Injuries are the major health problem of adolescents and a significant problem for individuals of all ages in the United States.
Since 1980, several excellent reviews have been published on the topic of the epidemiology of injuries in adolescence.1,2 This article will focus primarily on data published in the last three to four years or not previously discussed, with attention to unintentional injuries.
There are several interesting problems confronting the reviewer of these data: 1) the data are not collected in a uniform manner across data sets; and 2) individual data sets classify subjects differently by age grouping or grade in school. This latter problem can be particularly frustrating related to adolescence, which is defined as the period of life beginning with the appearance of secondary sex characteristics and terminating with the cessation of somatic growth, roughly from 11 to 19 years of age (emphasis added).3
Some of the data sets that are useful in injury epidemiology are: 1) the National Electronic Injury Surveillance System (NEISS) of the US Consumer Product Safety Commission, collecting information on product-related injuries from a sample of emergency rooms across the country and from death certificates; 2) the Fatal Accident Reporting System (EARS) of the US Department of Transportation's National Highway Traffic Safety Administration, collecting information on fatal motor vehicle-related injuries from police reports; 3) the National Poison Control Data Network, collecting information on poisonings from reports to 56 poison control centers in the US; 4) the National Health Interview Survey (NHIS) conducted by the National Center for Health Statistics, collecting information on nonfatal injuries through household surveys; and 5) individual research studies using a variety of methodologies.
There is no consistent way of creating age groupings in the various data sets noted above. Some provide breakdowns by single year of age or by grouping such as 6 to 12 and 13 to 17, making identification of adolescents relatively easy. Others, however, lump large age groups, such as ail those less than 17 or 5 to H and 15 to 24, making it difficult to select data relevant to adolescents. Still other authors use grade in school rather than age. One can pick out those grades in which students are usually adolescents, but there may be several different ages represented in any given grade. Finally, especially as it pertains to athletic injuries, Tanner staging may be a more important variable than either age or school grade, but no study I identified used such a classification system.
Causes of Death In United States- 1983
GENERAL EPIDEMIOLOGY OF INJURIES
Injuries are the leading cause of death for individuals 1 to 44 years of age; motor vehicle-related injuries are the leading cause of death for those aged 1 to 34. 4 Injuries cause 80% of all deaths in teenagers and young adults; half of all trauma deaths occur in people from age 13 to 34. 4 The leading causes of death in teens are motor vehicles, motorcycles, and drowning. Deaths and death rates for males exceed females (Table I).5
Deaths in teenagers and young adults due to all other causes declined from 1930 to 1980; however, deaths due to injuries increased, particularly from 1960 to 1980 (Figure). Because injuries kill so many children, adolescents, and young adults, injuries are the leading cause of productive years of life lost.6 When the causes of death in people of all ages are arrayed by productive years of life lost, the rank order is very different than when arrayed by number of deaths (Table 2).6 Among unintentional injuries, the leading causes of years of productive life lost are motor vehicle crashes followed by drownings, fire and flame, poisoning, falls, firearms, choking on food or objects, water transportation, air transportation, and motor vehicle non-traffic crash.4
Fatal and nonfatal injuries occur in different settings. For very young children, nearly all injuries occur in or near the home. For adolescents, from one third to one half of the injuries occUr at school or work, one half to one third occur at or near home, and the remainder occur in other environments7 (Table 3).
Not all injuries are fatal. In Massachusetts, injuries of all types resulting in death, hospitalization; or emergency room visits occurred at a rate of 2,239/10,000 children/year for children 0 to 19 years, with 96.5% of the children being treated and released, 3.4% being admitted, and 0.1% dying.8 Teens (13 to 19) had the highest injury rate of the various age groups (2,718) and teen males had the highest rates of all groups: 3,494 overall, 3,354 seen in emergency rooms, 136 admitted, and 3.4 dying (all per 10,000 population).8 Gallagher et al8 report that the leading causes of injury in 13 to 19 year olds are: sports, cutting/piercing, being struck by an object, falls, and being a motor vehicle occupant. The top five categories are the same for males and females although the rank order differs. Tabulating injury rates for 15 to 24 year olds seen in emergency rooms in northeast Ohio, Fife and colleagues7 report the major causes of injury being: motor vehicle-related, striking objects, being cut, falls, overexertion, and assault. Males have a higher rate than females for all categories and the rank order differs for males and females. Injuries to people of all ages are the leading reason for physician visits and generate over 7 million visits per year.6
Figura. Death rates from all diseases and injuries by year and age group. 1930-1980. Diseases ( - J Injuries - )
Alcohol plays a large role in fatal injuries in adolescents. In San Francisco, 50% of adolescents sustaining unintentional traumatic deaths were intoxicated. This was true for those killed in motor vehicle and nonmotor vehicle situations.9
THE ROAD ENVIRONMENT
The road is the most dangerous environment for adolescents both in terms of absolute numbers of deaths and death rates (Table 1). The road environment includes motor vehicle occupants, motorcyclists, bicyclists, and pedestrians.
The death rate due to motor vehicle-related injuries in 15 to 24 year olds rose from 34-4 in 1950 to 44-8 in 1980. * There was then a decline to 36. 5 in 1984. 1 3 White males have the highest motor vehicle-related death rate of all groups (1983 death rates: WM 57.0, BM 28.3, WF 18.8, BF 8.6).10 Death rates for motor vehicle occupants, motorcyclists, and pedestrians all increase during adolescence. Death rates for motor vehicle occupants peak at about 45 in 20 year olds, and motor vehicle occupants account for about 73% of all motor vehicle-related deaths at that age. u The death rate for bicyclists peaks between 11 and 15 years at about 2, and for motorcyclists peaks between 17 and 22 years at about 7."
In 1985, there were 12,460 deaths of people ages 15 to 24 due to motor vehicle-related injuries, except those sustained by pedestrians and pedalcyclists.5 Motor vehicle occupant deaths account for 1 in 3 of deaths due to all causes in 15 to 19 year old males." Although males have a higher exposure, ie, they travel more miles, their death rate per miles traveled is about 71 per 100 million miles at its peak at age 17, compared with 30 per 100 million miles at the peak for women at age 19. u Teenagers have the highest fatal crash involvement rates per 10,000 licensed drivers; and, as discussed more fully by Dr. Rivara in this issue, this rate is not improved among teens who have taken driver's education.
Motorcycles are a particularly hazardous mode of transportation. Because they offer so little protection to the rider, a driver's or passenger's chance of injury is vastly increased in a collision. In 1979, about 12,000 teenage motorcyclists (15 to 19 years) lost their lives.11 About 55% of all motorcyclist's deaths occur in 15 to 24 year olds, and the death rate for motorcyclists peaks between 18 and 24 years. Males have a death rate over 20 times that of females in one study, and most fatal injuries occur in the summer, on Friday and Saturday, in the late afternoon and early evening.12 Although motorcycle helmet use by riders will not prevent all deaths, helmets are effective in decreasing death rates.11
Ten Leading Causes of Death and Potentially Productive Years of Life Lost (PPYLL) United States
Injuries by Place
The number of deaths in pedestrians 15 to 19 years old each year is relatively small, about 880; but the death rate, which had peaked for young school age children, is peaking again in the late teens and early 20s (5.16 for males 20 to 24 years old and 2.11 for females 15 to 19 years old).11 About half of teenage pedestrians are injured crossing a street at or between intersections, and up to one third are injured walking or doing some other activity in the roadway.5
The numbers and rates of bicycle deaths peak in the younger adolescents, ie, 10 to 14 year olds. Bicycles account for about 270 deaths per year in that age range and 150 to 160 deaths per year in 15 to 19 year olds. Maximum death rates are 2. 19 for male bicyclists 10 to 14 and 0. 61 for female cyclists of the same age. ' ' Death is usually associated with trauma to the head or trunk.
Nonfatal injuries involving motor vehicles are not recorded in FARS or NEISS, although NEISS does record nonfatal bicycle injuries. The most detailed information on nonfatal injuries in the road environment comes from the Northeast Ohio Trauma Study7 and the Statewide Childhood Injury Prevention Program Surveillance System in Massachusetts.8 When looking at nonfatal injuries, the road environment no longer has the highest injury rates. Motor vehicle occupants aged 13 to 19 sustain nonfatal injuries at a rate of about 1,900; males predictably have a higher rate of injury. Motorcyclists had a rate of nonfatal injury near 100 in one study8 and over 300 in the other.7 Pedestrians had rates of near 1157 and near 160s while bicyclists had rates near 5508 in one study, but only near 997 in the other.
While alcohol intoxication, and presumably drug intoxication, are major factors in fatal injuries of all types, this is especially true in the road environment. About 25% of adolescent drivers in fatal day time, multi-vehicle crashes have a blood alcohol content (BAC) greater than 0.1%, as do nearly 75% of adolescent drivers in fatal, nighttime, single vehicle crashes.11 In a survey of fatally injured male drivers from 15 to 34 years of age in five California counties, one or more drugs were present in 81% of drivers tested.13 Adolescents (15 to 19 years old) accounted for 83 cases (19%); 35% of them had one drugand37% had two or more drugs in their system. As with adults, ethanol was the most prevalent drug in the teens (63%), while marijuana was present in 37% and cocaine in 4%. Fatally injured motorcyclists likewise have a high prevalence of a BAC greater than 0.1%, and about one quarter of adolescent pedestrians killed in the daytime and about one half of those killed at night are intoxicated.11
Finally, in relation to the road environment, it is necessary to emphasize the number of head and spinal cord injuries that occur. These injuries are particularly troubling because of the permanent sequelae that the survivors are left with and the high psychic and financial costs that accrue to the families of those injured. Over the last several years there have been multiple, detailed population-based studies of head and spinal cord injuries1419 (Table 4). The incidence of injuries severe enough to require admission range from 425 for females to 780 for males.5 Sixty percent of males and 69% of females admitted sustain head injuries; the peak incidence of these injuries is in preteens (5 to 9 year old females and 10 to 14 year old males). 19 In most of the studies, the incidence of head and spinal cord injury peaks in the adolescent and young adult age groups.4"6,18 Teens with head injuries frequently have long lengths of stay (mean 13.0 days) in acute care hospitals5; and about 4% of people of all ages with head injuries require transfer to long-term care facilities. 12 The direct and indirect costs of the care of these individuals is very high.19
High School Sports with High Injury Ratés
THE SCHOOL ENVIRONMENT AND SPORTS
Adolescents spend a large part of their day in the school environment; therefore, it is not surprising that from one third to one half of their injuries occur in that setting7 (Table 3). Fortunately, fatal injuries are very rare in the school setting.20'22 On the other hand, nonfatal injuries occur in secondary school students at a rate of 4.6/100 students/year for males and 2.9/100 students/year for females.20 The rate of serious injuries in the same study was 1.3/100 students/year; ie, most school injuries are minor. This was confirmed by Sheps et al22 who found that only 35% of injuries to secondary students were severe. As in most other environments, injuries in males exceed those in females. In one study, adolescent boys accounted for 30% of school injuries to children of all ages.21
Falls are the most common cause of injury in secondary schools and the most common injuries sustained are contusions, abrasions, or local swelling. Strains, sprains, and dislocations are also very frequent and the upper extremity is the body part most frequently injured by secondary school students.22 Head injuries occurring in school accounted for 26% of product-related head injuries in teens and about half of head injuries were related to sports or recreational equipment.23
School injuries may occur in the classroom, in shops and labs, on the playground, or in organized athletic events. Boyce et al21 found that the relative risk of injuries in athletics was 5.5 for students 14 or older and that athletics accounted for 44% of the school injuries in that age group.
Most of the available data on sports-related injuries have been summarized by Kraus and Conroy24 and by Gerberich.25 Football is clearly the most dangerous sport and one of the few with attendant mortality (5 to 10 deaths/year). This is a death rate of approximately 0.5/105 participants per year.25 About 80 out of 100 high school football players are injured per year. Other sports that have high injury rates among high school participants include wrestling, softball, gymnastics, basketball, soccer, track, and baseball (Table 5). As this list suggests, the incidence of severity of injury is greatest in collision sports and activities involving contact or having the potential for contact.25
In a study by Austin et al, cited by Kraus and Conroy,24 the rate of sports and recreation injuries varied from a low of 1.3/100 student years for ninth grade girls to a high of 5.2/100 student years for 12th grade boys. The ratio of male to female injuries was 3.7 in ninth grade, but declined to 0. 5 in 12th grade. The overall rates for the four years of high school were 3.7/100 student years for males and 3.5/100 student years for females, and the overall ratio of males to females injured was 1.1. In contrast, in a study of product-related injuries occurring in all environments, Rivara et al26 found a male to female ratio of 2.7 for sports equipment injuries in 13 to 18 year olds.
It must be recognized that all sports injuries do not occur at school, and with the exception of NEISS data on product-related injuries, there is no systematic data collection on sports injuries outside of school. In addition, the total number of individuals participating in a sport is often not known, making the calculation of injury rates impossible. It is known that 15 to 24 year olds have 27 emergency room visits/100,000 population for dance injuries, 66 emergency room visits/100,000 population for ice hockey injuries, and 45 medically treated injuries/100,000 population as a result of downhill skiing injuries.25
In the study by Gallagher and colleagues,8 7% of the teens hospitalized were admitted for sports-related injuries. Of all the teens injured, 19.9% were injured in football, 17.4% in basketball, 13.4% roller skating, and 9.4% in basketball.
THE HOME ENVIRONMENT
By age 15 to 24, the percent of injuries sustained in the home has declined to 22% for males, 39% for females, and 27% overall7 (Table 3). In 1985, there were approximately 1,400 deaths in the home environment among this age group.5 The leading causes of death were poisons; fires, burns, and deaths associated with fires, (ie, smoke inhalation); and firearms. In a study of poisoning hospitalizations and deaths from solid and liquids among children and teenagers in Maryland, Trinkoff and Baker27 found that 67% of 4,271 hospitalizations and 83% of 24 deaths were among adolescents 13 to 19 years old. Of those who died, about half were dead prior to reaching the hospl, tal; and those who were hospitalized, 58% had attempted suicide, fbisoning is one of the few types of injury where females exceed males in absolute numbers. However, in this study, among 13 to 19 year olds sustaining unintentional poisoning injuries who were admitted to the hospital, the injury rates were essentially the same: 15.4 males and 15.0 female. For those who were suicidal, the female rate was 89.5 versus 36. 1 for males; and women accounted for 66% of the cases. It should also be noted that nearly 25% of the cases could not be classed as either suicidal or unintentional. The American Association of Poison Control Centers collects data from 56 poison control centers.28 In 1984, there were 900,513 reported human exposures, which is estimated to represent 47.6% of human exposures. Children 13 to 17 accounted for 4.1% of all reports and 5.6% of reports in children. In this data set, 52.2% of the reports were of unintentional poisonings and 45.1% were of intentional poisonings. Only 21 fatal poisonings were reported and 22,406 (61.1%) of the exposures were rated to be of no effect or minor effect. On the basis of Trinkoff and Baker's study,27 there must be a major underreporting of fatal poisonings to poison control centers. The ten most frequent items involved in calls to poison control centers regarding 6 to 17 year olds are spiders, hydrocarbons, acetaminophen, chemicals of all types, cough and cold remedies, food, foreign bodies, ethanol, insecticides, and antibiotics.
In addition to poisonings by solids and liquids discussed above, poisoning occurs as a result of vapor or gases. Carbon monoxide in exhaust from motor vehicles is the most common agent in unintentional and suicidal poisoning deaths among people of all ages. The death rate for unintentional carbon monoxide poisoning peaks in 15 to 24 year olds, is more common among males, and occurs more often in low income areas.11
Firearms are generally thought of in terms of homicides and suicides; however, it is important to recognize that they are the third leading cause of fatal, unintentional injury in 10 to 19 year olds. The death rate for unintentional firearm injuries is highest among 13 to 17 year old boys; and there is little difference in death rates between black and white teenagers. Death rates are higher in poor and in rural areas.11 In North Carolina, Morris and Hudson29 found an unintentional firearm death rate of 7. 5 for 15 to 19 year olds. which was the highest for all age groups. They found that the largest percentage of deaths (28%) were hunting-related, and that 20% were due to "fooling around." Gallagher et al8 found firearm/explosive injury rates of 10/10,000 for males and 3/10,000 for females with 17% of these children requiring admission.
Tabulations of deaths usually list "fires, burns and deaths associated with fires. "5 Some of these deaths are due specifically to burns, but the majority are due to asphyxiation from carbon monoxide.11 On the other hand, tabulations of nonfatal injuries are truly bum injuries, and the most common are scalds, followed by flame, followed by chemical burns. There were about 300 deaths at home to 15 to 24 year olds in 1985 in the category of "fires, burns and deaths associated with fires."5 Death rates for teens from house fires are highest in Native Americans and blacks.11 Overall burn rates vary by community socioeconomic status30 and by sex (males ? females ).8,26,30 Teens are often burned in car fires, by steam from car radiators, and by acid from car batteries.7,11,30
THE FARM ENVIRONMENT
The farm environment has been separated out because it is a home environment, a work environment, and a recreational environment. The epidemiology of injuries occurring on the farm resemble the epidemiology of injuries occurring in each of these other environments. Rivara31 and Cogbill and associates32 have described the epidemiology of farm injuries in children.
Death rates for 15 to 19 year olds are greater for males (30.9) than females (1.3), and the rate of nonfatal injuries is very high (males 2,790, females 286). 31 Injuries are most likely to occur in the spring, summer, and fall. 31,32 Because it is often a long distance from a farm to the hospital, and because the injuries are frequently severe ones sustained on machinery, the children who die usually do so outside of the hospital (62.7%) or are dead on arrival (14.6%). 31 Nevertheless, of these injured, nearly 90% are treated and released.31 Cogbill et al32 found an 11% rate of very severe injuries and Ri vara31 found amputations and avulsions occurring at a rate of 725 and fractures and dislocations at a rate of 325. Many of the fatal and nonfatal injuries are related to machinery (Table 6); the tractor is the piece of equipment most often involved.31,32
Injuries are the major health problem of adolescents. Injuries are the leading cause of death in the adolescent age group and the leading cause of potentially productive years of life lost in the nation. Nonfatal injuries are also very common, generating frequent physician visits, hospital admission, and high medical care costs. The road is the most dangerous environment for teens where motor vehicle occupants, motorcyclists, pedestrians, and bicyclists all sustain frequent injuries. Alcohol and other drugs are often contributing factors to these injuries. Head and spinal cord injury result in many permanent disabilities. At school, children usually sustain nonfatal injuries in sports activities. Injuries at home are less common among adolescents than among younger children. The farm environment is an understudied, but dangerous environment. There is a need for standardization of data sets and age grouping within data sets to better understand the epidemiology of injuries in adolescents.
Mechanism of Farm Injury
1. Bass JL, Gallagher SS, Mehta KA: Injuries to adolescents and young adults. Pediotr CUn North Am 1985; 32:31-39.
2. HalperinSF, Bass JL, Mehta KA. et al: Unintentional injuries among adolescents and young adults: A review and analysis. J Adolesc Health Cart 1983; 4:175-181.
3. Dorlond's Illustrated Medical Dictionary, ed 26. Philadelphia. WBSaundersCo, 1985, ? 34.
4. Baker SP; Injuries: The neglected epidemic: Stone Lecture, 1985 American Trauma Society Meeting. J Trauma 1987; 27:343-348.
5. Accident Facts. Chicago, National Safety Council, 1987.
6. Center for Disease Control: Years of potential life lost, deaths and death rates, by cause of death, and estimated number of physician contacts by principle diagnosis. United States. MMVCR 1985; 34:761.
7. Fife D, Barancik JJ, Chatterjee BF: Northeastern Ohio Trauma Study: II: Injury rates by age, sex and cause. Am J Public Health 1984; 74:473-478.
8. Gallagher SS, Finison K, Guyer R, et al: The incidence of injuries among 87,000 Massachusetts children and adolescents: Results of the 1980-81 Statewide Childhood Injury Prevention Program Surveillance System. Am J Public Health 1984; 74:1340-1347.
9. Friedman IM: Alcohol and unnatural deaths in San Francisco youths. Pediatrics 1985; 76:191-193.
10. National Center for Health Statistics: Health, United States, 1985. DHHS Pub. No. (PHS) 86-1232. Public Health Service, Washington, US Government Printing Office. December 1985.
11. Baker SP. O'Neill B, Karpf RS: The Injun Fact Book. Lexington, MA. Lexington Books. 1984.
12. Smith JD, Buehler JW, Sikes RK. et al: Motorcycle associated fatalities in Georgia 1980-81. South Med) 1986; 79:291-294.
13. Williams AF, Pent MA, Crouch DJ, et al: Drugs in fatally injured male drivers. Pubüc Health Reports 1985; 100:19-25.
14. Kalsbeck WD, McLaurin RL, Harris BSH, et al: The national head and spinal cord injury survey: Major findings. J Neurosurg 1980; 53:S19-S31.
15. Klauber MR, Barrett-Connor E, Marshall LF, et al: The epidemiology of head injury: A prospective study of an entire community - San Diego County, California, 1978. Am J Epidemiol 1981; 113:500-509.
16. Kraus JF, Black MA, Hessol N, et al: The incidence of acute brain injury in a defined population. Am J Epidemiol 1984; 119:186-201.
17. Whitman S, Coonley-Hoganson R, Desai BT: Comparative head trauma experience in two socioeconomically different Chicago-area communities: A population study. Am J Epidemiol 1984: 119:570-580.
18. Fife D. Faich G, Hollineshead W, et al: Incidence and outcome of hospital-treated head injury in Rhode Island. AmJ Public Health 1986; 76:773-778.
19. Kraus JF, Fife D, Conroy C: Incidence, severity and outcome of brain injuries involving bicycles. AmJ Public Heath 1987; 77:76-78.
20. Feldman W, Woodward CA, Hodgson KC, et al: Prospective study of school injuries; Incidence, types, related factors, and initial management. Can Med Assoc J 1983: 129.1279-1283.
21. Boyce WT, Sprunger LW, Sobolewski S: Epidemiology of injuries in a large urban school district. Pediatrics 1984; 74:342-349.
22. Sheps SB. Evans GD: Epidemiology of school injuries; A 2-year experience in a municipal health department. Pediatrics 1987; 79:69-75.
23. Rivara F: Childhood injuries. HI: Epidemiology of non-motor vehicle head trauma. Dev Med Child Neurol 1984; 26:81-87.
24. Kraus JF. Conroy C: Mortality and morbidity from injuries in sports and recreation. Am Rev Public Health 1984; 5:165-192.
25. Gerberich SG: Sports injuries: Implications for prevention. Paper presented at the Conference on the Prevention of Injuries; Center for Environmental Health/Centers for Disease Control; Association of School of Public Health, Atlanta. GA. Oct. 15-17. 1984.
26. Rivara F. Bergman A, LoSerfo J: Epidemiology of childhood injuries. II. Sex differences in injury rates. Am J Dis Child 1982; 136:502-506.
27. Trinkoff AM, Baker SP: Poisoning hospitalizations and deaths from solids and liquids among children and teenagers. AmJ Public Health 1986; 76:657-660.
28. Litovitz TL, Norman SA, Veltri JC: 1985 Annual Report of the American Association of ftjison Control Center's National Data Collection System. Am ] Emerg Med 1986; 4:427-458.
29. Morrow PL, Hudson P: Accidental firearm'fàtalities in North Carolina, 1976-80. AmJ PuWc Health 1986; 76:1120-1123.
30. MacKay A1 Halpem J, McLoughlin E, et al: A comparison of age specific burn injury rates in five Massachusetts communities. AmJ Public Health 1979; 69:1146-1150.
31 . Rivara FP: Fatal and non-fatal farm injuries to children and adolescents in the United States. ftdiorrics 1985; 76:567-573.
32. Cogbill TH. Busch HM. Stiers GR: Farm accidenrs in children, ftdiarrics 1985; 76:562-566.
Causes of Death In United States- 1983
Ten Leading Causes of Death and Potentially Productive Years of Life Lost (PPYLL) United States
High School Sports with High Injury Ratés
Mechanism of Farm Injury