NCHS Data Brief ■ No. 343 ■ July 2019

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Disease Control and Prevention

National Center for Health Statistics

Unintentional Injury Death Rates in Rural and Urban Areas: 

United States, 1999–2017

R. Henry Olaisen, Ph.D., M.P.H., Lauren M. Rossen, Ph.D., Margaret Warner, Ph.D., and

Robert N. Anderson, Ph.D.

Key findings

Data from the National 

Vital Statistics System

● From 1999 through 2017, 

the age-adjusted unintentional 

injury death rate increased 40% 

from 35.3 deaths per 100,000 

standard population to 49.4. 

● Motor vehicle traffic death 

rates increased across all levels 

of urbanization between 2014 

and 2017, with the largest 

increase in small metropolitan 

(metro) counties. 

● Unintentional drug overdose 

death rates increased across all 

levels of urbanization between 

2014 and 2017, with the largest 

increase in large fringe metro 

counties. 

● Unintentional fall death rates 

increased across urbanization 

levels except for large central 

metro counties between 2014 

and 2017, with the largest 

increase in rural counties.

Unintentional injury is a leading cause of death in the United States (1). 

Higher death rates for unintentional injury have been reported in rural areas 

compared with urban areas (2–4). This report describes trends in the death 

rates for unintentional injuries and three leading causes of deaths due to 

unintentional injuries (motor vehicle traffic, drug overdose, and falls) from 

1999 through 2017. Given an observed increase in overall unintentional 

injury rates starting in 2014 (5), differences in death rates are described by 

urbanization level (rural, small metropolitan [metro], large fringe metro, and 

large central metro) for the leading causes of unintentional injury deaths for 

2014 and 2017. 

Overall, unintentional injury death rates increased from 1999 

through 2017, although trends varied by leading causes of 

the injury deaths.

NCHS reports can be downloaded from: https://www.cdc.gov/nchs/products/index.htm.

Figure 1. Age-adjusted rates for unintentional injury deaths, overall and by three leading causes: 

United States, 1999–2017

Unintentional fall4

Unintentional overdose Motor vehicle traffic 3 2

Overall, unintentional1

1

Significant increasing trends from 1999 through 2006 and from 2014 through 2017 (p < 0.05). 2

Significant decreasing trend from 2006 through 2009 and increasing trend from 2014 through 2017 (p < 0.05). 3

Significant increasing trend from 1999 through 2017 with different rates of change over time (p < 0.05). 4

Significant increasing trend from 1999 through 2017 (p < 0.05). 

NOTES: Unintentional injury deaths are identified using International Classification of Diseases, 10th Revision underlying 

cause-of-death codes: Overall unintentional injury deaths include V01–X59 and Y85–Y86; unintentional motor vehicle traffic 

deaths, (V02–V04 [.1, .9]), V09.2, (V12–V14 [.3–.9]), V19 (.4–.6), (V20–V28 [.3–.9]), (V29–V79 [.4–.9]), V80 (.3–.5), V81.1, V82.1, 

(V83–V86 [.0–.3]), V87 (.0–.8), and V89.2; unintentional drug overdose deaths, X40–X44; and unintentional fall deaths, W00–W19. 

Access data table for Figure 1 at: https://www.cdc.gov/nchs/data/databriefs/db343_tables-508.pdf#1.

SOURCE: NCHS, National Vital Statistics System, Mortality. Deaths per 100,000 standard population

0

10

20

30

40

50

1999 2001 2003 2005 2007 2009 2011 2013 2015 2017
NCHS Data Brief ■ No. 343 ■ July 2019

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● Overall, age-adjusted unintentional injury death rates increased 40% from 35.3 per 100,000 

standard population in 1999 to 49.4 in 2017, with an average annual increase of 1.9% from 

1999 through 2006 and 6.8% from 2014 through 2017 (Figure 1).

● Age-adjusted death rates for motor vehicle traffic injuries were stable from 1999 through 

2006, declined 8.5% annually from 2006 through 2009, and were stable again from 

2009 through 2014, but were followed by an average annual increase of 3.7% from 2014 

through 2017.

● Age-adjusted death rates for unintentional drug overdose increased nearly fivefold from 4.0 

in 1999 to 19.1 in 2017, with an average annual increase of 11.3% from 1999 through 2005, 

5.3% from 2005 through 2014, and 16.4% from 2014 through 2017. In 2013, the death rate 

for unintentional drug overdose surpassed the rate for motor vehicle traffic deaths.

● Age-adjusted death rates for unintentional falls increased an average 3.8% annually from 

1999 through 2017.

Age-adjusted death rates for motor vehicle traffic injuries were highest in 

rural counties and lowest in large central metro counties in 2017.

● Age-adjusted death rates for motor vehicle traffic injuries increased across all levels of 

urbanization between 2014 and 2017 (Figure 2).

Figure 2. Age-adjusted death rates for motor vehicle traffic injuries, by urbanization level: United States, 2014 and 2017

1

Significant increase between 2014 and 2017 (p < 0.05). 2

Significant linear trend in death rates by urbanization for 2017 (p < 0.05). 

NOTES: Unintentional motor vehicle traffic deaths are identified using International Classification of Diseases, 10th Revision underlying cause-of-death codes 

(V02–V04 [.1, .9]), V09.2, (V12–V14 [.3–.9]), V19 (.4–.6), (V20–V28 [.3–.9]), (V29–V79 [.4–.9]), V80 (.3–.5), V81.1, V82.1, (V83–V86 [.0–.3]), V87 (.0–.8), and 

V89.2. Classification of the decedent’s county of residence is based on the 2013 NCHS Urban–Rural Classification Scheme for Counties. Access data table for 

Figure 2 at: https://www.cdc.gov/nchs/data/databriefs/db343_tables-508.pdf#2.

SOURCE: NCHS, National Vital Statistics System, Mortality. Deaths per 100,000 standard population

2014 2017

Rural Small metro Large fringe metro Large central metro

17.9

11.2

1,219.7

1,212.8

8.5

1,29.6

7.5

1,28.3

0

5

10

15

20

25
NCHS Data Brief ■ No. 343 ■ July 2019

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● In 2017 compared with 2014, small metro counties had the largest increase in motor vehicle 

traffic death rates (14%, from 11.2 to 12.8 per 100,000).

● In 2017, the age-adjusted death rates for motor vehicle traffic injuries decreased with 

increasing level of urbanization and were highest in rural counties (19.7) and lowest in large 

central metro counties (8.3).

In 2017 compared with 2014, large fringe metro counties had the largest 

increase in unintentional drug overdose rates. 

● Age-adjusted death rates for unintentional drug overdoses increased across all levels of 

urbanization between 2014 and 2017 (Figure 3).

● In 2017 compared with 2014, large fringe metro counties had the largest increase in 

unintentional drug overdose rates (71%, from 11.9 to 20.3 per 100,000), followed by large 

central metro (62%, 11.3 to 18.3), small metro (53%, 13.2 to 20.2), and rural counties (34%, 

12.9 to 17.3). 

● In 2017, the age-adjusted death rates for unintentional drug overdose were highest in 

large fringe metro counties (20.3) and small metro counties (20.2), and lowest in rural 

counties (17.3).

Figure 3. Age-adjusted death rates for unintentional drug overdose, by urbanization level: United States, 2014 and 2017 Deaths per 100,000 standard population

2014 2017

1

Significant increase between 2014 and 2017 (p < 0.05). 2

Significant differences among all urbanization groups (p < 0.05), except for the difference between small and large fringe metro.

NOTES: Unintentional drug overdose deaths are identified using International Classification of Diseases, 10th Revision underlying cause-of-death codes 

X40–X44. Classification of the decedent’s county of residence is based on the 2013 NCHS Urban–Rural Classification Scheme for Counties. Access data table for 

Figure 3 at: https://www.cdc.gov/nchs/data/databriefs/db343_tables-508.pdf#3.

SOURCE: NCHS, National Vital Statistics System, Mortality.

0

5

10

15

20

25

Rural Small metro Large fringe metro Large central metro

12.9

1,217.3

11.9

1,220.2

13.2

1,220.3

11.3

1,218.3
NCHS Data Brief ■ No. 343 ■ July 2019

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Rural counties had the largest increase in death rates due to unintentional 

falls between 2014 and 2017. 

● Age-adjusted death rates for unintentional falls increased in rural, small metro, and large 

fringe metro counties between 2014 and 2017 (Figure 4).

● Between 2014 and 2017, rural counties had the largest increase in death rates due to 

unintentional falls (11%, from 8.9 to 9.9 per 100,000). 

● In 2017, the age-adjusted death rates for unintentional falls were highest in small metro 

(10.1) and rural counties (9.9), and lowest in large central metro counties (8.5). 

Figure 4. Age-adjusted death rates for unintentional falls, by urbanization level: United States, 2014 and 2017 Deaths per 100,000 standard population

2014 2017

1

Significant increase between 2014 and 2017 (p < 0.05). 2

Significant differences among all urbanization groups (p < 0.05) except for the difference between rural and small metro.

NOTES: Unintentional fall deaths are identified using International Classification of Diseases, 10th Revision underlying cause-of-death codes W00–W19. 

Classification of the decedent’s county of residence is based on the 2013 NCHS Urban–Rural Classification Scheme for Counties. Access data table for Figure 4 

at: https://www.cdc.gov/nchs/data/databriefs/db343_tables-508.pdf#4.

SOURCE: NCHS, National Vital Statistics System, Mortality.

0

5

10

15

20

25

Rural Small metro Large fringe metro Large central metro

8.9

1,29.9

8.7 1,29.1

1,210.1

9.2

8.3 2

8.5
NCHS Data Brief ■ No. 343 ■ July 2019

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Summary

This report describes trends in unintentional injury death rates from 1999 through 2017, with a 

focus on recent increases between 2014 and 2017 by urbanization level. Overall, age-adjusted 

unintentional injury death rates have risen 40% from 1999 through 2017, although the trends 

varied by leading causes of unintentional injury death (motor vehicle traffic, drug overdose, and 

falls). 

Between 2014 and 2017, large fringe metro counties had the largest increase in unintentional 

drug overdose death rates; small metro had the largest increase in motor vehicle death rates; and 

rural counties had the largest increase in death rates due to unintentional falls. Unintentional drug 

overdose death rates surpassed motor vehicle traffic death rates in 2013. In 2017, differences in 

death rates by urbanization level varied by leading causes of unintentional injury deaths. 

Definitions

Unintentional injury deaths: Defined as having International Classification of Diseases,

10th Revision (ICD–10) underlying cause-of-death (UCOD) codes V01–X59 and Y85–Y86. 

Motor vehicle traffic deaths: Defined as having ICD–10 UCOD codes (V02–V04 [.1, .9]), V09.2, 

(V12–V14 [.3–.9]), V19 (.4–.6), (V20–V28 [.3–.9]), (V29–V79 [.4–.9]), V80 (.3–.5), V81.1, 

V82.1, (V83–V86 [.0–.3]), V87 (.0–.8), and V89.2.

Drug overdose deaths: Defined as having ICD–10 UCOD codes X40–X44. Drug overdose 

deaths that are unintentional form a subset of the traditional drug-poisoning (overdose) death 

classification that is identified by UCOD codes X40–X44, X60–X64, X85, and Y10–Y14. This 

analysis focuses only on unintentional deaths and, therefore, excludes deaths due to intentional 

self-harm (X60–X64), assault (X85), or of unknown intent (Y10–Y14). Among drug overdose 

deaths, 87% are unintentional (6). Unintentional drug overdose deaths may be underestimated 

because some drug overdose deaths of undetermined intent (ICD–10 codes Y10–Y14, which are 

not included in this report) may be unintentional.

Unintentional fall deaths: Defined as having ICD–10 UCOD codes W00–W19.

Urbanization: Metropolitan (metro) counties are counties in metropolitan statistical areas (MSAs) 

as defined by the federal Office of Management and Budget. Nonmetropolitan (nonmetro) 

counties are counties that are not in MSAs. The 2013 NCHS Urban–Rural Classification Scheme 

for Counties (NCHS scheme) subdivides metro counties into four categories, based partly on 

MSA population size, and subdivides nonmetro counties into two categories (7). For this report, 

county of residence was categorized by collapsing the NCHS scheme into the following three 

metro and one nonmetro categories: large central metro (central counties in MSAs of

1 million or more population), large fringe metro (suburban counties in MSAs of 1 million or 

more population), small metro (counties in MSAs of less than 1 million population), and rural 

(nonmetropolitan counties).
NCHS Data Brief ■ No. 343 ■ July 2019

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Data source and methods

Estimates are based on the National Vital Statistics System underlying cause-of-death data for 

1999–2017 (8). Deaths are classified using the International Classification of Diseases,

10th Revision (ICD–10). Age-adjusted death rates are calculated using the direct method and the 

2000 standard population (9).

Given an observed nonlinear trend in the overall unintentional injury death rates and some of the 

cause-specific rates with a steeper trajectory around 2014, death rates by the three leading causes 

of unintentional injury death were compared between 2014 and 2017.

Linear and nonlinear time trends were tested with orthogonal polynomial contrasts (10). For 

trends that were nonlinear, piecewise linear regression was used to identify the years at which the 

trends changed using the segmented package in R, version 3.5 (11). Trends across urbanization 

levels were tested with Jonckheere-Terpstra, a test for ordered differences. Pairwise differences 

between 2014 and 2017 and between urbanization levels were assessed using z tests, with an 

alpha level of 0.05.

About the authors

R. Henry Olaisen is with the Centers for Disease Control and Prevention’s Epidemic Intelligence 

Service, assigned to the National Center for Health Statistics (NCHS), Division of Vital Statistics. 

Lauren M. Rossen is with the NCHS Division of Research Methodology. Margaret Warner 

and Robert N. Anderson are with the NCHS Division of Vital Statistics. The authors gratefully 

acknowledge the assistance of Jiaquan Xu, who provided content review.

References

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6. Hedegaard H, Miniño AM, Warner M. Drug overdose deaths in the United States, 1999–2017. 

NCHS Data Brief, no 329. Hyattsville, MD: National Center for Health Statistics. 2018. Available 

from: https://www.cdc.gov/nchs/data/databriefs/db329-h.pdf. 

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Center for Health Statistics. Vital Health Stat 2(166). 2014.

8. National Center for Health Statistics. CDC WONDER: About underlying cause of death 

1999–2017. 2019. Available from: https://wonder.cdc.gov/ucd-icd10.html. 

9. Anderson RN, Rosenberg HM. Age standardization of death rates: Implementation of the year 

2000 standard. National Vital Statistics Reports; vol 47 no 3. Hyattsville, MD: National Center 

for Health Statistics. 1998.

10. Ingram DD, Malec DJ, Makuc DM, Kruszon-Moran D, Gindi RM, Albert M, et al. National 

Center for Health Statistics guidelines for analysis of trends. National Center for Health Statistics. 

Vital Health Stat 2(179). 2018. Available from: https://www.cdc.gov/nchs/data/series/sr_02/

sr02_179.pdf.

11. R Foundation for Statistical Computing. R (version 3.5) [computer software]. 2018.
NCHS Data Brief ■ No. 343 ■ July 2019

Keywords: motor vehicle traffic • unintentional drug overdose • unintentional 

fall • National Vital Statistics System (NVSS)

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Suggested citation

Olaisen RH, Rossen LM, Warner M, 

Anderson RN. Unintentional injury death 

rates in rural and urban areas: United States, 

1999–2017. NCHS Data Brief, no 343. 

Hyattsville, MD: National Center for Health 

Statistics. 2019.

Copyright information

All material appearing in this report is in 

the public domain and may be reproduced 

or copied without permission; citation as to 

source, however, is appreciated.

National Center for Health 

Statistics

Jennifer H. Madans, Ph.D., Acting Director

Amy Branum, Ph.D., Acting Associate 

Director for Science

Division of Vital Statistics

Steven Schwartz, Ph.D., Director

Hanyu Ni, Ph.D., M.P.H., Associate Director 

for Science