s Injury Center 

online.

Academic Centers of Excellence 

www.cdc.gov/ncipc/res-opps/ACE/ace.

htm

American Association of Poison 

Control Centers

www.aapcc.org

American Red Cross 

“Preparedness Today”

www.redcross.org/preparedness/cdc_

english/CDC.asp

American Trauma Society (Trauma 

Information and Exchange Program, 

TIEP)

www.amtrauma.org

Brain Injury Association of America 

www.biausa.org

California Coalition Against Sexual 

Assault (Prevention Connection project)

www.calcasa.org

CDC Emergency Preparedness and 

Response

www.bt.cdc.gov

CDC Healthy Youth (School Health 

Index, School Health Policies and 

Programs Study, and other resources)

www.cdc.gov/HealthyYouth

CDC Injury Center Extramural Research 

Projects and Grants

www.cdc.gov/ncipc/res-opps/extra.htm

Guide to Community Preventive 

Services 

www.thecommunityguide.org

CDC’s Injury Center website: 

www.cdc.gov/injury

CDC’s website offers powerful data 

tools and quality information critical 

to injury and violence prevention 

and control efforts. In addition 

to WISQARS and Injury Maps 

(see Data Sharing, page 18), the 

website’s offerings include:

n E-mail list: CDC’s Injury Center 

reaches out to partners through 

its announcement e-mail list. 

Subscribers are notified of 

funding announcements and 

career opportunities. To stay 

informed, subscribe online at 

www.cdc.gov/ncipc/email_list.

htm.

n Fact sheets and topics: The 

Injury Center regularly updates 

and expands fact sheets and 

topic information highlighting 

relevant statistics, descriptions of 

related CDC activities, prevention 

tips, and resources.

n Programs and projects: 

Highlighting grantee 

accomplishments, this section 

summarizes and profiles CDCfunded injury and violence 

programs and projects. 

Profiles feature grantee 

contact information, goals, and 

achievements (injury-related 

research, publications, and 

conferences).

n Publications: CDC’s Injury 

Center offers a variety of 

publications about injury and 

violence prevention for public 

health and safety professionals, 

clinicians, and the public. The 

publications are available for 

online viewing or downloading, 

and many are available for 

ordering in hard copy.

Morbidity and Mortality Weekly Report

(includes other publications and state 

health statistics) 

www.cdc.gov/mmwr

National Council on Aging: Center for 

Healthy Aging (“Falls Free” initiative)

www.healthyagingprograms.org 

National Highway Traffic Safety 

Administration 

www.nhtsa.dot.gov

National Institute of Standards and 

Technology: Fire Research (home 

smoke alarm tests)

http://smokealarm.nist.gov

National Resource Center for Safe 

Aging

www.safeaging.org 

National Sexual Violence Resource 

Center 

www.nsvrc.org

National Youth Violence Prevention 

Resource Center 

www.safeyouth.org

PREVENT (Preventing Violence through 

Education, Networking and Technical 

Assistance)

www.prevent.unc.edu

Prevent Child Abuse America

www.preventchildabuse.org

Society for Advancement of Violence 

and Injury Research

ww.savirweb.org

Violence Against Women 

(national resources) 

www.vawnet.org

Websites

110 Publications and Resources
Publications and Resources 111

Toll-free Phone Numbers

These toll-free numbers are 

provided in the CDC Injury Fact 

Book and are just a few of the many 

resources available on the Injury 

Center’s website.

American Association of Poison 

Control Centers

1-800-222-1222

Brain Injury Association of America 

Family Helpline

1-800-444-6443

National Child Abuse Hotline

1-800-4-A-CHILD

(1-800-422-4453)

National Domestic Violence Hotline

1-800-799-SAFE

(1-800-799-7233)

National Sexual Violence Resource 

Center

1-877-739-3895

National Suicide Hotline

1-800-SUICIDE 

(1-800-784-2433)

National Youth Violence Prevention 

Resource Center 

1-866-SAFEYOUTH

(1-866-723-3968)

Poison Emergency Hotline

1-800-222-1222

Rape, Abuse, and Incest National 

Network (RAINN) Hotline

1-800-656-HOPE

(1-800-656-4673)

CDC-INFO is CDC’s toll-free public information contact center. CDC-INFO call center representatives are available 

24 hours a day, 7 days a week, and answer public inquiries in English and Spanish. This center allows CDC to 

quickly provide information to health professionals, the public, and others. Please contact CDC-INFO for your public 

health information needs.

CDC-INFO Contact Center

1-800-CDC-INFO (1-800-232-4636)

E-mail: cdcinfo@cdc.gov

Website: www.cdc.gov

Healthy People in Every Stage of Life

All people, and especially those at greater risk of health

disparities, will achieve their optimal lifespan with the best

possible quality of health in every stage of life.

Healthy People in Healthy Places

The places where people live, work, learn, and play

will protect and promote their health and safety,

especially those at greater risk of health disparities.

People Prepared for Emerging Health Threats

People in all communities will be protected from infectious,

occupational, environmental, and terrorist threats.

Healthy People in a Healthy World

People around the world will live safer, healthier

and longer lives through health promotion, health

protection, and health diplomacy.

Centers for Disease Control and Prevention

National Center for Injury Prevention and Control

www.cdc.gov/injury

1-800-CDC-INFO (1-800-232-4636)

CDC Health Protection Goals