Surveillance for Violent Deaths — National Violent Death Reporting System, 17 States, 2013

Introduction

In 2013, more than 57,000 persons died in the United States as a result of violence-related injuries (1). Suicide was the 10th leading cause of death overall in the United States and disproportionately affected young and middle-aged populations. It was among the top three leading causes of death for persons aged 10–34 years and among the top five for persons aged 35–54 years. American Indian/Alaska Natives were disproportionately affected by suicide; it was the second leading cause of death among those aged 10–34 years.

Homicide was the 16th leading cause of death overall in the United States but disproportionately affected young people (1). It was the third leading cause of death for children aged 1–4 years and persons aged 15–34 years, the fourth leading cause for children aged 5–9 years, and the fifth leading cause for persons aged 10–14 years and 35–44 years. Homicide disproportionately affected young African American males; it was the leading cause of death among those aged 15–34 years.

Public health authorities require accurate, timely, and comprehensive surveillance data to better understand and ultimately prevent the occurrence of violent deaths in the United States (2). In 2000, in response to an Institute of Medicine* report noting the need for a national fatal intentional injury surveillance system (3), CDC began planning to implement the National Violent Death Reporting System (NVDRS) (4). The goals are to

• collect and analyze timely, high-quality data for monitoring the magnitude and characteristics of violent deaths at national, state, and local levels;

• ensure data are disseminated routinely and expeditiously to public health officials, law enforcement officials, policymakers, and the public;

• ensure data are used to develop, implement, and evaluate programs and strategies that are intended to reduce and prevent violent deaths and injuries at national, state, and local levels; and

• build and strengthen partnerships among organizations and communities at national, state, and local levels to ensure that data are collected and used to reduce and prevent violent deaths and injuries.

NVDRS was conceived as a state-based active surveillance system that would collect data on the characteristics and circumstances associated with all violence-related deaths in participating states. Deaths would include homicides, suicides, legal intervention deaths (i.e., deaths caused by law enforcement and other persons with legal authority to use deadly force but excluding legal executions), unintentional firearm deaths, and deaths of undetermined intent.^† The term legal intervention is a classification incorporated into the International Classification of Diseases, Tenth Revision (ICD-10) and does not denote the lawfulness or legality of the circumstances surrounding a death caused by law enforcement. NVDRS data are used to assist the development, implementation, and evaluation of programs and strategies designed to reduce and prevent these deaths at the national, state, and local levels.

Before implementation of NVDRS, single data sources (e.g., death certificates or law enforcement reports) provided only limited information and few circumstances from which to understand patterns of violent deaths. NVDRS fills this surveillance gap by providing more detailed information. It is the first system to 1) provide detailed information on circumstances precipitating violent deaths, 2) link multiple source documents on violent deaths so that each incident can contribute to the study of patterns of violent deaths, and 3) link multiple deaths that are related to one another (e.g., multiple homicides, suicide pacts, or homicide followed by the suicide of the suspected perpetrator).

In 2003, NVDRS began data collection with seven states (Alaska, Maryland, Massachusetts, New Jersey, Oregon, South Carolina, and Virginia) participating; six states (Colorado, Georgia, North Carolina, Oklahoma, Rhode Island, and Wisconsin) joined in 2004, four (California, Kentucky, New Mexico, and Utah) in 2005, and two (Ohio and Michigan) in 2010 (Figure). CDC provides funding for state participation, and the ultimate goal is for NVDRS to expand to include all 50 states, U.S. territories, and the District of Columbia.^§

This report summarizes data for 2013 for deaths meeting NVDRS inclusion criteria from the 17 states that collected statewide data in that year (Alaska, Colorado, Georgia, Kentucky, Maryland, Massachusetts, New Jersey, New Mexico, North Carolina, Ohio, Oklahoma, Oregon, Rhode Island, South Carolina, Utah, Virginia, and Wisconsin); these states account for approximately 30.1% of the U.S. population (1,5). The analysis in this report does not include data from California, which concluded its participation in 2009, and Michigan, which did not collect data statewide during 2013. NVDRS data are updated annually and are available through CDC’s Web-based Injury Statistics Query and Reporting System (WISQARS)^¶ at http://www.cdc.gov/injury/wisqars/nvdrs.html.

Methods

NVDRS compiles information from multiple data sources. The core required data sources are death certificates, coroner/medical examiner reports, and law enforcement reports. Some participating states also collect information from secondary sources (e.g., child fatality review team data, supplemental homicide reports, and crime laboratory data). NVDRS collates documents for each death and links deaths that are related (e.g., multiple homicides, a homicide followed by a suicide, or multiple suicides) from a single incident. The ability to analyze linked data permits comprehensive assessment of violent deaths. This report presents data for 2013. Historical data and rates for 2011 and 2012 are available at https://stacks.cdc.gov/view/cdc/40576.

In NVDRS, a violent death is defined as a death resulting from the intentional use of physical force or power, threatened or actual, against oneself, another person, or a group or community. Information also is collected about unintentional firearm deaths (i.e., incidents in which the person causing the fatal injury did not intend to discharge the firearm) and deaths of undetermined intent (i.e., a death that results from the use of force or power against oneself or another person for which the evidence indicating one manner of death is no more compelling than evidence indicating another). NVDRS cases are coded on the basis of the International Classification of Diseases, Tenth Revision (ICD-10) (6) or on the basis of the manner of death assigned by the coroner/medical examiner, or law enforcement. Cases are included if they are assigned ICD-10 codes (Box 1) or if the manner of death specified in at least one of the three primary data sources is consistent with NVDRS case definitions.

Variables analyzed in NVDRS include

• manner of death (i.e., the intent [homicide/legal intervention, suicide, unintentional, undetermined] of the person inflicting a fatal injury);

• mechanism of injury (i.e., the method used to inflict a fatal injury) (Box 2);

• toxicology findings (i.e., for decedents who were tested);

• circumstances preceding injury (i.e., the events that preceded and were identified by investigators as relevant and therefore might have contributed to the infliction of a fatal injury) (Box 3);

• whether the decedent was a victim (i.e., a person who died as a result of a violence-related injury) or both a suspect and a victim (i.e., a person believed to have inflicted a fatal injury on a victim who then was fatally injured, such as the perpetrator of a homicide-suicide);

• information about suspects (i.e., a person believed to have inflicted a fatal injury on a victim);

• incident (i.e., an occurrence in which one or more persons sustained a fatal injury that was linked to a common event or perpetrated by the same suspect during a 24-hour period); and

• type of incident (i.e., a combination of the manner of death and the number of victims in an incident).

NVDRS is an incident-based system, and all decedents associated with a given incident are grouped in one record. Decisions about whether two or more deaths are related and belong to the same incident are made on the basis of the timing of the injuries rather than on the timing of the deaths. Deaths that occur within 24 hours of each other (i.e., the 24-hour rule) and are linked by source documents would be considered part of the same incident. Examples of an incident include 1) a single isolated violent death, 2) two or more related homicides (including legal intervention deaths) when the fatal injuries were inflicted <24 hours apart, 3) two or more related suicides or deaths of undetermined intent when the fatal injuries were inflicted <24 hours apart, and 4) a homicide followed by a suicide when both fatal injuries were inflicted <24 hours apart (7).

Data collected from individual information sources are entered into the NVDRS web-based data entry system (8). In 2013, NVDRS began using a streamlined coding system to facilitate data abstraction efficiency by eliminating the need to enter data into source-specific data entry screens. The streamlined interface allows data from multiple sources to be entered into the same incident record and includes internal validation checks, hover-over features that define selected fields, and other quality control measures. Primacy rules and hierarchal algorithms related to the source documents are now occurring at the state level. Access to the web system is provided to each state by CDC. State project personnel are provided coding training to help increase data quality. Data are transmitted continuously via the web to a CDC-based server. No personally identifiable information is transmitted to CDC.

Manner of Death

A manner (i.e., intent) of death for each decedent is assigned by a trained abstractor who assimilates information from all source documents. The manner of death assigned must be consistent with the manner of death noted in at least one source document. When there is a discrepancy, the abstractor must assign a manner of death on the basis of the preponderance of evidence in the source documents, but such occurrences are rare. For example, if two sources report a death as a suicide and a third reports it as a death of undetermined intent, the death is coded as a suicide.

NVDRS data are categorized into five abstractor-assigned manners of death: 1) suicide, 2) homicide, 3) unintentional firearm, 4) undetermined intent, and 5) legal intervention.

• Suicide. Suicide is a death resulting from the use of force against oneself when a preponderance of evidence indicates that the use of force was intentional. This category includes deaths of persons who intended only to injure rather than kill themselves, deaths associated with risk-taking behavior without clear intent to inflict fatal self-injury but associated with high risk for death (e.g., playing Russian roulette), and suicide involving another person providing only passive assistance to the decedent (e.g., supplying the means or information needed to complete the act). This category does not include deaths caused by chronic or acute substance abuse without the intent to die or deaths attributed to autoerotic behavior (e.g., self-strangulation during sexual activity). Corresponding ICD-10 codes included in NVDRS are X60–X84 and Y87.0 (Box 1).

• Homicide. Homicide is a death resulting from the use of physical force or power, threatened or actual, against another person, group, or community when a preponderance of evidence indicates that the use of force was intentional. Two special scenarios that the National Center for Health Statistics (NCHS) regards as homicides are included in the NVDRS case definition: 1) arson with no intent to injure a person and 2) a stabbing with intent unspecified. This category excludes vehicular homicide without intent to injure, unintentional firearm deaths (a separate category), combat deaths or acts of war, and deaths of unborn fetuses but includes acts of terrorism. Corresponding ICD-10 codes included in NVDRS are X85–X99, U01–U03, Y00–Y09, and Y87.1 (Box 1).

• Unintentional firearm. An unintentional firearm death is a death resulting from a penetrating injury or gunshot wound from a weapon that uses a powder charge to fire a projectile and for which a preponderance of evidence indicates that the shooting was not directed intentionally at the decedent. Examples include a person who dies as a result of celebratory firing that was not intended to frighten, control, or harm anyone; a soldier shot during a field exercise but not in a combat situation; a person who received a self-inflicted wound while playing with a firearm; and a person who mistakenly believes a gun is unloaded and shoots another person. This category excludes firearm injuries caused by unintentionally striking a person with the firearm (e.g., hitting a person on the head with the firearm rather than firing a projectile) and unintentional injuries from nonpowder guns (e.g., BB, pellet, or other compressed air-powered or gas-powered guns). Corresponding ICD-10 codes included in NVDRS are W32–W34 and Y86 (Box 1).

• Undetermined intent. A death of undetermined intent is a death resulting from the use of force or power against oneself or another person for which the evidence indicating one manner of death is no more compelling than evidence indicating another. This category includes coroner/medical examiner rulings (e.g., accident or suicide, undetermined, jumped or fell, or self-inflicted injury) when records give no evidence or opinions in favor of either unintentional or intentional injury. Corresponding ICD-10 codes in NVDRS are Y10–Y34, Y87.2, and Y89.9 (Box 1).

• Legal intervention. A death from legal intervention is a death in which a person is killed by a law enforcement officer or other peace officer (i.e., a person with specified legal authority to use deadly force), including military police, while on duty. The term legal intervention is a classification from ICD-10 codes and does not denote the lawfulness or legality of the circumstances surrounding the death. Legal intervention deaths include a small subset in which force was applied without clear lethal intent (e.g., during restraint or when applying force with a typically nondeadly weapon, such as a Taser [Taser International, Scottsdale, Arizona]) or in which the death occurred while the person was fleeing capture. This category excludes legal executions. Corresponding ICD-10 codes included in NVDRS are Y35.0–Y35.4, Y35.6–Y35.7, and Y89.0 (Box 1).

Variables Analyzed

NVDRS collects approximately 300 unique variables for each death. The number of variables recorded for each incident depends on the content and completeness of the source documents. Variables include manner of death; demographic information; ICD-10 cause of death codes and text descriptors; location, date, and time of injury and death; toxicology results; bodily injuries; precipitating circumstances; victim-suspect relationship; and method of injury (Box 1) (Box 2) (Box 3).

Circumstances Preceding Death

The circumstances preceding death are defined as the precipitating events that contributed to the infliction of a fatal injury (Box 3). The circumstances are reported on the basis of the content of the coroner/medical examiner and law enforcement investigative reports. Some circumstances are coded to a specific manner of death (e.g., suicide or death of undetermined intent); other circumstances are coded across all manners of death. The data abstractor selects from a list of potential circumstances and is required to code all circumstances known that relate to each incident. If circumstances are not known (e.g., for a body found in the woods with no other details reported) the data abstractor leaves the circumstances known variable blank; these deaths are excluded from the denominator for circumstance values. If either the coroner/medical examiner record or the law enforcement report indicates the presence of a circumstance, then the abstractor endorses the circumstance (e.g., if the law enforcement report indicated that a decedent had disclosed an intent to commit suicide, then suicidal intent is endorsed).

Coding Training and Quality Control

Ongoing coding support for data abstractors is provided through an e-mail help desk, monthly conference calls with all states, and regular conference calls with individual states. States can also conduct additional abstractor training workshops and activities at their own discretion. An NVDRS coding manual with CDC-issued standard guidance on coding criteria and examples for each data element is provided. Software features to enhance coding reliability include automated validation rules and a hover-over feature containing variable-specific information.

States are requested to perform annual blind reabstractions of a subset of cases using multiple abstractors to identify inconsistencies. CDC also runs a quality control analysis in which multiple variables are reviewed for their appropriateness, with special focus on abstractor-assigned variables (e.g., method and manner of death). If CDC finds inconsistencies, the state is notified and asked for a response or correction.

Time Frame

States are required to report all deaths within 6 months of the end of each calendar year for the preceding January–December. States then have an additional 12 months to complete each incident record. Although states typically meet these requirements, additional details sometimes arrive after a deadline has passed. New incidents also might be identified after the deadline (e.g., a death certificate is revised, new evidence is obtained that changes a manner of death, or an ICD-10 miscoding is corrected to meet NVDRS inclusion criteria). These additional data are incorporated into NVDRS. CDC estimates that case counts might increase 1.0%–2.0% after the 18-month data collection period.

Fatal Injuries in 2013

This report provides data concerning fatal injuries meeting the NVDRS case definition for violent deaths in 2013 for 17 participating states that were received by CDC as of October 5, 2015. Participating states used vital statistics death certificate files or coroner/medical examiner reports to identify violent deaths meeting NVDRS case definitions. Each state reported all violent deaths of residents that occurred within the state and those of nonresidents for whom a fatal injury occurred within the state (i.e., occurrent deaths). Once a violent death was identified, NVDRS data abstractors linked source documents, linked deaths within each incident, coded data elements, and wrote a short narrative of the incident. State-level data were then consolidated and analyzed for this aggregate report.

Numbers, percentages, and crude rates are presented in aggregate for all deaths by abstractor-assigned manner of death. Rates for cells with frequency <20 are not reported because of the instability of those rates (9). Rates could not be calculated for some variables (e.g., marital status and precipitating circumstances) because denominators were unknown. Bridged-race 2013 population estimates were used as denominators in the crude rate calculations (10). For compatible numerators for rate calculations to be derived, records listing multiple races were recoded to a single race, when possible, using race-bridging methods described by NCHS (available at http://www.cdc.gov/nchs/nvss/bridged_race.htm).

Results

All Deaths Captured by NVDRS

Deaths by Manner, Method, and Location

The 17 NVDRS states included in this report collected data concerning 18,765 incidents and 19,251 deaths that occurred in 2013. The crude death rate was 20.1 deaths per 100,000 population. Suicides (n = 12,747; 66.2% of total) accounted for the highest rate of violent deaths (13.3 per 100,000 population), followed by homicides (n = 4,459; 23.2% of total) (4.6 per 100,000 population). Deaths of undetermined intent (n = 1,698; 8.8% of total), legal intervention deaths (n = 222; <1.0% of total), and unintentional firearm deaths (n = 125; <1.0% of total) occurred at lower rates (1.8, 0.2, and 0.1 per 100,000 population, respectively). Firearms were the method used in 51.3% of deaths, hanging/strangulation/suffocation in 17.2%, and poisoning in 16.3% (rates: 10.3, 3.4, and 3.3 per 100,000 population, respectively). Rates for all other methods were lower. For all deaths, a house or apartment was the most common location where injury occurred (69.4%), followed by a street or highway (6.4%) (Table 1).

Toxicology Results of Decedent

Tests for alcohol were conducted for 59.2% of decedents and tests for amphetamines, antidepressants, benzodiazepines, cocaine, marijuana, and opiates were conducted for 35.6%, 28.7%, 35.1%, 38.8%, 30.6%, and 42.2%, respectively (Table 2). Among the 37.6% of tested decedents with positive results for alcohol, 67.8% had blood alcohol concentration (BAC) ≥0.08 g/dL (i.e., over the legal limit in all states). Opiates, including heroin and prescription pain medications, were identified in 31.8% of decedents tested for these substances, amphetamines in 9.2%, antidepressants in 33.2%, benzodiazepines in 29.0%, cocaine in 10.4%, and marijuana in 24.0% (Table 2). The other drugs/substances category includes over-the-counter drugs (e.g., diphenhydramine, a common antihistamine), nicotine, or other substances not otherwise categorized (e.g., hypnotics, tranquilizers, or other analgesics). Ninety-nine percent of decedents tested for other drugs/substances had positive results. The explanation for the high percentage of positive toxicology test results is believed to be twofold (1): Positive results 1) might indicate miscellaneous other substances that investigators had a reason to test for, given a decedent’s history, and 2) might indicate additional substances that were reported in a comprehensive exploratory toxicology panel.

Suicides

Sex, Race/Ethnicity, Age Group, and Marital Status

The 17 NVDRS states included in this report collected data for 2013 concerning 12,729 suicide incidents, which included 12,747 deaths (Table 1). Rates of suicide by month of death varied little throughout the year (range: 1.0–1.2 per 100,000 population) (Table 3). Overall, the crude suicide rate was 13.3 per 100,000 population (Table 3). The rate for males was nearly four times the rate for females (21.0 and 5.9 per 100,000 population, respectively) (Table 4). Non-Hispanic American Indian/Alaska Natives and non-Hispanic whites had the highest rates of suicides (18.7 and 16.4 per 100,000 population, respectively). The highest rates of suicide by age group occurred among persons aged 45–54 years, 55–64 years, and ≥85 years (19.8, 18.4, and 17.3 per 100,000 population, respectively). Persons aged 10–14 years had the lowest rate of suicide among all age groups (2.0 per 100,000 population). The suicide rate among persons aged 15–19 years (8.6 per 100,000 population) was approximately half of that for persons aged 35–64 years.

Decedents aged 35–64 years accounted for more than half (52.6%) of suicides among males. Rates among males were highest for men aged ≥85 years, followed by men aged 75–84 and 45–54 years (45.5, 33.0, and 29.6 per 100,000 population, respectively). Non-Hispanic whites (25.8 per 100,000 population) and non-Hispanic American Indian/Alaska Natives (30.2 per 100,000 population) had the highest rates of any male subgroups; these rates were more than three times the rate for males with the lowest rate, Asian/Pacific Islanders (8.2 per 100,000 population). Decedents aged 35–64 years accounted for the majority (60.9%) of suicides among females. The rate among females was highest for women aged 45–54 years (10.3 per 100,000). Non-Hispanic American Indian/Alaska Natives (7.7 per 100,000 population) and non-Hispanic whites (7.3 per 100,000 population) had the lowest suicide rates among females; rates were lowest among Asian/Pacific Islanders (2.5 per 100,000 population) and non-Hispanic blacks (2.0 per 100,000 population). Of suicide decedents aged ≥18 years, 34.5% were married, 29.7% had never married, and 21.6% were divorced at the time of death (Table 4).

Method and Location of Injury

Firearms were used in more than half of suicides (51.4%), followed by hanging/strangulation/suffocation (24.5%) and poisoning (15.5%) (rates: 6.8, 3.2, and 2.1 per 100,000 population, respectively) (Table 3). Among males, the most common method used was a firearm (56.9%) followed by hanging/strangulation/suffocation (24.7%) (Table 5). Among females, poisoning was the most common method used (34.6%), followed by a firearm (32.4%). The most common place of suicide was a house or apartment (75.2%), followed by a natural area (4.6%), a motor vehicle (4.6%), and a hotel/motel (2.1%). A total of 173 (1.4%) suicides occurred in a jail/prison (152 males and 21 females).

Toxicology Results of Decedent and Precipitating Circumstances

Tests for alcohol were conducted for 55.9% of suicide decedents and tests for amphetamines, antidepressants, benzodiazepines, cocaine, marijuana, and opiates were conducted for 34.2%, 28.4%, 33.9%, 36.3%, 28.9%, and 38.3%, respectively (Table 6). Among those with positive results for alcohol (38.2%), 70.3% had BAC ≥0.08 g/dL. Opiates, including heroin and prescription pain medications, were identified in 26.8% of decedents tested for these substances; cocaine and marijuana were identified in 5.8% and 16.6% of decedents tested, respectively. Of those tested for antidepressants, 35.3% had positive results at the time of their death (Table 6).

Precipitating circumstances were known for 88.5% of suicides. Overall, mental health problems were the most common circumstance; 38.3% of decedents were described as experiencing a depressed mood at the time of their death, 46.2% as having a current diagnosed mental health problem, and 32.1% as receiving mental health treatment (Table 7). Among the 5,204 decedents with a current diagnosed mental health problem, depression/dysthymia (72.8%), anxiety disorder (15.4%), and bipolar disorder (13.8%) were the most common diagnoses for males and females (Table 8).

Substantial percentages of female (40.5%) and male (37.7%) decedents were reported to have a depressed mood at the time of their suicide and 62.7% of females and 41.2% of males were reported to have a current diagnosed mental health problem. The percentages of females (47.0%) and males (27.6%) receiving treatment for a mental health problem were lower (Table 7).

Among 11,267 suicides with known circumstances, 34.8% of decedents left a suicide note, 32.4% had a history of suicidal thoughts or plans, 19.7% had a history of previous suicide attempts, and 25.7% had disclosed suicidal intent to another person (Table 7). The majority of decedents disclosed intent to a previous or current intimate partner (37.7%) or to some other family member (29.8%). Alcohol or other substance abuse problems were indicated for 18.3% and 16.3% of suicide decedents, respectively. Other common circumstances were a crisis in the preceding or upcoming 2 weeks (32.3%) and intimate partner problems (29.7%). Physical health problems (21.6%), an argument or conflict (16.2%), and job or financial problems (12.4% and 11.0%, respectively) were also reported to have preceded suicides.

Slightly more than one-fifth of male (21.4%) and female (22.3%) decedents experienced physical health problems that contributed to their suicide (Table 7). Job problems were noted as a precipitating circumstance in a higher percentage of males than females (13.6% and 8.3%, respectively), as were financial problems (11.7% and 8.5%), recent criminal legal problems (10.4% and 5.2%), and intimate partner problems (31.2% and 25%). In contrast, family (nonintimate) relationship problems were a precipitating circumstance in a higher percentage of females than males (12.3% and 8.8%, respectively). Although indicated in a relatively small percentage of suicides, among males being a perpetrator of interpersonal violence in the month before death was more common (3.7%) than being a victim of such violence (<1.0%); among females, the percentages were similar (1.0% and 1.2%, respectively) (Table 7).

Among suicide decedents for whom a crisis in the previous or upcoming 2 weeks was reported, intimate partner problems (42.9%), criminal legal problems (13.7%), and physical health problems (12.7%) were most common (Table 9). These percentages are similar to those for the most common precipitating circumstances.

Homicides/Legal Intervention Deaths

Sex, Race/Ethnicity, Age Group, and Marital Status

The 17 NVDRS states included in this report collected data concerning 4,448 homicide/legal intervention incidents, which included 4,681 deaths in 2013 (Table 10). Rates of homicides by month of death varied little throughout the year (range: 0.3–0.5 per 100,000 population). Overall, the crude homicide rate was 4.9 deaths per 100,000 population. The majority of homicide decedents aged ≥18 years (55.5%) had never been married, and 20.0% were married at the time of their death (Table 11). In more than half (52.8%) of homicides, the relationship of the victim to the suspect was not known; when the relationship was known, the suspect most often was an acquaintance or friend (22.6%), a spouse or intimate partner (21.0%), or a stranger (12.1%).

The homicide rate for males was three and half times the rate for females (7.7 and 2.2 per 100,000 population, respectively) (Table 12). Non-Hispanic blacks accounted for more than half (52.7%) of homicides and had the highest rate (16.7 per 100,000 population), followed by American Indian/Alaska Natives (7.7 per 100,000 population) and Hispanics (4.4 per 100,000 population). Non-Hispanic black males had the highest rate of homicide deaths among males of any other race/ethnicity (29.8 per 100,000 population). Age-specific homicide rates were highest (12.1 per 100,000 population) among persons aged 20–24 years, followed by persons aged 25–29 years (10.1 per 100,000 population). The rate for infants aged <1 year was more than three times the rate for children aged 1–4 years (7.6 and 2.1 per 100,000 population, respectively). Rates were lowest among persons aged 5–14 years and 65–84 years. Among males, the majority of homicide decedents (55.8%) were aged 15–34 years; the rate was highest among men aged 20–24 years (20.4 per 100,000 population). Among females, the homicide rate was highest (5.9 per 100,000 population) among infants aged <1 year. The rate among male infants aged <1 year was 9.3 per 100,000 population.

Method and Location of Injury

Firearms were used in 66.6% of homicides, followed by sharp instruments (11.1%), blunt instruments (5.6%), and personal weapons (e.g., hands, feet, fists) (4.7%) (Table 10). No other method was used in more than 4.0% of homicides. Firearms were the most common method used in homicides of males (71.8%) and females (48.8%) (Table 13). Hanging/strangulation/suffocation was more common among females (8.8%) than males (1.7%), as was use of blunt instruments (7.5% and 5.1%, respectively). A house or apartment was the most common location of homicide (51.9%; males and females 45.7% and 73.4%, respectively), followed by a street or highway (19.9%); a motor vehicle (6.7%); or a parking lot, a public garage, or public transport (3.9%) (Table 13).

Toxicology Results of Decedent and Precipitating Circumstances

Tests for alcohol were conducted for 61.8% of homicide decedents and tests for amphetamines, antidepressants, benzodiazepines, cocaine, marijuana, and opiates were conducted for 38.0%, 23.0%, 33.2%, 42.3%, 34.8%, and 41.3%, respectively (Table 14). Among those who had positive results for alcohol (38.1%), 63.6% had BAC ≥0.08 g/dL. Marijuana, opiates, and cocaine were identified in 42.5%, 18.3%, and 15.7% of homicide decedents tested, respectively (Table 14).

Precipitating circumstances were identified for 78.5% of homicides. Approximately one in three of those homicides were precipitated by another crime (Table 15); in 69.9% the crime was in progress at the time of the incident. The type of crime most frequently precipitating the homicide was assault/homicide (44.3%), followed by robbery (34.2%), burglary (13.1%), drug trade** (11.4%), rape/sexual assault (2.9%), motor vehicle theft (2.8%), and arson (1.3%) (Table 16). Other common precipitating circumstances were an argument or conflict (33.2%), drug involvement (12.7%), or victim’s use of a weapon (9.6%). In 18.8% of homicides with known circumstances, intimate partner violence was identified as a contributing factor (Table 15).

An argument or a conflict was a factor in more homicides among males (34.5%) than among females (29.3%). Drug involvement accounted for 15.2% of homicides among males and 5.3% among females. Intimate partner violence was a precipitating factor in 47.5% of homicides among females but only 9.3% among males. Male decedents also used a weapon during the incident in 12.1% and female decedents in 2.2% of homicides with known circumstances (Table 15).

Information was collected on crises experienced by decedents within the previous or upcoming 2 weeks (Table 17). The most common crises precipitating homicides were family relationship problems (22.5%) and jealousy (e.g., lovers’ triangle) (16.3%).

Legal Intervention Deaths

The 17 NVDRS states included in this report collected data concerning 222 legal intervention incidents, which included 222 deaths in 2013 (Table 18). When analyzed separately from homicides, the majority of legal intervention deaths occurred among males (93.7%), with the highest rate among men aged 30–34 (1.1 per 100,000 population). Non-Hispanic white males accounted for the highest percentage of legal intervention deaths (43.8%), but non-Hispanic black males had the highest rate (1.2 per 100,000 population), four times the rate for non-Hispanic white males (0.3 per 100,000). Firearms were used in almost all legal intervention deaths (92.3%) (Table 19). Legal intervention deaths occurred most frequently in a house or apartment (41.4%), followed by a street or highway (25.2%) and a motor vehicle (8.6%) (Table 19).

Tests for alcohol were conducted for 72.1% of legal intervention decedents and tests for amphetamines, antidepressants, benzodiazepines, cocaine, marijuana, and opiates were conducted for 46.4%, 33.8%, 53.2%, 59.0%, 43.2%, and 59.0%, respectively (Table 20). Among those who had positive results for alcohol (39.4%), 76.2% had BAC ≥0.08 g/dL. Opiates, including heroin and prescription pain medications, were identified in 18.3% of those tested for these substances; cocaine and marijuana were identified in 15.3% and 37.5%, respectively. Of legal intervention decedents who were tested for antidepressants, 22.7% had positive results at the time of their death (Table 20).

Precipitating circumstances were identified for 98.2% of legal intervention deaths. Approximately 87.6% were precipitated by another crime (Table 21); in 74.3% of those the crime was in progress at the time of the incident. The type of crime most frequently precipitating the legal intervention death was assault/homicide (68.1%), followed by robbery (9.9%), motor vehicle theft (5.2%), and burglary (4.7%) (Table 22). Other common precipitating circumstances were an argument or conflict (14.2%) or drug involvement (7.8%). In 10.6% of legal intervention deaths with known circumstances, intimate partner violence was identified as a contributing factor (Table 21). The decedent reportedly used a weapon in 72.5% of legal intervention deaths (Table 21). A recent crisis within the previous or upcoming 2 weeks was cited in 16.6% of legal intervention deaths (Table 23). The two most common crisis circumstances were family relationship problems (16.2%) and current diagnosed mental health problems (10.8%).

Deaths of Undetermined Intent

Sex, Race/Ethnicity, Age Group, and Marital Status

The 17 NVDRS states included in this report collected data concerning 1,688 incidents involving 1,698 deaths in 2013 for which a determination of intent could not be made (Table 24). Rates of deaths of undetermined intent varied little by month of death (range: 0.1–0.2 per 100,000 population) throughout the year. Overall, the crude rate of deaths of undetermined intent was 1.8 per 100,000 population. Rates were higher among males than among females (2.3 and 1.3 per 100,000 population, respectively) (Table 25). Non-Hispanic whites accounted for 78.2% of deaths of undetermined intent and also had the highest rate (2.0 per 100,000 population). Non-Hispanic white males had the highest rate of death of undetermined intent (2.5 per 100,000 population) compared with males or females of any other race/ethnicity. More than half (59.6%) of persons for whom the manner of death was undetermined were aged 35–64 years. Rates were highest (3.2 per 100,000 population) among infants aged <1 year and adults aged 45–54 years. Among decedents aged ≥18 years for whom intent of death was undetermined, 40.9% never had been married, 23.8% were married, and 24.9% were divorced at the time of death (Table 25).

Method and Location of Injury

The most common method of injury in deaths of undetermined intent was poisoning (67.4%) (Table 26). No other method accounted for >5.0% overall. The majority of deaths of undetermined intent occurred in a house or apartment (73.9%). A house or apartment was the most common place of injury for males and females (70.8% and 79.1%, respectively), followed by a street or highway (4.3% and 3.2%).

Toxicology Results of Decedent and Precipitating Circumstances

Tests for alcohol were conducted for 78.4% of death of undetermined intent decedents and tests for amphetamines, antidepressants, benzodiazepines, cocaine, marijuana, and opiates were conducted for 39.5%, 48.1%, 49.9%, 48.8%, 32.6%, and 75.1%, respectively (Table 27). Among those who had positive results for alcohol (33.7%), 63.5% had BAC ≥0.08 g/dL. Opiates, cocaine, marijuana, and antidepressants were identified in 72.2%, 23.8%, 17.2%, and 53.7% of decedents, respectively, for whom intent of death could not be determined (Table 27).

Precipitating circumstances were known in approximately 83.7% of deaths of undetermined intent. Of those, substance abuse problems (64.0%) and alcohol problems (26.9%) were most common (Table 28). Although a current depressed mood was reported for only 14.2% of decedents, 39.5% had a current diagnosed mental health problem, 32.9% were receiving mental health treatment at the time of their death, 12.8% had a history of suicide attempts, 11.3% had a history of suicidal thoughts or plans, 5.5% had disclosed intent to commit suicide, and 1.5% left a suicide note. Other common circumstances were physical health problems (21.0%), a crisis during the preceding or upcoming 2 weeks (19.4%), or intimate partner problems (9.4%) (Table 28). Of those with a current diagnosed mental health problem, depression/dysthymia (59.9%), anxiety disorder (23.5%), and bipolar disorder (21.0%) were the most common diagnoses (Table 29).

Among decedents for whom intent of death was undetermined, a greater percentage of males than females was reported to have alcohol problems (31.7% and 19.2%, respectively); the percentage with other substance abuse problems was similar for males and females (64.6% and 63.0%) (Table 28). Mental health problems were reported for approximately half of females (50.3%) and 32.8% of males. A higher percentage of females than of males was currently in treatment for a mental health problem (42.1% and 27.2%, respectively) or had a history of suicide attempts (16.1% and 10.8%) (Table 28).

A crisis within the previous or upcoming 2 weeks was experienced by 19.4% of decedents for whom intent of death was undetermined (Table 28). For males and females, the most common recent crises were health problems (33.7%), other (nonalcohol) substance abuse problems (21.4%), intimate partner problems, (18.5%), and family relationship problems (7.6%) (Table 30).

Unintentional Firearm Deaths

Sex, Race/Ethnicity, and Age Group

The 17 NVDRS states included in this report collected data concerning 125 incidents involving 125 unintentional firearm deaths in 2013 (Table 31). Fifty-five (44.0%) of these unintentional fatal firearm injuries were self-inflicted and 36 (29.0%) were known to be inflicted by another person; for the remaining 34 (27.0%), it was unknown who inflicted the injury (data not shown). Males accounted for 85.6% of decedents. The majority (78.4%) were non-Hispanic whites, followed by non-Hispanic blacks (12.8%). Persons aged 15–29 years accounted for 40.8% of all unintentional firearm deaths (Table 31).

Firearm Type, Seasonality, and Location of Injury

Handguns were involved in 46.4% of unintentional firearm deaths, shotguns in 16.0%, and rifles in 12.0%. The majority of unintentional firearm deaths occurred in March, April, October, November, and December (10.4% each month), while the fewest occurred in June (4.8%) (Table 31). Of all unintentional firearm deaths, 69.6% occurred in a house or apartment, followed by natural areas (10.4%) (Table 31).

Context of the Injury and Associated Circumstances

The context of the injury or associated circumstances were known for 77.6% of unintentional firearm deaths (Table 32). Overall, the most common context of injury was playing with a gun (28.9%), followed by hunting (13.4%) and showing a gun to others (8.2%). The most common associated circumstance was unintentionally pulling the trigger (20.6%), followed by thinking the gun was unloaded (14.4%) and thinking the magazine was disengaged (8.2%) (Table 32).

Discussion

Violent deaths occur among males and females of all ages, races, and ethnicities. NVDRS data can help identify populations particularly affected by violence. The system not only provides details on specific manners of violent deaths, but also identifies common factors for multiple types of violence. These details can increase knowledge about the circumstances associated with violence and can help public health authorities develop data-informed, effective approaches to violence prevention.

In participating states, updating to a web-based platform has simplified system operation and management, improved timeliness of data entry and reporting, and enhanced flexibility to adapt quickly to changing information needs in violence surveillance (8). Changes to the system have also improved its capacity for future expansion to additional states (8).

NVDRS data continue to illustrate that relationship problems, specifically intimate partner problems, frequently precede suicides and homicides. These findings underscore the importance of youth violence prevention programs that help improve communication skills, individual coping skills (11), and nonviolent conflict resolution skills such as impulse control, empathy, anger management, and problem solving (12–15). For example Safe Dates, which focuses on reducing dating violence among adolescents by enhancing awareness about abusive relationships, changing norms, and teaching skills to develop healthy relationships, has been reported to reduce long-term physical and sexual dating violence (16) and other types of youth violence (17). Other school-based, family-focused, or community-based prevention programs also have been reported to reduce youth violence (18,19).

Alcohol use also frequently precedes suicidal and interpersonal violent behavior (4,7,11,20–23). NVDRS data indicate that alcohol was the most commonly identified substance in decedents who underwent toxicology testing; in 2013 over two-thirds of decedents with positive results for alcohol had BAC ≥0.08 g/dL (i.e., over the legal limit in all states). These findings suggest that comprehensive violence prevention efforts can benefit from strategies that address alcohol and other substance abuse.

Among other variables, NVDRS collects information about circumstances associated with violence. For example, analysis of NVDRS data on precipitating circumstances indicates that when homicides involve females, almost half are related to intimate partner violence. The U.S. Department of Health and Human Services recommends that women’s preventive health care include screening and counseling for interpersonal and domestic violence (24). It is important that screening and counseling about abuse be done in a culturally sensitive and supportive way to address concerns about health and safety (25). An intervention with multiple counseling sessions to assess the risk for danger, discuss prevention options, develop a safety plan, and share appropriate community resources has been reported to reduce recurrence of partner violence among pregnant women (26).

At the state level, NVDRS data have been instrumental in planning, implementing, and evaluating public health policies and practices regarding violent deaths. For example, Utah Violent Death Reporting System (VDRS) data indicated that in 44.0% of intimate partner violence–related incidents, children and adolescents aged <18 years were living in the home. The state’s Violence and Injury Prevention Program and multidisciplinary Domestic Violence Fatality Review Committee used these data to help children of domestic violence–related homicide victims. The data-informed policy change allows the Department of Children and Family Services to help these children receive an assessment and get access to interventions such as mental health care (27).

Current diagnosed mental health problems were a common precipitating circumstance for suicides. Depression/dysthymia was the most common diagnosis, followed by anxiety disorder and bipolar disorder. However, only one-third of suicide decedents were receiving mental health treatment, which suggests the need for strategies to enhance access to care; reduce stigma for those seeking help; and enhance social connections and support, particularly during times of crisis (11).

Other studies have indicated that on average, as many as 45.0% of persons who die by suicide had visited their primary care physician within 1 month of their death (28) and as many as 67.0% of persons who attempt suicide receive medical attention as a result of their attempt (29). Such findings suggest opportunities for suicide prevention. Primary care providers have the potential to prevent suicides, connect patients to specialty care, and collaborate or formally partner with behavioral health care providers (30,31).

Colorado VDRS data on suicide among middle-aged men were used by the Colorado Department of Public Health and their partners to develop ManTherapy, a web-based suicide prevention initiative to engage and help connect men with appropriate resources (32,33). The initiative was driven by continued observation that men of working age (aged 25–64 years) comprise the population with the highest rate of suicide in Colorado. Some circumstances associated with suicide among working-aged men differed considerably from those associated with women (K Bol, MSPH, Colorado Department of Public Health and Environment, personal communication, March 2016, 33). Among suicides in Colorado from 2009 to 2013, 42.0% of men and 64.0% of women were noted to have a current diagnosed mental health problem during investigation; have ever been treated for a mental health problem (39.0% and 58.0%, respectively); have a diagnosis of depression (31.0% and 49.0%); or be receiving mental health treatment at the time of the suicide (30.0% and 51.0%). These findings suggest reticence among men to seek mental health care or to discuss a mental health diagnosis or treatment with those closest them (e.g., family members and friends). Initial web analytics indicate that the program had over 285,000 unique visits between mid-2012 and early 2014, with 83.0% of survey respondents reporting they would recommend the site to a friend in need and 73.0% reporting they were directed to appropriate resources (32).

Suicide data from the Rhode Island VDRS (27) identified working-age males as being at increased risk for suicide and suicide attempts. Mental health and substance abuse problems, interpersonal problems, and employment-related stressors were identified as common circumstances preceding suicide in this population. As a result, a symposium with the two largest employers in the state was conducted to present these findings and increase awareness of factors precipitating suicide among working-age adults. Strategies were provided for integrating suicide prevention into worksites (27). One large employee assistance program in the state integrated suicide prevention into its mission statement and began providing training to their clinical staff and clients in early identification and referral of at-risk employees.

At the national level, NVDRS data are relevant to two national prevention initiatives, the National Strategy for Suicide Prevention (NSSP) and Healthy People 2020 (34,35). The NSSP is a comprehensive national agenda for suicide prevention (34). Healthy People 2020 includes specific objectives for reducing the number of suicides, homicides, and firearm-related deaths and increasing the number of states that link data on violent deaths from death certificates, law enforcement reports, and coroner/medical examiner reports at state and local levels (35). Unlike other sources of data, NVDRS allows changing patterns in circumstances and risk profiles to be examined, which can affect how the rates are interpreted, help guide prevention activities, and monitor progress toward objectives.

In addition to providing more detail than other surveillance systems regarding the circumstances of violent deaths, NVDRS collects more complete information than other data sources on manners of death such as legal intervention deaths (36) and unintentional firearm deaths (37). In light of current calls for better data on legal intervention deaths in particular (38,39), continued expansion of the NVDRS is critical to understanding the national picture of these deaths. The findings from 17 states in 2013 provide preliminary evidence of racial disparities in rates of legal intervention deaths, but further analyses are needed.

Limitations

The findings provided in this report are subject to at least eight limitations. First, NVDRS data are available from a limited number of states and therefore are not nationally representative. Second, the availability, completeness, and timeliness of data are dependent on partnerships among state VDRS and state health departments, vital statistics registrars’ offices, coroners/medical examiners, and law enforcement personnel. Data sharing and communication among partners are particularly challenging when states have independent county coroner systems rather than a centralized coroner/medical examiner system, a large number of law enforcement jurisdictions, or both. NVDRS incident data might be limited or incomplete for areas in which these data-sharing relations are not fully developed. Third, toxicology data are not collected consistently across all states or for all alcohol and drug categories. Toxicology testing is not conducted for all decedents, so the percentage of those with positive results for specific substances might be affected by selective testing patterns in coroner/medical examiner offices (40). Fourth, abstractors are limited to the data included in the investigative reports they receive. Reports might not fully reflect all information known about an incident, particularly for homicides and legal intervention deaths, when data are less readily available until after a full investigation and adjudication are completed. Fifth, case definitions present challenges when a single death is classified differently in different documents (e.g., unintentional in a law enforcement report, homicide in a coroner/medical examiner report, and undetermined on the death certificate). NVDRS abstractors reconcile these discrepancies using standard NVDRS case definitions and select a single manner of death on the basis of all source documents; the manner of death assigned must be consistent with the manner of death noted in at least one source document. Sixth, variations in coding might occur depending on the abstractor’s level of experience. For this reason, CDC provides abstractor training and states conduct blinded reabstraction of cases to test consistency and identify training needs. Seventh, medical and mental health information (e.g., type of condition and whether the decedent was currently receiving treatment) are not often captured directly from medical records but from coroner/medical examiner reports and the decedent’s family members and friends. Therefore, the completeness and accuracy of this information are limited by the knowledge of the informant. Finally, protective factor data (i.e., characteristics or circumstances that reduce the risk for violent death) are not collected by NVDRS because of the nature of death certificates, coroner/medical examiner reports, and law enforcement reports, which typically contain only circumstances associated with risk factors.

Conclusion

Public health surveillance is the foundation for public health practice. Surveillance is essential to monitoring the prevalence and incidence of violence-related fatal injuries, defining priorities, and directing programmatic and violence prevention activities (41). Development and expansion of NVDRS are crucial to public health efforts at the federal, state, and local levels to reduce violence and the personal, familial, and societal consequences and costs. Further efforts are needed to increase the number of states participating in NVDRS to include all 50 states, U.S. territories, and the District of Columbia, with the ultimate goal of full national representation.