Childhood Injury Report 2011-2014
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Transcript of Childhood Injury Report 2011-2014
Injury and Violence Prevention BranchNorth Carolina Division of Public Health
July 2016
North Carolina Childhood Injury Report: 2011-2014
ChildhoodInjuriesinNorthCarolina:2011-2014
NorthCarolinaDivisionofPublicHealth–2016 1
N.C.ChildhoodInjuryReport:2011-2014
July2016
ElisabethClymerSocialClinicalResearchAssistantN.C.DivisionofPublicHealth
StateofNorthCarolinaPatrickMcCrory,Governor
DepartmentofHealthandHumanServices
RickBrajer,M.B.A.,Secretary
DivisionofPublicHealthRandallWilliams,M.D.,StateHealthDirector
InjuryandViolencePreventionBranch
www.injuryfreenc.ncdhhs.gov
NorthCarolinaDHHSisanequalopportunityemployerandprovider.
ChildhoodInjuriesinNorthCarolina:2011-2014
NorthCarolinaDivisionofPublicHealth–2016 2
Acknowledgements
ContributorsandReviewers
ScottK.Proescholdbell,M.P.H.Head,EpidemiologyandSurveillanceUnitInjuryandViolencePreventionBranchNorthCarolinaDivisionofPublicHealth
MaryBethCox,M.P.H.AlcoholEpidemiologistInjuryandViolencePreventionBranchNorthCarolinaDivisionofPublicHealth
KellaHatcher,J.D.ExecutiveDirectorNorthCarolinaChildFatalityTaskForceNorthCarolinaDivisionofPublicHealth
MegLangstonDirector,SafeKidsNorthCarolinaDeputyDirector,InjuryPreventionOfficeoftheStateFireMarshalNorthCarolinaDepartmentofInsurance
JessicaTufte,M.P.H.InjuryPreventionConsultantInjuryandViolencePreventionBranchNorthCarolinaDivisionofPublicHealth
WewishtoacknowledgetheUNCInjuryPreventionResearchCenter(IPRC)forhelpingtoestablishthereportingformatandcontent.
ChildhoodInjuriesinNorthCarolina:2011-2014
NorthCarolinaDivisionofPublicHealth–2016 3
TableofContents
1.OverviewofChildhoodInjuryinNorthCarolina:2011-2014.....................................4Introduction............................................................................................................................................................................4TheProblemofChildhoodInjury............................................................................................................................................6LeadingCausesofChildhoodInjury........................................................................................................................................7CausesofChildhoodUnintentionalInjury..............................................................................................................................8Deaths,Hospitalizations,andEmergencyDepartmentVisitsbyAgeandSex........................................................................9RegionalInjuryRates............................................................................................................................................................10HospitalizationChargesforChildhoodInjuriesfrom2011-2013..........................................................................................12
2.TypesofChildhoodInjury.......................................................................................13
2.1UnintentionalInjury..................................................................................................................................................13MotorVehicleInjury.............................................................................................................................................................13Suffocation............................................................................................................................................................................13Drowning..............................................................................................................................................................................15Fire/Burn...............................................................................................................................................................................16Falls.......................................................................................................................................................................................17Poisoning...............................................................................................................................................................................18Pedestrian.............................................................................................................................................................................19
2.2IntentionalInjury.......................................................................................................................................................20Assault...................................................................................................................................................................................20
2.3Self-Inflicted..............................................................................................................................................................22Suicide/Self-InflictedInjury.................................................................................................................................................22
3.ConclusionsandRecommendations.......................................................................24SummaryofStatistics...........................................................................................................................................................24Recommendations................................................................................................................................................................25
4.Appendix...............................................................................................................27AppendixA:DataSourcesandTechnicalNotes...................................................................................................................27AppendixB:InjuryPreventionResources.............................................................................................................................31
5.References.............................................................................................................32
ChildhoodInjuriesinNorthCarolina:2011-2014
NorthCarolinaDivisionofPublicHealth–2016 4
1.OverviewofChildhoodInjuryinNorthCarolina:2011-2014
IntroductionInjuryisthenumberonecauseofdeathamongchildrenintheUnitedStates[1].Injuriesaredefinedbyintentandoutcome:unintentionalorintentional,andfatalornonfatal.Unintentionalinjuryisconsistentlythenumberonecauseofdeathamongchildrenages1-18inboththestateofNorthCarolinaandnationally[2].InNorthCarolinaduringtheyear2014,therewere353deathsinthisagegroup,229ofwhichwereunintentionalinnature.Forthissamegroupnationally,therewere6,374deathsfromunintentionalinjury[3].Commoncausesofallunintentionalinjuriesaremotorvehiclecrashes,suffocation,drowning,fireandburns,falls,poisoning,andpedestrianinjuries.Thesearedistinctfromintentionalinjuries,whichareclassifiedashomicidesorassaultsandsuicidesorself-inflicted.TheCDCreports:
• OnechilddiesfrominjuryeveryhourintheUnitedStates[2].• Nearly20%(oneinfive)ofalldeathsamongchildrenareduetoinjury[2].• Everyfourseconds,achildistreatedforaninjuryinanemergencydepartmentintheUnitedStates[2].• Annually,anestimated9.2millionchildrenhaveemergencydepartmentvisitsforanunintentionalinjury
intheU.S.[4].• Thenationaleconomicburdencreatedbyunintentionalinjuries(allages)was$671billionin2013[5].
Thisreportprovidesanoverviewofthepublichealthburdenofinjuryinchildrenages0-18inthestateofNorthCarolina(N.C.).InanefforttoevaluateandunderstandthescopeoftheproblemofchildinjuryinN.C.,analyseswereperformedoninjury-relateddeathsfrom2011-2014,hospitalizationsfrom2011-2013,andemergencydepartmentvisitsfrom2013-2014.Eachcauseofinjurywasstratifiedbyageandsex.Injurydeaths,hospitalizations,andemergencydepartmentvisitrateswerecalculatedper100,000childrenresidinginthestate.AdetailedexplanationofthedataanalysisisprovidedinAppendixA.Dataforthisreporthasbeenobtainedfromthreesources:N.C.DivisionofPublicHealthdeathcertificatedata,N.C.HospitalDischargedata,andN.C.EmergencyDepartmentVisitdatahasbeenanalyzedseparatelyforthreeagegroups;0-4,5-9,10-14,and15-18.Thisreportisintendedtoincreasepublichealthpractitioners’andpolicymakers’understandingsofprevalent,yetpreventable,causesofinjuryandconsequentlydirectprogrammaticandpolicydecisionstodecreasetheburdenofchildhoodinjury.Thedatacanimproveprioritizationofinjurypreventionresources,assistresearcherswithsurveillance,andhelpphysicianseducatechildrenandparentsonpreventivemeasures.Thereportisanupdatetothe“N.C.ChildInjuryReport:2007-2010.”
ChildhoodInjuriesinNorthCarolina:2011-2014
NorthCarolinaDivisionofPublicHealth–2016 5
Theburdencausedbychildhoodinjurycanbebetterunderstoodfromthe“InjuryIceberg”inFigure1.Deathsfrominjuryaretherepresentedbythe“tipoftheiceberg”–asmallfraction,yetthemostvisible,ofthetotalnumberofchildhoodinjuryevents.Thesecondtieroftheicebergreferstohospitalizations,whicharemoreprevalentthandeathsbutstillunderestimatethe“true”numberofinjury-relatedevents.Thethirdlevelsignifiesemergencydepartment(ED)visitsasaresultofinjury.Thelarger,lowerlayersoftheicebergembodyunidentified,highfrequenciesofchildhoodinjuriesthatarenotrecordedaspartofroutinesurveillanceefforts.Suchinjuriesincludethoseseenandtreatedinoutpatientfacilitiesorthosewherenomedicalattentionissought.In2013,foreveryonechildhoodinjurydeath,therewere29hospitalizations,710emergencydepartmentvisits,andanunknown,butlikelyhigh,numberofoutpatientmedicalvisits.Evenmoreinjuriesgounreportedandunattended.
Figure1:InjuryIceberg,NorthCarolinaChildhoodInjuries,Ages0-18:Deaths,Hospitalizations,andED,2013.InjuryandViolencePreventionBranch,ChronicDiseaseandInjurySection,DivisionofPublicHealth.
IN J URY ICEBERGINJ URY ICEBERG
251 Deaths
7,314 Hospitalizations
178,283 EDVisits
? OutpatientVisits
? MedicallyUnattendedInjury
(Home,Work,School)
ChildhoodInjuriesinNorthCarolina:2011-2014
NorthCarolinaDivisionofPublicHealth–2016 6
TheProblemofChildhoodInjuryAmongNorthCarolinachildrenages0-18,injuriesresultedin1,068deaths(11.7per100,000)from2011-2014,22,775hospitalizations(332per100,000)from2011-2013,and352,049emergencydepartment(ED)visits(7,698per100,000)from2013-2014.Unintentionalinjuriescaused70%ofdeaths(Figure2),33%ofhospitalizations(Figure3),and69%ofEDvisits(Figure4).Figure2showsthat13%ofchildhooddeathsweretheresultofsuicide/self-inflictedinjury;15%resultedfromahomicide/assault;andtheremaining2%haveanundeterminedintentorresultedfromanothermechanism.AsdemonstratedinFigure3,theintentsofinjury-relatedhospitalizationsarewidespread.While19%ofhospitalizationsareself-inflicted,another19%aretheresultofundeterminedintent,and6%arefromotherintents.Assaultaccountsfor7%ofhospitalizationsbetween2011and2013,and6%ofhospitalizationcaseshadmissingorunknownintent.Whileunintentionalinjuryaccountedfor69%ofEDvisits,Figure4showsthat27%ofEDvisitshaveamissingorunknownintent.Theremaining4%ofEDvisitswereduetoassault(2%),otherintent(1%),andself-inflicted(1%)injuries.
15% 1%
13%
1%70%
Figure2:N.C.ChildInjuryDeathsbyIntent,Ages0-18:2011-2014(N=1,068)
AssaultOtherSelf-InflictedUndeterminedUnintenkonal
3%
25%
9%
1%
43%
19%
Figure3:N.C.ChildInjuryHospitalizaconbyIntent,Ages0-18:2011-2013(N=22,775)
Assault
Other
Self-Inflicted
Undetermined
Unintenkonal
Missing/Unknown
2% 1% 1%0%
69%
27%
Figure4:N.C.ChildInjuryEDVisitbyIntent,Ages0-18:2013-2014(N=352,049)
Assault
Other
Self-Inflicted
Undetermined
Unintenkonal
Missing/unknown
ChildhoodInjuriesinNorthCarolina:2011-2014
NorthCarolinaDivisionofPublicHealth–2016 7
LeadingCausesofChildhoodInjuryTheleadingcauseofinjury-relateddeathamongchildreninNorthCarolinafrom2011-2014wasmotorvehiclecrashes,accountingfor32%(n=343)ofdeaths.Adverseeffectscausedbyotherintentsweretheleadingcauseofinjury-relatedhospitalizations,accountingfor24%(n=5,543)admissionsfrom2011-2013,andunintentionalfallswerethesecondleadingtypeofinjuryforEDvisits,responsiblefor20%(n=71,203)visitsfrom2013-2014.Motorvehiclecrashesarethefourthleadingcauseofhospitalizations(6%,n=1,443)andthesixthleadingcause(5%,n=17,979)ofEDvisitsforchildrenages0-18.Fallswerethemechanismresponsiblefor10%(n=2,194)ofhospitalizationsand20%(n=71,203)ofEDvisits.Suffocationwasthemechanismunderlying11%(n=116)ofdeaths.Inregardstochildhoodinjuries,19%(n=4,334)ofhospitalizationsand27%(n=95,145)ofEDvisitshavebothunknowninjurymechanismsandunknownintent.Note:Alldeathdataisfrom2011-2014;hospitalizationdatafrom2011-2013;allEDvisitdatafrom2013-2014.
Table1:N.C.LeadingTypesofChildhoodInjuryDeaths,Ages0-18:2011-2014
InjuryType NumberofDeaths
MotorVehicle(Unintentional) 343
Suffocation(Unintentional) 116
Drowning(Unintentional)
95
Firearm(Assault) 81
Suffocation(Self-Inflicted) 70
Firearm(Self-Inflicted)
59
Poisoning(Unintentional)
38
Fire/Burn(Unintentional) 34
Unspecified(Assault) 25
OtherSpecified/Classified(Assault)
24
AllOtherCauses 183
Total 1,068
Table2:N.C.LeadingTypesofChildhoodInjuryHospitalizations,
Ages0-18:2011-2013
InjuryType NumberofAdmissions
AdverseEffects(Other) 5,543
UnknownCause(UnknownIntent) 4,334
Fall(Unintentional)
2,194
MotorVehicle(Unintentional) 1,448
Poisoning(Self-Inflicted) 1,309
Fire/Burn(Unintentional)
1,010
Poisoning(Unintentional)
844
OtherSpecified/Classified(Unint.) 768
Unspecified(Unintentional) 680
Natural/Environment(Unintentional)
595
AllOtherCauses 4,050
Total 22,775
Table3:N.C.LeadingTypesofChildhoodInjuryEDVisits,
Ages0-18:2013-2014
InjuryType NumberofVisits
UnknownCause(UnknownIntent) 95,145
Falls(Unintentional) 71,203
Struck(Unintentional)
43,760
Natural/Environment(Unintentional) 20,621
Unspecified(Unintentional) 18,117
MotorVehicle(Unintentional)
17,979
Overexertion(Unintentional)
16,132
OtherSpecified/Classified(Unint.) 15,096
Cut/Pierce(Unintentional) 13,518
Poisoning(Unintentional)
6,714
AllOtherCauses 33,764
Total 352,049
ChildhoodInjuriesinNorthCarolina:2011-2014
NorthCarolinaDivisionofPublicHealth–2016 8
CausesofChildhoodUnintentionalInjuryUnintentionalinjuriesaccountfor70%ofallchildhoodinjury-relateddeaths(Figure2).Theleadingcausesofunintentionalinjury-relatedmortalityaremotorvehiclecrashes(46%),suffocation(16%),anddrowning(13%)for2011-2014.Whileonly9%ofchildrenmortallysufferfromfall-relatedinjuries,fallsaretheleadingmechanismofchildhoodunintentionalinjury-relatedhospitalizations(22%)andEDvisits(29%).Injury-relatedhospitalizationsforchildrenages0-18werelargelycausedbyfalls(22%),motorvehiclecrashes(15%),fire/burn(10%),andpoisoning(9%).EDvisitswerelargelycausedbyfalls(29%),strikes*(18%),andnatural/environment(9%)factors.Notethat,whilemotorvehicle-relatedinjuriescausedlargeproportionsofchildhoodmortality(46%)andhospitalization(15%),motorvehiclecrasheswerethemechanismforonly7%ofEDvisits.
Table4:N.C.LeadingTypesofChildhoodUnintentionalInjuryDeaths,Ages0-18:2011-2014
UnintentionalInjuryType
NumberofDeaths
MotorVehicle 343
Suffocation 116
Drowning 95
Poisoning 38
Fire/Burn 34
Firearm 21
OtherLandTransport
15
Pedestrian(Other) 15
Natural/Environment 14
Unspecified 13
Fall 9
AllOtherCauses 32
Total 745
Table5:N.C.LeadingTypesofChildhoodUnintentionalInjury
Hospitalizations,Ages0-18:2011-2013
UnintentionalInjuryType
NumberofAdmissions
Fall 2,194
MotorVehicle 1,448
Fire/Burn 1,010
Poisoning 844
OtherSpecified/Classified 768
Unspecified 680
Natural/Environment
595
Struck 546
Transport(Other) 487
OtherSpecified/NotClassified
315
AllOtherCauses 930
Total 9,817
Table6:N.C.LeadingTypesofChildhoodUnintentionalInjuryED
Visits,Ages0-18:2013-2014
UnintentionalInjuryType
NumberofVisits
Fall 71,203
Struck 43,760
Natural/Environment 20,621
Unspecified 18,117
Motor-Vehicle 17,979
Overexertion 16,132
OtherSpecified/Classified 15,096
Cut/Pierce 13,518
Poisoning 6,714
OtherSpecified/NotClassified 5,841
AllOtherCauses 13,444
Total 242,425
*Strikeisdefinedas:beingstruckbyoragainstanobject;strikebythrown,projectedorfallingobject;accidentalstrikeagainstorbumpintoorbyanotherperson;crushed,pushed,orsteppedonbyacrowdorhumanstampede;orintentionalassault,self-harm,undeterminedintent,orlegalinterventionbybluntobjectorbodilyforce.Examplesofsuchobjectsaresportsequipment,automobileairbag,furniture,walls,andotherstationaryobjects.
ChildhoodInjuriesinNorthCarolina:2011-2014
NorthCarolinaDivisionofPublicHealth–2016 9
Deaths,Hospitalizations,andEmergencyDepartmentVisitsbyAgeandSexChildhoodinjurymortalityratesinN.C.aredisplayedbyageandsexinFigure5for2011-2014.Deathratesarehighestforadolescents,ages15-18,withmales’mortalityratemorethantwotimeshigherthanfemales’.Childrenages5-9hadthelowestmortalityratesamongsttheotheragegroups.Malesconsistentlyhavehighermortalityratesthanfemalesinallagegroupsforinjury-relateddeaths.Overall,0.01%oftheN.C.childpopulationdiedofinjuryfrom2011-2014.ThehospitalizationratesinFigure6showthatmaleshaveahigheradmissionratethanfemalesineveryagegroup.Thehighesthospitalizationratesareseenintheyoungestagegroup,0-4yearsold,andarefollowedbytheoldestagegroup,15-18yearsold.Contrarily,10-14yearoldshadthefewesthospitalizationsasaresultofinjury.OftheentireN.C.childhoodpopulationfrom2011-2013,0.33%werehospitalizedasaresultofaninjury.AsFigure7exemplifies,maleshadaconsistentlyhigherrateofEDvisitsthanfemales,forallagesin2013-2014.Amongmales,thehighestratewas10,699visitsper100,000males,ages15-18.Femalesofthesameagegrouphadarateof7,822visitsper100,000.Childrenages10-14hadthelowestratesformaleandfemaleEDvisitsinNorthCarolina.During2013-2014,8%ofthechildhoodpopulationvisitedtheEDvisitsforaninjury.
Note:29missingsex(Figure7)
9,5468,911
7,413
10,699
7,1686,251
5,329
7,822
0
2000
4000
6000
8000
10000
12000
0-4 5-9 10-14 15-18
Rateper100,000
Age
Figure7:N.C.ChildhoodInjuryEDVisitsbyAgeandSex,Ages0-18:2013-2014(n=352,049)
MaleFemale
509
308 280
377399
276224
287
0
100
200
300
400
500
600
0-4 5-9 10-14 15-18
Rateper100,000
Age
Figure6:N.C.ChildhoodInjuryHospitalizaconsbyAgesandSex,Age0-18:
2011-2013(n=22,775)
MaleFemale
Note:29missingsex(Figure7)
Note:2missingsex(Figure6)
16.8
5.99.1
35.9
13.6
3.1 4.9
15.0
0
10
20
30
40
0-4 5-9 10-14 15-18
Rateper100,000
Age
Figure5:N.C.ChildhoodInjuryDeathsbyAgeandSex,Age0-18:2011-2014(n=1068)
MaleFemale
Note:4missingage(Figure5)
ChildhoodInjuriesinNorthCarolina:2011-2014
NorthCarolinaDivisionofPublicHealth–2016 10
RegionalInjuryRatesFigure8illustratesthechildhoodinjuryratefordeaths(2011-2014),hospitalizations(2011-2013),andEDvisits(2013-2014)inthewestern,central(Piedmont)andeasternregionsofNorthCarolina.Theeasternregionhasthehighestratesofinjury-relateddeaths,hospitalizations,andEDvisits.Thecentralregionhadthelowestinjury-relateddeathrate,whilethewesternregionhadthelowestratesforinjury-relatedhospitalizationsandEDvisits.Thechildhoodinjury-relatedfatalityratewas15,11,and10deathsper100,000,intheeastern,western,andcentralregions,respectively.Thewesternregionhadthelowesthospitalizationrate(307per100,000),followedbythecentralregion(318per100,000)andtheeasternregion(370per100,000).ThewesternregionalsohadthelowestratesofEDvisits(7,022per100,000),whiletheeasternregionhadthehighestratesofchildhood,injury-relatedEDvisits(9216per100,000).
West Central EastDeathsper100,000 11 10 15Hospitalizationsper100,000 307 318 370EDvisitsper100,000 7,022 7,100 9,216
Pitt
Wake
Bladen
Duplin
Hyde
Bertie
Pender
Wilkes
Moore
Union
Halifax
Nash
Robeson
Surry
Onslow
Sampson
Iredell
Columbus
SwainBurke
Johnston
Ashe
Anson
Guilford
Randolph
Harnett
Brunswick
Jones
Wayne
Chatham
Macon
Rowan
Martin
Hoke
Stokes
LeeStanly
Lenoir Craven
Granville
Franklin
Tyrrell
Warren
BuncombeHaywood
Davidson
Person
Jackson
Gates
Dare
Carteret
CaswellForsyth
Caldwell
Beaufort
Cumberland
MadisonOrange
Rutherford
Wilson
Polk
Yadkin
GastonCherokee
Rockingham
Catawba
Richmond
Davie
McDowell
Hertford
Cleveland
Northampton
Clay
Vance
Avery
Mecklenburg
Alamance EdgecombeYancey
Montgomery
PamlicoCabarrus
Durham
GrahamGreene
Scotland
Watauga
Henderson
Washington
Transylvania
Camden
Alexander
CurrituckAlleghany
Chowan
New Hanover
FIGURE 8: North Carolina Childhood Injury Rates by Region, Ages 0-18 Deaths (n=1,064): 2011-2014, Hospitalizations (n=22,775): 2011-2013 and
ED Visits (n=352,049): 2013-2014
LEGEND: West Central/Piedmont East
ChildhoodInjuriesinNorthCarolina:2011-2014
NorthCarolinaDivisionofPublicHealth–2016 11
Comparison to the United States and Comparison over Time
Thechildhoodinjury-relatedmortalityratesinNorthCarolinaandtheUnitedStatesfollowedsimilartrendsfrom1999-2013.In2013-2014,thechildhoodinjury-relateddeathrateinN.C.increased(13.4to14.6deaths/100,000children)whilethenationalmortalityrateplateaued(13.1deaths/100,000children).Throughoutthe15yearperiodinFigure9,N.C.hadaconsistentlyhigherinjury-relatedrateofdeathforchildrenages0-18thantheratefortheentireU.S.
Assaultandmotorvehicleinjuriesweretheleadingcausesofinjury-relateddeathfor0-18yearoldsintheU.S.andN.C.from2011-2014.N.C.’schildhoodmortalityrateformotorvehiclecrashes(4.98deaths/100,000children)wasgreaterthanthenationalrate(3.73deaths/100,000children).N.C.’smortalityratefordrowningandpoisoningalsoexceededtheU.S.’mortalityrates.However,theU.S.hadahigherassaultmortalityrate(4.6deaths/100,000children)thanN.C.(4.3deaths/100,000children)duringthesametimeperiod.NationalchildhoodmortalityrateswerealsogreaterthanN.C.’sratesforsuicide,suffocation,fire/burn,andpedestrian(other)injuries.
Note:AlltypesofinjuryinFigure10areunintentional,unlessotherwiseindicated.RatesfromWISQARSareage-adjustedandcomparabletonationalrates.
4.304.98
1.991.22 1.19
0.640.35 0.20
4.60
3.73
2.111.55
1.100.56 0.37 0.22
0
1
2
3
4
5
6
Assault(Intenkonal)
MotorVehicle Self-Inflicted(Suicide)
Suffocakon Drowning Poisoning Fire/Burn Pedestrian-Other
Ratesp
er100
,000
Figure10:ChildInjuryDeathRatesinNorthCarolinaandtheUnitedStatesbyTypeofInjury,Ages0-18:2011-2014
NorthCarolinaRateU.S.Rate
0
5
10
15
20
25
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Rateper100
,000
Figure9:ChildInjuryDeathRatesintheUnitedStatesandNorthCarolina,Ages0-18:1999-2014
NorthCarolinaRate U.S.Rate
ChildhoodInjuriesinNorthCarolina:2011-2014
NorthCarolinaDivisionofPublicHealth–2016 12
HospitalizationChargesforChildhoodInjuriesfrom2011-2013Between2011and2013,hospitalizationsfromchildhoodinjuriesinNorthCarolinageneratednearly$842millioninmedicalandeconomicexpenses.ReferringtoFigure11,unintentionalchildhoodinjurieswerethecauseof34%($289million)oftotalhospitalizationcharges.Assaultandself-inflictedinjurieseachaccountedfor3%oftotalcharges.Figure12reflectstheeconomicburdenofunintentionalmotorvehiclecrashes,falls,andfireandburninjuriesonchildrenandtheirfamilies.MedianchargesinFigure13estimatethechargeperinjuryforspecifictypesofchildhoodinjury.Disparitiesinmedianchargescanbeattributedtodifferencesineachpatient’scase,includingtheextentoftrauma,typesofproceduresandtreatments,andlengthofhospitalstay.Firearm(assault,self-inflicted,andunintentional)injurieshavethemostexpensivemedianhospitalizationchargespercase,followedbymotorvehiclecrashes.Thesechargesprovideanestimateofthefinancialtollofthemedicalcarerequiringhospitalizationforchildhoodinjuries,butdonotaccountfortheindirectcostsofchildhoodinjurythatcontributetoagreaterburdenonchildrenandtheirfamilies.Suchindirectcostsincludelostproductivityandadecreasedqualityoflife.Note:Int=intentionalinjury;Unint=unintentionalinjury;Self-Infl=self-inflictedinjury.
$841.9
$495.5
$289.3
$26.4 $23.8 $6.9$0
$100$200$300$400$500$600$700$800$900
Millions
Figure11:TotalHospitalizaconChargesforChildhoodInjuriesinN.C.,Age0-18:2011-2013
$80.5
$42.0
$29.1$20.0
$13.2 $9.9 $9.6 $9.5
$0$10$20$30$40$50$60$70$80$90
Millions
Figure12:TotalHospitalizaconChargesforChildhoodInjuryinN.C.byTypeofInjury,
Age0-18:2011-2013
$42.5$38.4
$35.6 $33.4
$20.2 $19.9 $18.4 $16.8
$0$5
$10$15$20$25$30$35$40$45
Thou
sand
s
Figure13:MedianHospitalizaconChargesforChildhoodInjuryinN.C.byTypeofInjury,
Age0-18:2011-2013
ChildhoodInjuriesinNorthCarolina:2011-2014
NorthCarolinaDivisionofPublicHealth–2016 13
2.TypesofChildhoodInjury2.1UnintentionalInjuryMotorVehicleInjury AmongchildhoodinjuriesinN.C.,motorvehiclecrashesweretheleadingcause(32%)ofmortality,thefourthleadingcause(6%)ofhospitalizations,andthesixthoverallcause(5%)ofEDvisits.AsseeninFigures14,15,and16,childhoodinjuriescausedbymotorvehiclecrashesresultedin:343deaths(3.7per100,000children)from2011-2014,1,448hospitalizations(21per100,000children)form2011-2013,and17,979EDvisits(393per100,000children)from2013-2014.Motorvehiclecrashes’hospitalizationchargestotaled$80.5millionfrom2011-2013.Motorvehicleinjurieswerethehighestmechanismfortotalhospitalizationchargesandthefourth-highestmechanismformedianhospitalizationchargesat$33,392,withanaveragechargeof$55,619,asshowninTable7.Childrenages15-18aresignificantlymoreaffectedbymotorvehicleinjuriesindeaths,hospitalizations,andEDvisits.Notethedistinctcorrelationbetweennovicedrivingagesandratesofincidence.Additionally,maleshavethehighestmortalityandhospitalizationrates,whilefemaleshavethehighestEDvisitrates.
Table7:EstimatedHospitalizationChargesResultingfromChildhoodUnintentional
MotorVehicleInjuriesinN.C.,Age0-18:2011-2013
TotalCharges $80,536,090MedianCharges $33,392AverageCharge $55,619
166.8
270.9
374.0
582.2
430.9356.5
0
100
200
300
400
500
600
0-4 5-9 10-14 15-18 Female Male
Rateper100,000
Figure16:N.C.ChildhoodUnintenconalMotorVehicleEDVisitsbyAgeandSex,Ages0-18:2013-2014(n=17,979)
2.71.9 2.2
11.2
3.24.3
0
2
4
6
8
10
12
0-4 5-9 10-14 15-18 Female Male
Rateper100,000
Figure14:N.C.ChildhoodUnintenconalMotorVehicleDeathsbyAgeandSex,Ages0-18:2011-2014(n=343)
10.714.7 15.2
59.3
18.323.8
0
10
20
30
40
50
60
0-4 5-9 10-14 15-18 Female Male
Rateper100,000
Figure15:N.C.ChildhoodUnintenconalMotorVehicleInjuryHospitalizaconsbyAgeandSex,
Ages0-18:2011-2013(n=1448)
Note:10missingsex(Figure16)
ChildhoodInjuriesinNorthCarolina:2011-2014
NorthCarolinaDivisionofPublicHealth–2016 14
Suffocation AmongchildhoodinjuriesinN.C.,unintentionalsuffocationwasthesecondleadingcause(11%)ofmortality,caused1%ofhospitalizations,and0.1%ofEDvisits.AsseeninFigures17,18,and19,childhoodinjuriescausedbysuffocationresultedin:116deaths(1.3per100,000children)from2011-2014,185hospitalizations(2.7per100,000children)from2011-2013,and352EDvisits(7.7per100,000children)from2013-2014.Suffocationinjuries’hospitalizationchargestotaled$9.5millionfrom2011-2013.Suffocationwastheeighthleadingmechanismforbothtotalandmedianhospitalizationchargesandhadanaveragechargeof$51,398,asshowninTable8.Childrenages0-4aremoreaffectedbysuffocationinjuriesindeaths,hospitalizations,andEDvisits.Infantsandyoungchildrenaresignificantlymoresusceptibletosuffocation.Additionally,maleshavethehighestmortalityandhospitalizationrates,whilefemaleshavethehighestEDvisitratesforsuffocationinjuries.
Table8:EstimatedHospitalizationChargesResultingfromChildhoodUnintentional
SuffocationInjuriesinN.C.,Ages0-18:2011-2013
TotalCharges $9,508,653MedianCharges $16,817AverageCharge $51,398
4.2
0.3 0.1 0.2
1.1 1.4
0
1
2
3
4
5
6
0-4 5-9 10-14 15-18 Female Male
Rateper100,000
Figure17:N.C.ChildhoodUnintenconalSuffocaconDeathsbyAgeandSex,
Ages0-18:2011-2014(n=116)
7.1
1.2 1.12.3
3.2
0
2
4
6
8
10
0-4 5-9 10-14 15-18 Female Male
Rateper100,000
Figure18:N.C.ChildhoodUnintenconalSuffocaconHospitalizaconsbyAgeandSex,
Ages0-18:2011-2013(n=185)
24.3
2.91.0 0.4
7.9 7.5
0
5
10
15
20
25
0-4 5-9 10-14 15-18 Female Male
Rateper100,000
Figure19:N.C.ChildhoodUnintenconalSuffocaconEDVisitsbyAgeandSex,
Ages0-18:2013-2014(n=352)
Note:Datasuppressedifn<10(Figure18)
ChildhoodInjuriesinNorthCarolina:2011-2014
NorthCarolinaDivisionofPublicHealth–2016 15
Drowning AmongchildhoodinjuriesinN.C.,drowningwasthethirdleadingcause(8.9%)ofmortalityandresponsiblefor0.5%ofhospitalizationsand0.05%EDvisits.AsseeninFigures20,21,and22,Childhoodinjuriescausedbydrowningresultedin:95deaths(1.0per100,000children)from2011-2014,119hospitalizations(1.7per100,000children)from2011-2013,and173EDvisits(3.8per100,000)from2013-2014.Drowninginjuries’hospitalizationchargestotaled$4.1millionfrom2011-2013.Drowningwasthe10thleadingmechanismfortotalhospitalizationchargesand13thleadingmechanismformedianhospitalizationcharges,withamedianchargeof$9,474andanaveragechargeof$34,129,asreferencedinTable9.Childrenages0-4aremostaffectedbydrowninginjuriesindeaths,hospitalizations,andEDvisits.Infantsandyoungchildrenaresignificantlymoresusceptibletodrowning.Additionally,maleshavegreatermortality,hospitalization,andEDvisitratesthanfemalesfordrowninginjuries.
Table9:EstimatedHospitalizationChargesResultingfromChildhoodUnintentional
DrowningInjuriesinN.C.,Ages0-18:2011-2013
TotalCharges $4,061,386MedianCharges $9,474AverageCharge $34,129
2.1
0.4 0.7 0.90.5
1.5
0
1
2
3
4
5
6
0-4 5-9 10-14 15-18 Female Male
Rateper100,000
Figure20:N.C.ChildhoodUnintenconalDrowningDeathsbyAgeandSex,
Ages0-18:2011-2014(n=95)
4.1
0.9 0.7 1.1 1.32.1
0
2
4
6
8
10
0-4 5-9 10-14 15-18 Female Male
Rateper100,000
Figure21:N.C.ChildhoodUnintenconalDrowningHospitalizaconsbyAgeandSex,Ages0-18:2011-2013(n=119)
8.6
2.4 1.8 1.13.0
4.5
0
5
10
15
20
25
0-4 5-9 10-14 15-18 Female Male
Rateper100,000
Figure22:N.C.ChildhoodUnintenconalDrowningEDVisitsbyAgeandSex,
Ages0-18:2013-2014(n=173)
Note:1missingsex(Figure21)
ChildhoodInjuriesinNorthCarolina:2011-2014
NorthCarolinaDivisionofPublicHealth–2016 16
Fire/Burn AmongchildhoodinjuriesinN.C.,fire/burnsweretheeighthleadingcause(3%)ofmortality,thesixthleadingcause(4%)ofhospitalizations,andthe14thoverallcause(1%)ofEDvisits.AsseeninFigures23,24,and25,childhoodinjuriescausedbyfire/burnsresultedin:34deaths(0.4per100,000children)from2011-2014,1,010hospitalizations(14.7per100,000children)from2011-2013,and3,820EDvisits(83.5per100,000children)from2013-2014.Fireandburns’hospitalizationchargestotaled$29.1millionfrom2011-2013.Fireandburninjurieswerethethird-highestmechanismfortotalhospitalizationchargesandtheseventh-highestmechanismformedianhospitalizationchargesat$18,436,withanaveragechargeof$28,792,asshowninTable10.Childrenages0-4aremostaffectedbyfireandburnsinhospitalizationsandEDvisits,andareequallyaffectedaschildrenages5-9indeath.Additionally,maleshavethehigherratesthanfemalesformortality,hospitalizations,andEDvisitsrelatedtofireandburninjuries.
Table10:EstimatedHospitalizationChargesResultingfromChildhoodFire/Burn
UnintentionalInjuriesinN.C.,Ages0-18:2011-2013
TotalCharges $29,079,886MedianCharges $18,436AverageCharge $28,792
33.0
9.2 7.0 7.212.2
17.1
0
10
20
30
40
50
60
0-4 5-9 10-14 15-18 Female Male
Rateper100,000
Figure24:N.C.ChildhoodUnintenconalFire/BurnHospitalizaconsbyAge&Sex,Ages0-18:2011-2013(n=1010)
163.9
57.9 43.9 38.678.1 88.7
0
100
200
300
400
500
600
0-4 5-9 10-14 15-18 Female Male
Rateper100,000
Figure25:N.C.ChildhoodUnintenconalFire/BurnEmergencyDepartmentVisitsbyAge&Sex,Ages
0-18:2013-2014(n=3820)
0.5 0.5 0.3 0.0 0.3 0.4
0
1
2
3
4
5
6
0-4 5-9 10-14 15-18 Female Male
Rateper100,000
Figure23:N.C.ChildhoodUnintenconalFire/BurnDeathsbyAge&Sex,
Ages0-18:2011-2014(n=34)
ChildhoodInjuriesinNorthCarolina:2011-2014
NorthCarolinaDivisionofPublicHealth–2016 17
Falls AmongchildhoodinjuriesinN.C.,fallsarethesecondleadingcause(20%)ofEDvisits,andthethirdleadingcause(10%)ofhospitalizations.AsseeninFigures26,27,and28,childhoodinjuriescausedbyfallsresultedin:9deaths(0.1per100,000children)from2011-2014,2,194hospitalizations(32per100,000children)from2011-2013,and71,203EDvisits(1,557per100,000children)from2013-2014.Hospitalizationchargesresultingfromfallstotaled$42millionfrom2011-2013.Fallinjurieswerethesecond-highestmechanismfortotalhospitalizationchargesandtheseventh-highestmechanismformedianhospitalizationchargesat$13,986,withanaveragechargeof$19,137,asshowninTable11.Childrenages0-4aremostaffectedbyfallinjuriesinhospitalizationandEDvisits,whileadolescentsages15-18sufferthemostdeathsfromunintentionalfalls.However,childrenofallagessufferinjuriesfromfallsthatresultinEDvisits,hospitaladmissionsandmortality.Additionally,malesaremoresusceptibletofallinjuriesthanfemales.
Table11:EstimatedHospitalizationChargesResultingfromChildhoodUnintentionalFall
InjuriesinN.C.,Ages0-18:2011-2013
TotalCharges $41,967,724MedianCharges $13,986AverageCharge $19,137
45.4
30.824.6 24.7 22.4
41.2
0
10
20
30
40
50
60
0-4 5-9 10-14 15-18 Female Male
Rateper100,000
Figure27:N.C.ChildUnintenconalFallInjuryHospitalizaconsbyAgeandSex,Ages0-18:2011-2013(n=2194)
2,189
1,473 1,3511,039
1,385
1,795
0
500
1000
1500
2000
2500
0-4 5-9 10-14 15-18 Female Male
Rateper100,000
Figure28:N.C.ChildUnintenconalFallInjuryEDVisitsbyAgeandSex,
Ages0-18:2013-2014(n=71,200)
0.1 0.0 0.1 0.3 0.0 0.20
1
2
3
4
5
6
0-4 5-9 10-14 15-18 Female Male
Rateper100,000
Figure26:N.C.ChildUnintenconalFallInjuryDeathsbyAgeandSex,
Ages0-18:2011-2014(n=9)
ChildhoodInjuriesinNorthCarolina:2011-2014
NorthCarolinaDivisionofPublicHealth–2016 18
Poisoning AmongchildhoodinjuriesinN.C.,unintentionalpoisoningwastheseventhleadingcauseofbothmortality(4%)andhospitalizations(4%),andthe10thoverallcause(2%)ofEDvisits.AsseeninFigures29,30,and31,childhoodinjuriescausedbyunintentionalpoisoningresultedin:38deaths(0.4per100,000children)from2011-2014,844hospitalizations(12.3per100,000children)from2011-2013,and6,714EDvisits(146.8per100,000children)from2013-2014.Unintentionalpoisonings’hospitalizationchargestotaled$10millionfrom2011-2013.Poisoninginjurieswerethesixth-highestfortotalhospitalizationchargesandthe15thrankedmechanismformedianhospitalizationchargesat$6,368,withanaveragechargeof$11,711,asshowninTable12.Childrenages15-18andmalessufferedthemostfatalitiesasaresultofunintentionalpoisoning.Childrenages0-4weredramaticallymoreaffectedbypoisoninginhospitalizationsandEDvisits.Additionally,maleshadslightlyhigherratesofincidenceforhospitalizationsandEDvisits.Table12:EstimatedHospitalizationChargesResultingfromChildhoodUnintentional
PoisoningInjuriesinN.C.,Ages0-18:2011-2013
TotalCharges $9,872,467MedianCharges $6,368AverageCharge $11,711
0.2 0.1 0.2
1.5
0.2 0.6
0
1
2
3
4
5
6
0-4 5-9 10-14 15-18 Female Male
Rateper100,000
Figure29:N.C.ChildhoodUnintenconalPoisoningDeathsbyAgeandSex,
Ages0-18:2011-2014(n=36)
26.4
4.4 5.2
14.8 11.8 12.8
0
10
20
30
40
50
60
0-4 5-9 10-14 15-18 Female Male
Rateper100,000
Figure30:N.C.ChildhoodUnintenconalPoisoningHospitalizaconsbyAgeandSex,
Ages0-18:2011-2013(n=844)
346.7
81.3 59.8 50.5
140.2 153.2
0
100
200
300
400
500
600
0-4 5-9 10-14 15-18 Female Male
Rateper100,000
Figure31:N.C.ChildhoodUnintenconalPoisoningEDVisitsbyAgeandSex,Ages0-18:2013-2014(n=6,714)
ChildhoodInjuriesinNorthCarolina:2011-2014
NorthCarolinaDivisionofPublicHealth–2016 19
Pedestrian AmongchildhoodinjuriesinN.C.,unintentionalpedestrianinjurieswerethefourteenth-rankedcause(1%)ofmortality,the28thcause(0.2%)ofhospitalization,andthe25thoverallcause(0.1%)ofEDvisits.AsseeninFigures32,33,and34,childhoodinjuriescausedbypedestrianinjuriesresultedin:15deaths(0.2per100,000children)from2011-2014,50hospitalizations(0.2per100,000children)from2011-2013,and191EDvisits(191per100,000children)from2013-2014.Pedestrianinjuries’hospitalizationchargestotaled$2.1millionfrom2011-2013,the12thhighestmechanismfortotalhospitalizationcharges,andthefifth-highestmechanismformedianhospitalizationchargesat$20,187,withanaveragechargeof$42,312,asshowninTable13.Childrenages0-4aremostaffectedbypedestrianinjuriesindeathsandhospitalizations.Childrenages0-9areequallyaffectedbypedestrianinjuriesinEDvisits.MaleshavethehighestratesofhospitalizationandEDvisits,whilefemaleshaveahighermortalityrate.
Table13:EstimatedHospitalizationChargesResultingfromChildhoodUnintentional
PedestrianInjuriesinN.C.,Ages0-18:2011-2013
TotalCharges $2,115,597MedianCharges $20,187AverageCharge $42,312
0.50.0 0.0 0.2 0.2 0.1
0
1
2
3
4
5
6
0-4 5-9 10-14 15-18 Female Male
Rateper100,000
Figure32:N.C.ChildUnintenconalPedestrianInjuryDeathsbyAgeandSex,Ages0-18:2011-2014(n=15)
1.2 0.8 0.3 0.5 0.5 0.9
0
2
4
6
8
10
0-4 5-9 10-14 15-18 Female Male
Rateper100,000
Figure33:N.C.ChildUnintenconalPedestrian-RealtedInjuryHospitalizaconsbyAgeandSex,
Ages0-18:2011-2013(n=50)
4.3 4.3 4.1 3.8 2.85.7
0
5
10
15
20
25
0-4 5-9 10-14 15-18 Female Male
Rateper100,000
Figure34:N.C.ChildUnintenconalPedestrianInjuryEDVisitsbyAgeandSex,Ages0-18:2013-2014(n=191)
ChildhoodInjuriesinNorthCarolina:2011-2014
NorthCarolinaDivisionofPublicHealth–2016 20
2.2IntentionalInjuryAssault AmongchildhoodinjuriesinN.C.,assaultwasthesecondleadingoverallcause(15%)ofmortality,thefifthleadingcause(7%)ofhospitalization,andthethirdleadingcause(2%)ofEDvisits.AsseeninFigures35,36,and37,Childhoodinjuriescausedbyassaultresultedin:159deaths(1.7per100,000children)from2011-2014,712hospitalizations(10.4per100,000children)from2011-2013,and5,201EDvisits(113.7per100,000children)from2013-2014.Assaultistheintentunderlying3%oftotalhospitalizationcharges,withatotalof$26millionfrom2011-2013.Assaultinflictedbyfirearmswasninth-leadingmechanismfortotalhospitalizationchargesandtheleadingmechanismformedianhospitalizationchargesat$42,466,withanaveragechargeof$64,542,asshowninTable14.Childrenages0-14and15-18havethehighestmortalityandhospitalizationrates,withthe15-18yearoldagegroupbeingmostaffected.Additionally,malesaremoreaffectedbyassaultinjuriesthanfemales,asexemplifiedbyamortalityratemorethandoublethatoffemales.
Table14:EstimatedHospitalizationChargesResultingfromChildhoodAssaultInjuriesin
N.C.,Ages0-18:2011-2013
TotalCharges $6,066,982MedianCharges $42,466AverageCharge $64,542
2.8
0.4 0.6
4.3
1.1
2.4
0
1
2
3
4
5
6
0-4 5-9 10-14 15-18 Female Male
Rateper100,000
Figure35:N.C.ChildhoodIntenconalAssaultInjuryDeathsbyAgeandSex,Ages0-18:2011-2014(n=159)
19.3
2.2 4.0
20.5
8.012.7
0
10
20
30
40
50
60
0-4 5-9 10-14 15-18 Female Male
Rateper100,000
Figure36:N.C.ChildhoodIntenconalAssaultInjuryHospitalizaconsbyAgeandSex,
Ages0-18:2011-2013(n=712)
30.5 33.4
127.1
360.4
93.8132.8
0
100
200
300
400
500
600
0-4 5-9 10-14 15-18 Female Male
Rateper100,000
Figure37:N.C.ChildhoodIntenconalAssaultInjuryEDVisitsbyAgeandSex,Ages0-18:2013-2014(n=5,201)
ChildhoodInjuriesinNorthCarolina:2011-2014
NorthCarolinaDivisionofPublicHealth–2016 21
Injuriesresultingfromassaultaccountedfor15%ofoverallchildhoodinjury-relatedmortality,atarateof1.7deathsper100,000childrenfrom2011-2014.Theleadingcausesofassaultdeathsarefirearms(50%),unspecified(16%)andotherspecified/classified(15%).Hospitalizationsfromassaultonlyaccountedfor3%ofadmissionsfrom2011to2013,occurringatarateof10.4per100,000children.Theotherspecified/classifiedmechanism(44%)wastheleadingcausesofassaulthospitalizations,followedbyunspecified(13%),otherspecified/notclassified(12%),andstriking(10%).Assaultwasresponsiblefor1%ofEDvisitsfrom2013-2014,witharateof113.7visitsper100,000children.OfassaultEDvisits,theleadingmechanismsofassaultwerestriking(49%),otherspecified(bothclassifiedandnotclassified,31%),unspecified(14%),cutorpiercing(3%),andfirearms(2%).Whilefirearmsarealeadingmechanismforbothassaultmortalityandhospitalizations,therewereatotalof268assaultinjuriesinvolvingfirearms.Incontrast,therewere2,607injuriesfromstrikingand206injuriesfromacutorpiercing.
Table15:N.C.TypesofChildhoodAssaultInjury
Deaths,Ages0-18:2011-2014
InjuryType NumberofDeaths
Firearm 80
Unspecified 25
OtherSpecified/Classified 24
Cut/Pierce 10
Suffocation 9
OtherSpecified/NEC* 5
Poisoning 3
Drowning 1
Struck 1
Fire/Burn 1
Total 159
Table16:N.C.TypesofChildhoodAssaultInjury
Hospitalizations,Ages0-18:2011-2013
InjuryType NumberofAdmissions
OtherSpecified/Classified 313
Unspecified 96
Firearm 94
OtherSpecified/NotClassified 85
Struck 68
Cut/Pierce 36
Fire/Burn 12
Poisoning 5
Suffocation 2
Fall 1
Total 712
Table17:N.C.TypesofChildhoodAssaultInjuryEDVisits,Ages0-18:2013-2014
InjuryType NumberofVisits
Struck 2,538
OtherSpecified/NotClassified 855
OtherSpecified/Classified 775
Unspecified 746
Cut/Pierce 160
Firearm 84
Suffocation 14
Fire/Burn 13
Fall 7
Poisoning 7
MotorVehicle 2
Total 5,201
Note:NEC=notelsewhereclassified.
ChildhoodInjuriesinNorthCarolina:2011-2014
NorthCarolinaDivisionofPublicHealth–2016 22
2.3Self-InflictedSuicide/Self-InflictedInjury AmongchildhoodinjuriesinN.C.,self-inflictedinjurieswerethethirdleadingoverallcause(13%)ofmortality,thesecondleadingcause(19%)ofhospitalization,andthefourthleadingcause(1%)ofEDvisits.Childhoodinjuriescausedbyself-inflictionresultedin:136deaths(1.5per100,000children)from2011-2014,2,086hospitalizations(30.4per100,000children)from2011-2013,and3,136EDvisits(68.6per100,000children)from2013-2014.Self-inflictionistheintentresponsiblefor3%ofallinjuryhospitalizationcharges,totalingat$24millionfrom2011-2013.Self-harmbyintentionaldrugpoisoningisthefifthleadingmechanismfortotalhospitalizationcharges;whileself-harmbyfirearmisthesecond-highestmechanismformedianhospitalizationcharges.Thoughchildrenages10-14sufferfromself-inflictedinjuries,ages15-18aremostaffectedbyself-inflictedinjuriesindeaths,hospitalizations,andEDvisits.Additionally,maleshavehighestmortalityrate,whilefemaleshavethehighesthospitalizationandEDvisitratesforself-inflictedinjuries.
Table18:EstimatedHospitalizationChargesResultingfromIntentionalSelf-Inflicted
InjuriesinChildreninN.C.,Ages0-18:2011-2013
TotalCharges $23,766,677MedianCharges $8,722AverageCharge $11,393
0.0 0.0
1.9
5.7
0.9
2.1
0
1
2
3
4
5
6
0-4 5-9 10-14 15-18 Female Male
Rateper100,000
Figure38:N.C.ChildhoodSuicidesbyAgeandSex,Ages0-18:2011-2014(n=136)
0.4 0.7
38.0
117.3
44.7
16.8
0
20
40
60
80
100
120
0-4 5-9 10-14 15-18 Female Male
Rateper100,000
Figure39:N.C.ChildhoodIntenconalSelf-InflictedInjuryHospitalizaconbyAgeandSex,
Ages0-18:2011-2013(n=2086)
1.2 2.886.9
256.7
102.036.5
0
100
200
300
400
500
600
0-4 5-9 10-14 15-18 Female Male
Rateper100,000
Figure40:N.C.ChildhoodIntenconalSelf-InflictedInjuryEDVisitsbyAgeandSex,Ages0-18:2013-2014(n=3136)
ChildhoodInjuriesinNorthCarolina:2011-2014
NorthCarolinaDivisionofPublicHealth–2016 23
Injuriesresultingfromintentionalself-inflictionsaccountedfor13%ofoverallchildhoodinjuryrelatedmortality,atarateof1.5deathsper100,000childrenfrom2011to2014.Themostprevalentmethodsofsuicidearesuffocation(51%)andfirearms(43%).Hospitalizationsfromself-inflictionsaccountedfor9%ofadmissionsfrom2011to2013,occurringatarateof30.4per100,000children.Poisoning(63%)wastheleadingcauseofintentionalself-inflictedhospitalizations,followedbycutorpiercing(19%)andunspecified(13%).Intentionalself-inflictedinjuriescaused1%ofEDvisitsfrom2013-2014,atarateof68.6visitsper100,000children.Ofintentionallyself-inflictedEDvisits,theleadingmechanismswerepoisoning(63%)andcutandpiercing(33%).Poisoningandcutsandpiercingwerethemostfrequentlyutilizedmechanismsforintentionallyself-inflictedinjuries.Fromthisdataset,therewereatotalof3,301incidencesofpoisoningand1,418incidencesofcutsandpiercing.WhilebothpoisoningandcutsandpiercingslargelycontributedtohospitalizationsandEDvisits,theywerenotprimarycausesofmortality.
Table19:N.C.TypesofChildhoodSelf-InflictedInjuryDeaths,Age0-18:2011-2014
TypeofSelf-InflictedInjury
NumberofDeaths
Suffocation 70
Firearm 58
Poisoning 3
Drowning 2
OtherSpecified/Classified 2
Fire/Burn 1
Total 136
Table20:N.C.TypesofChildhoodSelf-InflictedInjury
Hospitalizations,Age0-18:2011-2013
TypeofSelf-InflictedInjury
NumberofAdmissions
Poisoning 1,309
Cut/Pierce 398
Unspecified 265
Suffocation 40
OtherSpecified/NotClassified 37
Firearm 12
Fall 11
Fire/Burn 7
OtherSpecified/Classified 5
MotorVehicle 2
Total 2,086
Table21:N.C.TypesofChildhoodSelf-InflictedInjuryEDVisits,Age0-18:2011-2013
TypeofSelf-Inflictedinjury
NumberofVisits
Poisoning 1,989
Cut/Pierce 1,020
OtherSpecified/NotClassified 232
Unspecified 142
Suffocation 27
Fall 11
Firearm 5
Fire/Burn 4
OtherSpecified/Classified 3
Drowning 1
MotorVehicle 1
Natural/Environment 1
Total 3,136
ChildhoodInjuriesinNorthCarolina:2011-2014
NorthCarolinaDivisionofPublicHealth–2016 24
3.ConclusionsandRecommendationsInjuryisasignificantsourceofmorbidityandmortalityforchildrenages0-18inNorthCarolina,anditisalargelypreventableproblem.Thepurposeofthisreportistoachieveagreaterunderstandingofthemostsignificantcausesofchildhoodinjuryinthestate,especiallythosethatcreatethegreatestsocial,psychological,andeconomicburdenonsociety.Abetterunderstandingoftheseinjuriescanhelpguidepreventioneffortstowheretheywillbemosteffective.
SummaryofStatistics• ChildhoodinjuriesinN.C.resultedinatotalof:1,068deathsfrom2011-2014,22,775hospitalizations
from2011-2013,and352,049emergencydepartmentvisitsfrom2013-2014.o 70%ofinjurydeathswereunintentionalinnature.o Overall,maleshadhigherratesofinjuryincidencethanfemales.
EverydayinN.C.…1childdiesfrominjury.
21childrenarehospitalizedforaninjury.322childrenvisittheemergencydepartmentforaninjury.
• Leadingmechanismsofdeathamongstchildrenfrom2011-2014inN.C.areunintentionalmotorvehiclecrashes(32%),unintentionalsuffocation(11%),andunintentionaldrowning(9%).
o Forchildrenages0-4,theleadingcauseofdeathwasunintentionalsuffocation,andmotorvehiclecrashesclaimedthemostlivesofchildren5-18.
• Leadingcausesofhospitalizationfrom2011-2013inN.C.childrenwereadverseeffects(24%),unknowncauses(19%),unintentionalfalls(10%),andunintentionalmotorvehiclecrashes(6%).
o Forchildrenages0-9,theleadingcauseofhospitalizationwasunintentionalfalls.Childrenages10-18sufferedthemosthospitalizationsfromself-inflictedinjuries.
o Forchildrenages10-18,theleadingcauseofhospitalizationwasintentionallyself-inflictedinjuries.
• Leadingscausesofemergencydepartmentvisitsfrom2013-2014inN.C.wereunknown(27%),unintentionalfalls(20%),unintentionalstriking(12%),andunintentionalnatural/environmentalmechanisms(6%).
o FallsweretheleadingmechanismofinjuryrelatedEDvisitsforallchildren,ages0-18.• InjurymortalityratesforchildreninN.C.havebeenconsistentlyhigherthanthenationalaverage,
withanincreaseindisparityfrom2013-2014.BothnationalandN.C.rateshaveanoveralldecreasingtrendininjuryfrom1999-2014.
ChildhoodInjuriesinNorthCarolina:2011-2014
NorthCarolinaDivisionofPublicHealth–2016 25
RecommendationsStatewideinjurypreventioneffortsshouldmirrornationalinitiativestoreducechildhoodinjuryrates.Thefollowingevidence-basedrecommendationsarebasedonexpertreviewforTheCommunityGuideforPreventiveServicesandtheNationalActionPlanforChildInjuryPrevention.Thebelowlistofrecommendationsisnotexclusiveandaremerelyexamplesofeffortsthatcanreduceinjury.MotorVehicle&TrafficInjuryPreventionForyoungerchildren,childsafetyseatlawsandaccesscanreducethefrequencyofinjuriescausedbymotorvehicleandtrafficcrashes.
• Increasingtheenforcementofchildsafetyseatlawsthat“requirechildrenridinginmotorvehiclestoberestrainedinfederallyapprovedinfantorchildsafetyseats,”candecreasetheinjuriesincurredtosmallerchildrenuponimpact[6].
• Increaseseatdistributionprogramstoincreaseaccessofchildsafetyseatstolow-incomeparentsandcaregivers[6].
Forteenagersandyoungdrivers,whosufferthesignificantlymorefrommotorvehiclecrashinjuries,strongevidenceencouragespolicyforgraduateddriverslicensingprograms.
• Implementand/orstrengthengraduateddriverslicensingprogram[7].• Driverinexperienceisthechiefcauseofmotorvehiclecrashesinvolvingteenagers.Teenagedriversare
thebiggestsafetythreattothemselvesandtheirpeers.Hence,graduateddriverlicensingprotectsandpreventsinjuriesforalldriversandpassengersthroughthree-stagesystems:learner’spermit,provisionallicense,andthenunrestrictedlicense.
• Intermediate,orprovisional,licensescanrestrictteenagedrivers’passengers,curfews,cellphoneusage,andmore[8].
Forallpassengersanddrivers,seatbeltusageiscriticalinpreventing,oratleastlimitingtheextentof,motorvehiclecrashinjuries.
• Increasingandenhancingprimaryenforcementofsafetyseatbeltlawscandecreasethenumberofinjuriesincurredbymotorvehicles.Suchinitiativesinclude“Click-it-or-ticket”campaigns[6],[7].
Itisillegalforanychildtoconsumealcohol.Forallchildrenandadults,driversundertheinfluenceofalcoholriskthesafetyandhealthofeverypersoninamotorvehicle.
• Maintaininglawsthatprohibitpersonsages21andyoungerfromconsumeralcoholareanadditionalmeasuretopreventmotorvehiclecrashes[6].
SuffocationInjuryPreventionKnowledgeofcardiopulmonaryresuscitation(CPR)procedurescanimprovehealthoutcomesunderthecircumstancesofasuffocationinjury.
• IncreasingandfacilitatingopportunitiesforCPRtrainingtargetedtowardsolderchildren,parents,daycareprovidersandcaregiverscanpreventdeathswhenachildisdeprivedofadequateairandoxygen[7].
Youngchildrenarevulnerabletosuffocationwhilesleeping.Hence,itisimportantforallparentsunderstandhealthysleepingpositions.
• Educatingparentsontheimportanceofsafesleepingandhealthysleeppositionscandecreasetherateofchildsuffocationincidents.Well-childexamsareeffectiveplatformstodiscusshealthysleepingpositionsandforproviderstopromotethe“SafetoSleep”campaign[7].
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Communityandschoolrecreationalgroundscancontributetowardpreventivemeasuresagainstchildhoodsuffocation.
• Parkandschoolgrounddesignersshouldcarefullydesignandmaintainplaygroundssothatthey“reduceentrapment,suffocation,andstrangulation”[7].
DrowningInjuryPreventionIncreasingtheknowledgeandprevalenceoflifesavingskillsincommunitiescandecreasetherateofchildrensufferingfromdrowninginjuries.
• IncreasingtheaccessibilityandavailabilityofCPRtrainingincommunitiescanincreasethenumberofolderchildrenandadultsthatareabletosavelivesindrowning(andothermedical)emergencies.OfferingfreeorreducedCPRclassesand/orofferingcoursesatmoreconvenientlocationswillincreasethenumberofpeoplewhowillbeabletoreceiveCPRtraining.
• Similarly,byincreasingtheaccessibilityandavailabilityofswimminglessonsincommunities,morechildrenwilldevelopandstrengthentheirswimmingandwatersurvivalskills.Offeringfreeorreduced-costswimminglessonsallowsmorechildrentodevelopstrongenoughwaterskillstopreventdrowning[7].
Private,backyardswimmingpoolsposeagreatrisktoyoungchildren’ssafety.Smallchildrencanaccidentallyfallintopoolswithoutparentalknowledgeorsupervisionanddrown.
• Requiringallswimmingpoolstohaveafour-sidedisolationfence,completelyseparatefromthehouseandyard,withself-closingandself-latchinggateswillpreventunsupervisedchildrenfromaccessingabodyofwaterandconsequentdrowninghazard[7].
Swimmingpoolsarenottheonlydrowninghazardforchildren;naturalbodiesofwaterthreatenchildhooddrowning,aswell.
• Enforcinglawsmandatingchildrenyoungerthan13towearlifejackets“inandaroundnaturalbodiesofwater,suchaslakesortheocean”(regardlessofswimmingability)andswimmingpools(forweakerswimmers)willreducechildren’sriskfordrowninginjuries[7].
FallsInjuryPreventionHomescontainaplethoraoffallhazards.Toreducetheriskoffallinjuriesathome,preventivemeasurescanbetakentoprotectchildren’shealthandsafety.
• “Build[ing]capacitythroughcommunitypreventiveservicesandlocalhealthdepartmentstointegrateassessmentoffallhomehazardsintootherongoinghomeassessments(e.g.leadpoisoning)”canincreasetheidentificationandrecommendationforremovaloffallhazards[7].
• Particularlyforyoungerchildren,increasingthe“amountanduseofprotectivedevices,”suchashandrailsinstairwellsandwindowguardscanreducetheriskofchildhoodfalls[7].
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4.AppendixAppendixA:DataSourcesandTechnicalNotesComparisonofU.S.andNorthCarolinaInjuryRates1999-2014TheWeb-based InjuryStatisticsQueryandReportingSystem(WISQARS) fromtheCenters forDiseaseControland Prevention, National Center for Injury Prevention and Control provided the comparative U.S. and NorthCarolina fatal injury rates for the years 1999 to 2014 and by injury type for 2011 to 2014. Crude rateswerereportedunlessotherwisenoted.TheWISQARSinjurymortalityreportswereretrievedonMarch15,2016from:http://webappa.cdc.gov/sasweb/ncipc/dataRestriction_inj.html.NorthCarolinaPopulationEstimates2011-2014TheNorth Carolina State Center for Health Statistics (SCHS) providedNorth Carolina population data for theyears 2011 to 2014. SCHS obtained the population data from the CDC National Center for Health Statisticsbridgedpopulationfile(2014version).NorthCarolinaDeathData2011-2014TheNorthCarolinaStateCenter forHealthStatisticsprovideddeath certificatedata foreverydeath inNorthCarolina.OnlystateresidentswithaNorthCarolinacountyaddressandages0-18yearsoldwereanalyzedforthis report. Primary cause of death was assignedwith the International Classification, 10th Revision; ClinicalModification (ICD-10) codes. Injuries were then classified intomanner andmechanism using CDC’s standardinjurymatrixframework.NorthCarolinaHospitalDischargeData2011-2013TheNorthCarolinaStateCenterforHealthStatisticsprovideddataforeveryNorthCarolinahospitaldischargeofNorth Carolina residents ages 0-18. A hospital discharge occurs after a patient leaves a hospital followingadmission.Thesedatadonotrepresentnumberofpatients,butnumberofdischarges(multipledischargesperpatient are possible). Cause of injury was assigned with International Classification, 9th Revision, ClinicalModification (ICD-9-CM) diagnosis codes and External Causes of Injury codes (E-Codes). Injuries were thenclassified into manner and mechanism using the CDC’sRecommended Framework of E-code groupings forPresentingInjuryMortalityandMorbidityData.NorthCarolinaEmergencyDepartmentData2013-2014TheNorthCarolinaDisease Event Tracking andEpidemiologic Collection Tool (NCDETECT) isNorthCarolina'sstatewide syndromic surveillance system.NC DETECT collects data from a number of secondary sources toaddresstheneedforearlyeventdetectionandtimelypublichealthsurveillance.NCDETECTcollectsnearreal-time emergency department (ED) visit data from all civilian24/7 acute-care hospital-affiliatedEDs in NorthCarolina.In2013,NCDETECTcollectedEDvisitdatafromall124of124qualifyingEDsandin2014NCDETECTcollecteddatafromall123of123qualifyingEDs(onefacilityclosedin2014).TheEDvisitdata,deathdata,andthe hospital discharge data are notmutually exclusive. The nature andmechanismof injurywasassigned byhospital coders using theInternational Classification, 9th Revision, Clinical Modification (ICD-9-CM) diagnosiscodes and External Causes of Injury codes (E Codes) as part of standard administrative and hospitalbillingprocedures. Injuries were then classified into manner and mechanism of injury using theCDC’sRecommended Frameworkof E-code groupings for Presenting InjuryMortality andMorbidityData. FormoreinformationaboutNCDETECTEDdata,pleasevisithttp://www.ncdetect.org.
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UnintentionalMotorVehicle,Traffic(MVT)Unintentional Motor Vehicle, Traffic (MVT) injuries were categorized as an occupant, pedestrian and/ormotorcyclistinjuredinamotorvehicletrafficcrashwithanunintentionalintent.Thisdefinitionincludedinjuriesfrom incidents that involved automobiles, trucks, vans,motorcycles, andmotorized cycles travelingonpublicroadways.Thisclassificationdidnotincludemotorvehiclenon-traffic,otherlandtransportandothertransport.Causeofdeath ICD-10codes:V02-V04 (.1, .9),V09.2,V12-V14 (.3-.9),V19 (.4-.6),V20-V28 (.3-.9),V29 (.4-.9),V30-V79 (.4-.9), V81.1, V82.1, V83-V86 (.0-.3), V80 (.3-.5), V87 (.0-.8), V89.2. Hospital and emergencydepartmentE-codes:E810-E819(.0-.9).UnintentionalSuffocationDeaths,HospitalizationsandEDvisits resulting fromchokingandsuffocation refer tomechanical causes (e.g.,plastic bags, refrigerator entrapment, or fallen earth); pressure on the trachea (e.g., drapery cords, clothingdrawstrings); and inhalation of food or foreign bodies. Fatal suffocation, such as choking in young children,typically involvesnotonly roundfoodproductssuchascandies,nuts,grapesandhotdogs,butalsonon-foodproductssuchasundersizedpacifiers,small toys,and latexballoons.Causeofdeath ICD-10codes:W75-W84.HospitalandEDE-codes:E911-E913.9UnintentionalDrowningorNearDrowning:Drowningandnear-drowninginjuriesrefertothoseinjuriescausesbysuffocationornear-suffocationasaresultofsubmersioninwater. Ifthevictimsurvivesthesuffocation,severneurological injuriesmayresult.Drowningand near-drowning primarily occur in three environments: pools, bathtubs, and naturally occurring bodies ofwater suchas streams, lakes, andwatersalong theNorthCarolina coast.Causeofdeath ICD-10codes:W65-W74.HospitalandEDE-codes:E830.0-.9,E832.0-.9,E910.0-.9.UnintentionalFireorBurnUnintentionalfireorburninjuriesincludedinjuriescategorizedwithanunintentionalintentandresultingfromexposuretoafireandcontactwithheatorhotsubstances.CauseofdeathICD-10codes:X00-X19.HospitalandemergencydepartmentE-codes:E890.0-E899,E924.0-.9.UnintentionalFallUnintentional falls included falls with an unintentional intent and the following mechanisms: on same levelinvolving ice and snow; on same level from slipping, tripping and stumbling; involving ice-skates, skis, roller-skatesorskateboards;onsamelevelduetocollisionwith,orpushingby,anotherperson;whilebeingcarriedorsupported by other persons; involving wheelchair, bed, chair or other furniture; involving playgroundequipment;onandfromstairsandsteps;onandfromladder;onandfromscaffolding;from,outof,orthroughabuildingorstructure;fromtree;fromcliff;divingorjumpingintowatercausinginjuryotherthandrowningorsubmersion; from one level to another; other on same level; and unspecified. Cause of death ICD-10 codes:W00-W19.HospitalandemergencydepartmentE-codes:E880.0-E-886.9,E888.UnintentionalPoisoningsUnintentionalpoisoningincludedinjurieswithanunintentionalintentresultingfromingestionofharmfuldrugs,medicines,gases,householdproducts,solvents,chemicals,acids,andpoisonousfoodsorplants.CauseofdeathICD-10codes:X40-X49.HospitalandemergencydepartmentE-codes:E850.0-E869.9.UnintentionalPedestrianInjuries(Non-motorvehiclerelated)Deaths,hospitalizations,andEDvisitsresultingfrompedestrianinjuriesarecodeintwodifferentcategories:asa subcategoryundermotorvehicle traffic collision (meaning the injury resulted froma collisionwithamotorvehicle on a public highway) or through a category labeled “Pedestrian,Other”. A “Pedestrian,Other” injury
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involvesapedestrianinjuredinacollisionwitharailwayvehicle,amotorvehiclenotonpublichighway,orotherroad vehicle (e.g., bicycle, animal being ridden, streetcar, non-motorized vehicle of object in motion).“Pedestrian,other”injuriesarereportedinthisdocument.CauseofdeathICD-10codes:V01,V02-V04(.0),V05,V06,V09(.0,.1,.3,.9).HospitalandEDE-codes:800-807(.2),E820-E825(.7),E826-E829(.0)Homicide/AssaultAssaultinjurieswerecategorizedasassaultintentbyanymechanism(e.g.,firearm,struck,etc.).Causeofdeathcodes:X85-Y09,Y87.1.HospitalandemergencydepartmentE-codes:E960.0-E969.9,E979,E999.1.Suicide/Self-InflictedSelf-inflictedinjurieswerecategorizedasself-inflictedintentbyanymechanism(e.g.,firearm,poisoning,etc.).Causeofdeathcode:X60-X84,Y87.0.HospitalandemergencydepartmentE-codes:E950-E959.MethodsInordertoexploretheextentofthecurrentolderadult injuryprobleminNorthCarolina,twomethodologicalapproacheswere undertaken: (a) a quantitative analysis ofmortality, hospital dischargedata and emergencydepartmentvisitstodetermineinjuryrates;and(b)adescriptionofhospitalchargesforinjuries.InjuryRateCalculationsCruderateswerereportedunlessotherwisespecified.Mortalityandhospitalizationrateswerecalculatedbasedon theNorth CarolinaDeath andHospitalization files for 2011-2014 and 2011-2013, respectively. Emergencydepartment visit rateswere calculatedbasedonNCDETECT for 2013-2014. Theprocesses for calculating therates for North Carolina older adult injuries were similar. First, duplicate records or records with a primarydiagnosis other than injurywere excluded.Next, E-codes using CDC’s injurymatrix standard definitionswerecollapsedtocreateinjurygroupsthatweresuitablefordescribingtheexternalcausesofinjuries.Denominatorsfor rate calculationswere based upon age group population estimates over the specified time period (2011-2014fordeaths,2011-2013forhospitalizations,2013-2014forEDvisits)fromtheNorthCarolinaStateCenterforHealthStatisticsandwereexpressed“per100,000persons”unlessotherwisenoted.HospitalChargesCalculationsHospital charge estimateswere computed by summing the charges across all caseswithin each injury group(e.g.,overall,unintentionalfalls,motorvehicletraffic,etc.).Itisimportanttonotethathospitalchargesreflectonly a part of the cost of injuries. Physician charges, emergency vehicle services, out-patient drug charges,medicalequipmentandtimelostfromworkwerenotincludedinthisreport.Allchargeswerereportedinthatyear’sdollarsandwerenotadjustedforinflation.Hospitalchargesalsoreflectcontractsthathospitalshavewithinsurancecompanies.StandardizationofGraphicAnalysisUsecautionandobservethescalewhenanalyzingandcomparinggraphs.Whiletheimportanceofstandardizedscales in graphs is acknowledged, itwas not possible in this report, due to thewide variation of rate rangeswithinmortality,hospitalization,andEDvisitdata.OtherE-CodesUsedinAnalysisAdditionalinjurycodingwasusedtocategorizedifferingtypesofunintentionalinjuries.ThesecodeswerebasedontheCDCInjuryMatrixFramework:Deaths/Mortality:www.cdc.gov/nchs/data/ice/icd10_transcode.pdf
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HospitalizationDischargeandEmergencyDepartmentVisitsNonfatal:www.cdc.gov/ncipc/osp/matrix2.htmAgeGroupsUsedinAnalysisThroughoutthisreport,eachagegroupisdefinedaslessthanitsupperboundaryage.Forexample,the15-18yearoldbracketincludeschildrenfrom15yearsoldthroughchildrenyoungerthan18yearsold.Itdoesnotincludechildren18yearsofageandolder.
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AppendixB:InjuryPreventionResourcesCDCCentersforExcellenceUNCInjuryPreventionResearchCenterUniversityofNorthCarolinaCVSPlaza,Suite500137EastFranklinStreet,CB#7505ChapelHill,NC27599-7505Phone:(919)966-2251www.iprc.unc.edu/Director:StephenMarshall,Ph.D.InjuryandViolencePreventionBranchChronicDiseaseandInjury,NorthCarolinaDivisionofPublicHealthNorthCarolinaDepartmentofHealthandHumanServices1915MailServiceCenterRaleigh,NC27699-1915Phone:(919)707-5425Email:[email protected]/injuryBranchHead:AlanDellapenna,Jr.,R.S.,M.P.H.ChiefDirectorofChronicDiseaseandInjury:RuthPetersen,M.D.,M.P.H.NationalCenterforInjuryPreventionandControlCentersforDiseaseControlandPreventionMailstopF634770BufordHighwayNEAtlanta,GA30341-3717Phone:(800)232-4636Email:[email protected]/injuryDirector:DebraHoury,M.D.,M.P.H.SafeKidsNorthCarolinaNorthCarolinaDepartmentofInsurance–OfficeofSafetyandFireMarshall1202MailServiceCenterRaleigh,NC27699-1202Phone:(919)647-0080www.ncdoi.com/OSFM/ProgramsPreventionAndGrants/SafeKidsMesssage.aspChairman:WayneGoodwinDeputyDirector:MegLangston
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5.References[1]NationalCenterforInjuryPreventionandControl(2015).10LeadingCausesofDeathbyAgeGroup,United
States–2014.CentersforDiseaseControlandPrevention.Retrievedfromwww.cdc.gov/inquiry/wisqars/leadingcauses.html
[2]NationalCenterforInjuryPreventionandControl,DivisionofUnintentionalInjuryPrevention(2012).Vital
Signs:ChildInjury.CentersforDiseaseControlandPrevention.Retrievedfromhttp://www.cdc.gov/vitalsigns/childinjury/
[3]NationalCenterforInjuryPreventionandControl.Web-basedInjuryStatisticsQueryandReportingSystem(WISQARS)(2015).CentersforDiseaseControlandPrevention.Retrievedfromhttps://www.cdc.gov/injury/wisqars/fatal_injury_reports.html
[4]NationalCenterforInjuryPreventionandControl(2015).CDCChildhoodInjuryReport.CentersforDisease
ControlandPrevention.Retrievedfromhttp://www.cdc.gov/safechild/child_injury_data.html[5]CentersforDiseaseControlandPrevention(2015).InjuriescosttheUS$671billionin2013.CDCNewsroom.
Retrievedfromhttp://www.cdc.gov/media/releases/2015/p0930-injury-costs.html[6]TheCommunityGuideforPreventiveServices(2016).Retrievedfromhttp://www.thecommunityguide.org/[7]NationalCenterforInjuryPreventionandControl(2016).NationalActionPlanforChildInjuryPrevention.
CentersforDiseaseControlandPrevention.Retrievedfromhttp://www.cdc.gov/safechild/nap/index.html
[8]NationalCenterforInjuryPreventionandControl,DivisionofUnintentionalInjuryPrevention(2015).Parents
aretheKeytoSafeTeenDrivers.CentersforDiseaseControlandPrevention.Retrievedfromhttp://www.cdc.gov/parentsarethekey/index.html