Surveillance for Violent Deaths — National Violent Death Reporting System, 16 States, 2009

Debra L. Karch, PhD

Joseph Logan, PhD

Dawn McDaniel, PhD

Sharyn Parks, PhD

Nimesh Patel, MS

Division of Violence Prevention, National Center for Injury Prevention and Control, CDC

Corresponding author: Joseph Logan, PhD, Division of Violence Prevention, National Center for Injury Prevention and Control, CDC, 4770 Buford Hwy, N.E., MS F-64, Atlanta, GA 30341-3724. Telephone: 770-488-1529; Fax: 770-488-4222; E-mail: jlogan@cdc.gov.

Abstract

Problem/Condition: An estimated 50,000 persons die annually in the United States as a result of violence-related injuries. This report summarizes data from CDC's National Violent Death Reporting System (NVDRS) regarding violent deaths from 16 U.S. states for 2009. Results are reported by sex, age group, race/ethnicity, marital status, location of injury, method of injury, circumstances of injury, and other selected characteristics.

Reporting Period Covered: 2009.

Description of System: NVDRS collects data regarding violent deaths obtained from death certificates, coroner/medical examiner reports, and law enforcement reports. NVDRS data collection began in 2003 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, for a total of 19 states. This report includes data from 16 states that collected statewide data in 2009. California is excluded because data were collected in only four counties. Ohio and Michigan are excluded because data collection did not begin until 2010.

Results: For 2009, a total of 15,981 fatal incidents involving 16,418 deaths were captured by NVDRS in the 16 states included in this report. The majority (60.6%) of deaths were suicides, followed by homicides and deaths involving legal intervention (i.e., deaths caused by police and other persons with legal authority to use deadly force, excluding legal executions) (24.7%), deaths of undetermined intent (14.2%), and unintentional firearm deaths (0.5%). Suicides occurred at higher rates among males, non-Hispanic whites, American Indians/Alaska Natives, and persons aged 45–54 years. Suicides occurred most often in a house or apartment and involved the use of firearms. Suicides were preceded primarily by mental health, intimate partner, or physical health problems or by a crisis during the previous 2 weeks. Homicides occurred at higher rates among males and persons aged 20–24 years; rates were highest among non-Hispanic black males. The majority of homicides involved the use of a firearm and occurred in a house or apartment or on a street/highway. Homicides were preceded primarily by arguments and interpersonal conflicts or in conjunction with another crime. Characteristics associated with other manners of death, circumstances preceding death, and special populations also are highlighted in this report.

Interpretation: This report provides a detailed summary of data from NVDRS for 2009. The results indicate that violent deaths resulting from self-inflicted or interpersonal violence disproportionately affected adults aged <55 years, males, and certain racial/ethnic minority populations. For homicides and suicides, relationship problems, interpersonal conflicts, mental health problems, and recent crises were among the primary factors that might have precipitated the fatal injuries. Because additional information might be reported subsequently as participating states update their findings, the data provided in this report are preliminary.

Public Health Action: For the occurrence of violent deaths in the United States to be better understood and ultimately prevented, accurate, timely, and comprehensive surveillance data are necessary. NVDRS data can be used to monitor the occurrence of violence-related fatal injuries and assist public health authorities in the development, implementation, and evaluation of programs and policies to reduce and prevent violent deaths at the national, state, and local levels. The continued development and expansion of NVDRS is essential to CDC's efforts to reduce the personal, familial, and societal costs of violence. Additional efforts are needed to increase the number of states participating in NVDRS, with an ultimate goal of full national representation.

Introduction

An estimated 50,000 persons die annually in the United States as a result of violence-related injuries. Homicide is the second leading cause of death for persons aged 15–24 years, the third leading cause for persons aged 1–4 and 25–34 years, and the fourth leading cause for persons aged 5–9 and 10–14 years. Suicide is the second leading cause of death for persons aged 25–34 years, the third leading cause for persons aged 10–14 years and 15–24 years, and the fourth leading cause for persons aged 35–44 and 45–54 years. Only unintentional injury in those aged 1–44 years and malignant neoplasms and congenital anomalies in children aged 1–14 years of age were more common (1).

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, CDC started planning to implement the National Violent Death Reporting System (NVDRS) (3,4). The goals of this system are to:

• collect and analyze timely, high-quality data that monitor the magnitude and characteristics of violent death at the national, state, and local levels;
• ensure that data are disseminated routinely and expeditiously to public health officials, law enforcement officials, policy makers, and the public;
• ensure that data are used to develop, implement, and evaluate programs and strategies that are intended to reduce and prevent violent deaths and injuries at the national, state, and local levels; and
• build and strengthen partnerships among organizations and communities at the 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 risk-factor data concerning all violence-related deaths, including homicides, suicides, and legal intervention deaths (i.e., deaths caused by police and other persons with legal authority to use deadly force; excluding legal executions), as well as unintentional firearm deaths and deaths of undetermined intent. NVDRS data are used to assist the development, implementation, and evaluation of programs and strategies designed to reduce and prevent these deaths and injuries at the national, state, and local levels.

Before implementation of NVDRS, single data sources (e.g., death certificates or law enforcement data systems) provided only limited information and few circumstances from which to understand patterns of deaths collected by this system. NVDRS fills this gap in national surveillance; it is the first system to provide detailed information on circumstances precipitating violent deaths, the first to link multiple source documents to enable researchers to understand each death more completely, and the first to link multiple deaths that are related to one another (e.g., multiple homicides, suicide pacts, and cases of homicide followed by the suicide of the suspected perpetrator).

NVDRS began data collection in 2003 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 more (California, Kentucky, New Mexico, and Utah) in 2005; and two (Ohio and Michigan) in 2010 for a total of 19 states (Figure). CDC provides funding for state participation and anticipates that NVDRS will expand to include all 50 states, the District of Columbia, and U.S. territories.

This report summarizes data for 2009 for deaths meeting NVDRS inclusion criteria from 16 states that collected statewide data (approximately 26% of the U.S. population). California data are not included in this report because data were collected in only four counties. Ohio and Michigan were excluded because data collection did not begin until 2010. Because additional information might be reported subsequently as participating states update their findings, the data provided in this report are preliminary. Annual updates of NVDRS data also are available through a web-based query system (WISQARS) at http://wisqars.cdc.gov:8080/nvdrs/nvdrsDisplay.jsp.

Methods

NVDRS uses multiple, complementary data sources, including death certificates, coroner/medical examiner (CME) records, and law enforcement reports. In addition, some participating states use secondary sources (e.g., child fatality review team data, supplementary homicide reports, hospital data, crime laboratory data, and trace information from the Bureau of Alcohol, Tobacco, Firearms, and Explosives concerning firearms). NVDRS links multiple documents for each death and also links multiple deaths that are related to each other (e.g., multiple homicides, a homicide followed by a suicide, or multiple suicides) into a single incident. The ability to analyze data linked in this way permits a comprehensive assessment of violent deaths.

NVDRS defines a violent death as a death resulting either from the intentional use of physical force or power against oneself, another person, or a group or community. In addition, NVDRS collects information regarding unintentional firearm injury deaths (i.e., incidents in which the person causing the injury did not intend to discharge the firearm) and deaths of undetermined intent. NVDRS case definitions are coded on the basis of the International Classification of Diseases, Tenth Revision (ICD-10) (5). Cases with selected ICD-10 codes are included in NVDRS (Box 1). ICD-10 case finding is completed by participating states.

Variables analyzed in NVDRS include the following:

• manner of death (i.e., the intent of the person inflicting a fatal injury);
• mechanism of injury (i.e., the method used to inflict a fatal injury);
• circumstances preceding injury (i.e., the events that preceded and therefore might have contributed to the infliction of a fatal injury);
• whether the decedent was a victim (i.e., a person who died as a result of a violence-related injury);
• whether the decedent was a suspect (i.e., a person believed to have inflicted a fatal injury on a victim);
• whether the decedent was both a suspect and a victim (i.e., a person who is believed to have inflicted a fatal injury on a victim and who then was fatally injured);
• incident (i.e., an occurrence in which one or more persons sustained a fatal injury that was linked to a common event 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 (both victims and alleged perpetrators [suspects]) 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 that of the deaths. Examples of a violent death incident include 1) a single isolated violent death, 2) two or more related homicides (including legal interventions) 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 related suicide when both fatal injuries were inflicted <24 hours apart.

Data are obtained from individual information sources and entered into source-specific computerized data entry screens (i.e., law enforcement report data are entered into law enforcement report screens and death certificate data into death certificate screens). In addition to allowing independent entry of each source, this approach permits later review of what each source contributed and identification of missing sources. This permits comparisons of the quality and completeness of state-specific data sources and allows states to provide feedback to sources regarding the consistency of their data compared with data from other sources. In addition, the system permits automatic electronic importation of specific data sources without requiring manual entry.

Abstraction of identical variables across multiple source documents can result in data inconsistencies, which NVDRS resolves by assigning a primacy (i.e., hierarchical) rule for each variable. The primacy rules are applied to create a final analysis data set that uses data from all available sources. For each variable in NVDRS, primacy is established on the basis of a hierarchy of assumed reliability of all the sources for a single variable. For example, sex is collected in all three required documents (death certificate, CME record, and law enforcement report). The primacy for sex is expressed as death certificate/CME record/law enforcement report, which means the analysis file is constructed using the sex recorded in the death certificate. If the sex is left blank or is unknown on the death certificate, the sex recorded in the CME record is used, and if the CME record does not provide the sex or lists the sex as unknown, the law enforcement report is used.

Manner of Death

A manner (i.e., intent) of death for each decedent is assigned by a trained abstractor who takes into account information from all source documents. Typically, these documents are consistent regarding the manner of death, and the abstractor-assigned manner of death corresponds to that reported in all the source documents. On rare occasions, when a discrepancy exists among the source documents, the abstractor must assign a manner of death on the basis of the preponderance of evidence in the source documents. For example, if two sources classify a death as a suicide and a third classifies it as undetermined, the death will be coded as a suicide.

NVDRS classifies data using one of five abstractor-assigned manners of death:

• Suicide. Suicide is defined as a death resulting from the use of force against oneself when a preponderance of the 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 injury but associated with high risk of death (e.g., "Russian roulette"), and suicides involving only passive assistance to the decedent (e.g., supplying the means or information needed to complete the act). The 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.
• Homicide. Homicide is defined as 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 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. Corresponding ICD-10 codes included in NVDRS are X85–X99, Y00–Y09, and Y87.1.
• Unintentional firearm. An unintentional firearm death is a death that results 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 of deaths included in this category include the death of a person 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; and a person who received a self-inflicted wound while playing with a firearm. 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 with a method of firearm.
• Undetermined intent. A death of undetermined intent is 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. This category includes CME rulings (e.g., accident or suicide, undetermined, jumped or fell, and self-inflicted injuries) when records give no evidence or opinions in favor of either unintentional or intentional injury. Corresponding ICD-10 codes included in NVDRS are Y10–Y34, Y87.2, and Y89.9.
• Legal intervention. A death from legal intervention is a death in which a decedent is killed by a police officer or other peace officer (a person with specified legal authority to use deadly force), including military police, acting in the line of duty. This category excludes legal executions. Corresponding ICD-10 codes included in NVDRS are Y35.0–Y35.4, Y35.6, Y35.7, and Y89.0.

Variables Analyzed

NVDRS collects approximately 250 unique variables (available at http://www.cy118119.com/ViolencePrevention/NVDRS/index.html) 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, demographics, ICD-10 and underlying cause-of-death codes and text, location and date/time of injury and death, toxicology results, bodily injuries, precipitating circumstances, decedent-suspect relationship, and method of injury (Boxes 2 and 3).

Comparability of 2008 and 2009 NVDRS Surveillance Summary Data

Three changes made to the way variables were reported between 2008 and 2009 affect their comparability. These changes involve method of injury, relationship of victim to suspect, and age limits for suicide among older adults.

Method of Injury

In 2008, weapon type for all manners of death was captured in 18 categories such as firearm, sharp instrument, blunt instrument, poisoning, and hanging/strangulation/suffocation. If a decedent was injured by multiple weapon types (e.g., a homicide decedent who experienced both stabbing and firearm injuries), the death was categorized as "firearm and other method type" rather than counted twice in both the individual firearm and sharp instrument categories because NVDRS did not specify which mechanism of the two caused the fatal wound or whether the death was attributable to both types of injuries. Changes to the 2009 software required data abstractors to code weapons as primary, secondary, or tertiary mechanisms, based on lethality, as documented in death certificate and CME reports. For example, the death of a suicide decedent with self-inflicted wrist lacerations experienced before a self-inflicted gunshot wound to the head would have two weapon codes (both firearm and sharp instrument); the primary weapon would be firearm and the secondary weapon a sharp instrument. The death of a homicide decedent who was shot in the foot and then stabbed in the heart would have a sharp instrument coded as the primary method and gunshot wound as the secondary method. The method of injury data reported in this surveillance summary are based on the primary weapon type only and do not include secondary or tertiary weapons. This change allows for better comparability with other violence-related data.

Relationship of Victim to Suspect

The relationship of the victim to the suspect is coded from a list of 31 options in NVDRS. In 2008, each decedent could have up to two relationship categories for each suspect. For example, a suspect could be both the cousin and the roommate of the decedent. As with weapon type, the relationship variables for 2009 include codes for the primary, secondary, and tertiary relationship. Abstractors code the familial relationship first (if appropriate) and then the social relationship (i.e., friend, acquaintance, babysitter, or rival gang member) if no familial relationship exists. This change allows greater specificity for those previously categorized as "more than one relationship" and for better comparability with other violence-related data.

Age Limits for Suicides Among Older Adults

The 2008 suicides among older adults included adults aged 50–59 years. To be consistent with the CDC definition of older adult (i.e., adults aged ≥60 years), the age group 50–59 years was removed in 2009; therefore, the total columns for suicides among older adults for 2009 are not comparable to (i.e., are lower than) 2008 and previous years because this age group is excluded for 2009.

Circumstances Preceding Death

The circumstances preceding death are defined as the events that preceded and therefore might have contributed to the infliction of a fatal injury (described as precipitating circumstances in this report) (Box 3). The circumstances that preceded a fatal injury are reported on the basis of the content of the CME record and police reports. Common sets of circumstances are coded for suicide/undetermined deaths, homicide/legal intervention deaths, and unintentional firearm deaths. The variable "circumstances known" is a gateway variable to a list of potential circumstances. Each incident requires the data abstractor to code all circumstances in cases for which the circumstances are known. If circumstances are not known (e.g., for a body found in the woods with no other detail), the data abstractor leaves the gateway variable blank, and these cases are excluded from the denominator for circumstance values. If either the CME record or the police report indicates that the circumstance is reported to be true, then the abstractor enters data as confirmed (e.g., if the police report indicated that a decedent had disclosed an intent to commit suicide, then suicidal intent is accepted to be true).

Coding Training and Quality Control

Coding training is held annually for all participating states. Ongoing coding support is provided through an e-mail help desk, monthly conference calls with all states, and regular conference calls with individual states. A coding manual is provided. Software features enhance coding reliability, including automated validation rules and a hover-over feature containing variable-specific information. Details regarding NVDRS procedures and coding are available at http://www.cy118119.com/ViolencePrevention/NVDRS/publications.html.

States are requested to perform blind reabstraction 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 selection and manner of death). If CDC questions any variable, CDC notifies the state and asks 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 time frame. States then have an additional 12 months to complete each incident record. Although states typically meet these timelines, additional details sometimes arrive after a deadline has passed. New incidents also might be identified after the deadline; for example, if a death certificate is revised, new evidence is obtained that changes a manner of death, or a miscoded ICD-10 is corrected to meet NVDRS inclusion criteria. These additional data are incorporated into NVDRS. Analysis files are updated monthly at CDC. On the basis of previous experience, CDC estimates that case counts might increase 1%–2% after the initial 18-month data collection period.

Fatal Injuries During 2009

This report provides preliminary data concerning fatal injuries meeting the NVDRS case definition in 2009 for 16 participating states that were received by CDC as of August 31, 2011. Participating states used vital statistics death certificate files to identify violent deaths meeting NVDRS case definitions. Each state reported all deaths of their residents that occurred within the state and deaths of state residents that occurred elsewhere. Once a 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. These narratives were reviewed for all incidents in which coded data were unclear or incomplete. State-level data then were 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 and for special situations and populations (e.g., homicide followed by suicide, suicides of former or current military personnel, and intimate-partner–related homicides). Rates are not presented when the number of decedents for a variable is <20 because the rates are unstable. In addition, rates could not be calculated for some variables (e.g., marital status and precipitating circumstances) because denominators were unknown. Bridged-race 2009 population estimates were used as denominators in the rate calculations (6). For compatible numerators for rate calculations to be derived, records listing multiple races were recoded to a single race when possible, using a bridging algorithm provided by NCHS (available at http://www.cy118119.com/nchs/nvss/bridged_race.htm).

Results

All Deaths Captured by NVDRS

Deaths by Manner, Method, and Location

The 16 NVDRS states included in this report collected data concerning 15,981 incidents and 16,418 deaths that occurred during 2009. The crude death rate was 20.1 deaths per 100,000 population. Suicides (n = 9,949) accounted for the highest rate of violent deaths (12.2 per 100,000 population) followed by homicide/legal-intervention deaths (n = 4,057; 5.0 per 100,000 population). Deaths of undetermined intent (n = 2,325) and unintentional firearm deaths (n = 87) occurred at lower rates (2.8 and 0.1 per 100,000 population, respectively). Of all incidents occurring in 2009 in the 16 states included in this report, only 2.3% were known to have multiple victims. Firearms accounted for 48.8% of included deaths, poisoning for 19.1%, and hanging/strangulation/suffocation for 16.1% (rates: 9.8, 3.8, and 3.2 per 100,000 population, respectively); rates for other methods were lower. For all deaths, a house or apartment was the most common location (70.9%). The second most common location of injury (7.4%) was a street or highway (Table 1).

Toxicology Results of Decedent

Tests for alcohol were conducted for 72.3% of decedents, and drug tests for amphetamines, antidepressants, cocaine, marijuana, and opiates were conducted for 54.6%, 45.5%, 55.4%, 36.9%, and 55.0% of decedents, respectively. Among decedents who tested positive for alcohol (32.3%), 62.4% had a blood alcohol concentration (BAC) of ≥0.08 g/dL (the legal limit in all states). Opiates, including heroin and prescription pain killers, were identified in 25.4% of cases tested for these substances, antidepressants in 19.9%, marijuana in 12.9%, cocaine in 8.6%, and amphetamines in 3.7% (Table 2).

Suicides

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

The 16 NVDRS states included in this report collected data concerning 9,935 fatal suicide incidents and 9,949 suicides that occurred during 2009. Rates of suicide by month showed little variation throughout the year (range: 0.9–1.1 per 100,000 population) (Table 3). Overall, the crude suicide rate was 12.2 per 100,000 population. The rate for males was nearly four times that for females (19.5 and 5.1 per 100,000 population, respectively) (Table 4). Non-Hispanic whites accounted for the largest number and highest rate (15.1 per 100,000 population) of suicide deaths, followed by American Indian/Alaska Natives (AI/ANs) (14.9 per 100,000 population). The highest rates of suicide by age group occurred among persons aged 45–54 years, 35–44 years, and 55–64 years (19.2, 16.9, and 16.6 per 100,000 population, respectively). Children aged 10–14 years had the lowest rates of suicide among all age groups (1.2 per 100,000 population). Rates of suicide among adolescents aged 15–19 years (8.0 per 100,000 population) were approximately half of those for persons aged 35–64 years.

Decedents aged 35–64 years accounted for 55.9% of suicide deaths among males. Rates among males were highest for adults aged ≥85 years followed by adults aged 75–84 and 45–54 years (40.9, 29.8, and 29.6 per 100,000 population, respectively). Non-Hispanic white males and AI/AN males had the highest rates of any racial/ethnic population and had rates that were more than three times the rate for the group with the lowest rates, Hispanic males. Among females, decedents aged 35–64 years accounted for 64.8% of suicides. Rates for females peaked at 9.1 per 100,000 among those aged 45–54 years. Female suicide rates were highest among AI/ANs (7.4), followed closely by non-Hispanic whites (6.4). Among females, the lowest rates of suicide were among non-Hispanic blacks (1.7) and Hispanics (1.8). Of all suicide decedents aged ≥18 years for whom marital status was known, 38.3% were married, 29.0% had never married, and 23.7% were divorced at the time of death (Table 4).

Method and Location of Injury

Firearms were used in the majority (51.8%) of suicide deaths, followed by hanging/strangulation/suffocation (24.7%) and poisoning (17.2%) (Table 5). The most common method used by male suicide decedents was a firearm (56.7%), followed by hanging/strangulation/suffocation (25.3%). Among females, poisons were used most often (36.9%) followed by firearms (33.8%). The most common place of self-inflicted injury was a house or an apartment (76.4%), followed by natural areas (4.0%) and streets or highways (3.5%). A total of 160 (1.6%) suicides occurred in a jail or prison setting (142 males and 18 females) (Table 5).

Toxicology Results of Decedent and Precipitating Circumstances

Tests for alcohol were conducted for 69.2% of suicide decedents, and drug tests for amphetamines, antidepressants, cocaine, marijuana, and opiates were conducted for 47.3%, 41.3%, 48.1%, 36.8%, and 48.2% of suicide decedents, respectively (Table 6). Among suicide decedents who tested positive for alcohol (33.3%), 64.5% had a BAC of ≥0.08 g/dL. Opiates, including heroin and prescription pain killers, were identified in 20.8% of decedents tested for these substances; cocaine and marijuana were identified in 5.2% and 9.3% of tested decedents, respectively. Of suicide decedents who were tested for antidepressants, 23.1% were positive at the time of their death (Table 6).

Precipitating circumstances were known for approximately 90% of suicide decedents. Overall, mental health problems were the most commonly noted circumstance for suicide decedents, with 41.0% described as experiencing a depressed mood at the time of their deaths. Approximately 44.1% were described as having a diagnosed mental health problem; 31.3% were receiving treatment (Table 7). Of those with a diagnosed mental disorder, 74.1% had received a diagnosis of depression/dysthymia, 14.6% bipolar disorder, and 10.6% anxiety disorder (Table 8).

Among suicide decedents with known circumstance information, 19.8% had a history of previous suicide attempts, 28.3% disclosed their intent before dying, and 33.1% left a suicide note (Table 7). Other than mental health conditions, circumstances noted most often were intimate partner problems (31.4%) and a crisis of some kind in the preceding or impending 2 weeks (26.6%). Physical health problems also were noted in 21.0% of cases with circumstance information and job or financial problems in 14.6% and 13.8% of deaths, respectively.

Approximately 40% of male and female suicide decedents were observed to have a depressed mood at the time of death; however, a higher percentage of females than males had received a diagnosis of a mental health problem (61.3% and 39.3%, respectively) or were being treated for a mental health problem (48.9% and 26.4%, respectively) (Table 7). Among those with a diagnosed mental health problem, females were more likely than males to have received a diagnosis of bipolar, anxiety, or eating disorders, whereas males were more likely than females to have received a diagnosis of posttraumatic stress disorder (PTSD) and attention deficit disorder/attention deficit and hyperactivity disorder (ADD/ADHD) (Table 8). An estimated one fifth of both male (20.5%) and female (22.9%) suicide decedents experienced physical health problems in the period before their deaths (Table 7). Also in the period before their deaths, job problems were noted in higher proportions of males than females (15.9% and 10.0% respectively), as were financial problems (14.2% and 12.1%) and criminal legal problems (10.6% and 5.3%). Intimate partner problems also were cited as a precipitating factor in a higher percentage of male suicides than female suicides (33.0% and 25.5%, respectively). Although occurring in only a limited percentage of cases, being a perpetrator of interpersonal violence in the month before death was more common among male suicide decedents (4.8%) than being a victim of such violence (0.3%), whereas the proportions were similar for females (1.4% and 0.8%, respectively) (Table 7).

Homicides

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

The 16 NVDRS states included in this report collected data concerning 3,840 homicide incidents and 4,057 homicides that occurred during 2009. Overall, the crude homicide rate was 5.0 deaths per 100,000 population in 2009. Rates of homicide by month showed little variation throughout the year (range: 0.3–0.5 per 100,000 population) (Table 9).

The majority (54.3%) of homicide decedents aged ≥18 years for which marital status was known had never been married, and 22.8% were married at the time of their death (Table 10). In 54.2% of homicides, the relation of the victim to the suspect was not known. When a suspect was identified, the suspect most often was a spouse or intimate partner (10.3%), an acquaintance or friend (10.2%), or a stranger (4.6%). Perpetrators were other relatives of the decedent in <8.0% of cases with known information about the relation of the victim to the suspect (Table 10).

The homicide rate for males was approximately 3.2 times higher than that for females (7.7 and 2.4 per 100,000 population, respectively) (Table 11). Non-Hispanic blacks accounted for half (48.7%) of homicide deaths and had the highest rate (15.6 deaths per 100,000 population), followed by AI/ANs (9.4) and Hispanics (4.9). Overall, the highest rate was among black males (27.4 per 100,000). Age-specific homicide rates were highest (11.9 deaths per 100,000 population) among adults aged 20–24 years, followed by adults aged 25–29 years (10.0 deaths per 100,000 population). The rate for infants aged <1 year was nearly four times that for children aged 1–4 years (7.8 and 2.1 per 100,000 population, respectively). Rates were lowest among children aged 5–14 years and adults aged 75–84 years. The majority (56.2%) of all male homicide decedents were aged 15–34 years; males aged 20–24 years had the highest rates of homicide (19.6 per 100,000 population). For females, homicide rates were highest (7.1 deaths per 100,000 population) among infants aged <1 year (Table 11).

Method and Location of Injury

Firearms were used in 66.5% of homicides, followed by sharp instruments (12.9%) and blunt instruments (7.0%). No other single method was used in >3.7% of homicides (Table 9). Firearms were the most common method used in homicides of males (72.1%) and females (48.8%) (Table 12). Hanging/strangulation/suffocation was more than six times more common among female homicide decedents than among males (10.5% and 1.6%, respectively). A house or apartment was the most common location of homicide for both males and females (46.5% and 74.0%, respectively). The next most common location of homicide for males was a street or highway (24.2%), a parking lot or public garage (5.2%), and a commercial/retail area (4.1% each); for females, the next most common locations were a street or highway (6.7%), a natural area (3.1%), and a motor vehicle (2.3%) (Table 12).

Toxicology Results of Decedent and Precipitating Circumstances

Tests for alcohol were conducted for 75.8% of homicide decedents, and drug tests for amphetamines, antidepressants, cocaine, marijuana, and opiates were conducted for 59.5%, 41.9%, 60.4%, 36.2%, and 57.8% of homicide decedents, respectively (Table 13). Among tested homicide decedents who tested positive for alcohol (34.2%), 60.9% had a BAC of ≥0.08 g/dL. Marijuana, cocaine, and opiates were identified in 23.4%, 10.1%, and 9.1% of homicide decedents tested, respectively (Table 13).

Precipitating circumstances were identified for 70.6% of homicide deaths. Nearly one in three of those homicides were precipitated by another crime (Table 14). In 73.4% of cases precipitated by another crime, the crime was in progress at the time of the incident (Table 14). The crime was most often robbery (36.7%), followed by assault/homicide (22.0%), burglary (11.0%), drug trade (7.7%), rape/sexual assault (3.9%), or motor-vehicle theft (1.9%) (Table 15). Other common precipitating circumstances were an argument, abuse, or conflict over something other than money or property (36.0%); drug involvement (11.5%); justifiable self-defense/law enforcement (6.7%); or an argument over money or property (6.1%). In 17.6% of cases with known circumstance information, intimate partner violence was identified as a contributing factor (Table 14).

An argument, abuse, or conflict unrelated to money or property was a factor in more homicides among males than among females (40.8% and 22.2% respectively). Drug-involvement homicides accounted for 14.0% of male homicides and 4.4% of female homicides. Intimate partner violence was a precipitating factor in 45.1% of female homicides but only 8.1% of male homicides. In 11.6% of male homicides with known circumstance information, the decedent also used a weapon during the altercation, compared with 1.9% of female homicides (Table 14).

Deaths of Undetermined Intent

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

The 16 NVDRS states included in this report collected data concerning 2,316 incidents involving 2,325 deaths during 2009 for which a determination of intent could not be made. Rates of undetermined death by month were at 0.2 or 0.3 per 100,000 population throughout the year (Table 16). Overall, the crude rate of undetermined deaths was 2.8 per 100,000 population. Rates of undetermined death were higher among males than among females (3.6 and 2.1 per 100,000 population, respectively) (Table 17). Although non-Hispanic whites accounted for 74.1% of undetermined deaths, rates were highest among AI/ANs (6.6 per 100,000 population). More than half (56.1%) of decedents for whom the manner of death was undetermined were aged 35–64 years. Rates were highest (27.3 per 100,000 population) among infants aged <1 year. Among decedents with an undetermined manner of death aged ≥18 years for which marital status was known, 37.1% never had been married, 26.2% were married, and 27.8% were divorced at the time of death. AI/AN females had the highest rates (7.0 per 100,000 population) of undetermined deaths compared with males or females of any other racial/ethnic population (Table 17).

Method and Location of Injury

The most common method of injury was poisoning (60.5%) (Table 18). No other known single method accounted for >3.2% of undetermined deaths. Among both males and females for which the method of injury was known, poisoning was reported for 58.8% and 63.2% of deaths, respectively. The majority of undetermined violent deaths occurred in a house or apartment, making it the most common place of injury for both males and females (76.4% and 82.6%, respectively). A natural area was the second most common setting, accounting for 3.4% of deaths among males and 1.1% among females, followed by a street or highway, accounting for 2.6% of deaths among males and 0.9% among females (Table 18).

Toxicology Results of Decedent and Precipitating Circumstances

Tests for alcohol were conducted for 80.7% of decedents of undetermined intent, and drug tests for amphetamines, antidepressants, cocaine, marijuana, and opiates were conducted for 77.7%, 70.7%, 79.0%, 39.0%, and 80.5% of decedents, respectively (Table 19). Among decedents who tested positive for alcohol (26.0%), 56.3% had a BAC of ≥0.08 g/dL. Among decedents tested for opiates, 58.2% were positive; of those tested for cocaine, 15.7% were positive; of those tested for marijuana, 10.4% were positive; and of those tested for antidepressants, 27.8% were positive (Table 19).

Precipitating circumstances were known for approximately 72% of deaths of undetermined intent. Of those, 29.9% of decedents had a problem with alcohol, and 56.8% had other substance abuse problems (e.g., those involving an illicit drug or prescription abuse) (Table 20). Although a current depressed mood was reported for only 13.8% of decedents, 40.9% of decedents with known circumstance information had a diagnosed current mental health problem, 29.8% were in treatment at the time of their death, 11.8% had a history of suicide attempts, 7.8% had disclosed intent to commit suicide, and 2.1% left a suicide note. Other circumstances noted most often were physical health problems (33.3%), a crisis during the preceding or impending 2 weeks (14.8%), or an intimate partner problem (11.0%) (Table 20). Of those with a current mental health problem, 63.7% had received a diagnosis of depression/dysthymia, 17.4% of bipolar disorder, and 14.8% of an anxiety disorder (Table 21).

A greater percentage of male than female decedents was reported to have an alcohol problem (32.9% and 25.0%, respectively) or other substance abuse problems (57.9% and 54.9%, respectively) at the time of death. Mental health problems were reported in a higher percentage of undetermined deaths of females than of males (53.2% and 33.3%, respectively). Females were more often diagnosed with bipolar and eating disorders than males, whereas males had higher percentages of anxiety disorders, schizophrenia, PTSD, and ADD/ADHD (Table 21). A higher percentage of females were currently in treatment for a mental health problem than males (43.2% and 21.4%, respectively) and had a history of suicide attempts (17.4% and 8.3%, respectively) (Table 20).

Unintentional Firearm Deaths

Sex, Race/Ethnicity, Age Group, and Seasonality

The 16 NVDRS states included in this report collected data concerning 87 unintentional firearm deaths during 2009 (Table 22). Males accounted for 87.4% of decedents. The majority (71.3%) were non-Hispanic whites, followed by non-Hispanic blacks (16.1%). Nearly one third of unintentional firearm deaths occurred among persons aged 15–19 years (14.9%) and 35–44 years (13.8%). Handguns accounted for 48.3% of unintentional firearm deaths, shotguns for 20.7%, and rifles for 17.2%.

Location of Injury

Approximately 65.5% of all unintentional firearm deaths took place in a house or apartment followed by natural areas (19.5%) (Table 22).

Context of Injury and Precipitating Circumstances

Overall, unintentional firearm injury deaths occurred most commonly while victims were playing with a gun (29.9%) or hunting (26.9%). The circumstances of injury included believing the firearm was unloaded (25.4%) and unintentionally pulling the trigger (11.9%) (Table 23).

Special Topics

Violent Deaths with Multiple Decedents

The 16 NVDRS states included in this report collected data concerning 374 incidents that resulted in multiple decedents. Firearms were the most common method (77.4%) used in incidents with multiple decedents, followed by sharp instruments (8.1%), blunt instruments (3.3%), poisoning (3.1%), and hanging/strangulation/suffocation (2.8%) (Table 24). Of a total of 815 victims, 486 (59.6%) were males; 348 (89.5%) of 389 suspects also were males. Non-Hispanic whites accounted for the highest percentage of decedents (56.1%), followed by non-Hispanic blacks (28.2%) and Hispanics (9.0%). Rates for victims were highest for AI/ANs and persons aged 20–34 years. Suspects most commonly were aged 35–44 years (Table 25).

Homicide Followed by Suicide

The 16 NVDRS states included in this report collected data concerning 198 violent incidents that occurred during 2009 in which a homicide was followed by the suicide of the suspect. Of 229 homicide decedents, 166 (72.5%) were female, and 187 (94.0%) suspects (suicide decedents) were male. More than 60% of both homicide and suicide decedents were non-Hispanic whites. The highest percentages of homicide decedents were aged 35–44 years (20.1%), whereas suicide decedents were most commonly aged 45–54 years (23.6%) (Table 26).

With respect to location, 82.5% of the homicides occurred in a house or apartment and 3.5% in a natural area. Firearms were the most common method used by suspects both in committing the homicide (87.8%) and in subsequently killing themselves (89.9%) (Table 27).

Tests for alcohol were conducted for 73.4% of homicide decedents and 68.8% of suicide decedents. Among decedents who tested positive for alcohol (20.2% of homicide victims and 32.1% of suicide decedents), 35.3% of homicide decedents and 72.7% of suicide decedents had a BAC of ≥0.08 g/dL at the time of death. Suspects who killed themselves following a homicide and who were tested subsequently for drugs had slightly higher percentages of positive tests for cocaine and marijuana than homicide victims (Table 28).

Overall, 10.4% of persons who killed themselves following a homicide had a current depressed mood, and 9.3% were receiving mental health treatment at the time of the fatal incident. Intimate partner relationship problems preceded homicide followed by suicide in 70.5% of suspect suicides. Other nonintimate partner relationship problems contributed to 12.6% of suspect suicides. Of suspects who killed themselves, 73.2% had had a personal crisis within the preceding or impending 2 weeks. Recent criminal legal problems were noted in 21.9% of suspect suicides and noncriminal problems in 2.7%; financial and job problems were contributing circumstances in 10.4% and 4.4% of suspect suicides respectively; 12.0% of suicide decedents had disclosed their intent to kill themselves; and 2.7% had a history of suicide attempts (Table 29).

Intimate Partner–Related Homicide

The 16 NVDRS states included in this report collected data concerning 567 incidents comprising 671 deaths resulting from intimate partner–related homicide that occurred during 2009. Of 671 homicide victims, 353 (52.6%) were female (Table 30). Although 58.4% of homicide victims were non-Hispanic whites, rates were higher for AI/ANs and non-Hispanic blacks (2.5 and 1.5 per 100,000 population respectively). Of 511 suspects, 410 (80.2%) were male; 222 (43.4%) were non-Hispanic whites and 141 (27.6%) were non-Hispanic blacks. The highest percentages of victims and suspects (25.2% and 17.6%, respectively) were persons aged 35–44 years. The highest percentage (41.4%) of victims were married at the time of death (Table 30). Tests for alcohol were conducted for 80.0% of victims. Of the 34.3% of decedents who tested positive for alcohol, 75.0% had a BAC of ≥0.08 g/dL. The percentage of victims tested for substances other than alcohol differed (range: 38.0%–58.1%) for various drugs; marijuana and antidepressants were evident in approximately 14.5% and 11.9% of victims tested for these substances respectively (Table 31).

Suicides Among Former or Current Military Personnel

The 16 NVDRS states included in this report collected data concerning 1,876 suicides by former or current military personnel that occurred during 2009. Of these decedents, 1,806 (96.3%) were male, and 1,695 (90.4%) were non-Hispanic whites. The greatest percentage of decedents were persons aged >35 years. The most common method (69.2%) used was a firearm, followed by hanging/strangulation/suffocation (14.3%) and poisoning (11.6%) (Table 32). Among the 63.6% former or current military personnel suicide decedents who were tested for alcohol, 29.9% tested positive; 65.0% of these decedents had a BAC of ≥0.08 g/dL (Table 33). Of those tested for antidepressants and opiates, 19.6% and 15.9% respectively, were positive. Although 41.5% were reported to be depressed at the time of death, and 39.6% had a diagnosed mental health problem, only 26.0% were receiving mental health treatment (Table 34). With respect to substance abuse, 15.9% had an alcohol problem, and 7.5% had a problem with other substances. Among those with known circumstance information, 27.3% had experienced a problem with an intimate partner, 35.6% had a physical health problem, and 26.9% had experienced an acute crisis during the preceding or impending 2 weeks. With respect to life stressors, 12.5% had experienced a financial problem, 13.8% a job problem, and 8.6% a recent criminal legal problem. Approximately one third (35.4%) left a suicide note, 13.4% had made a previous suicide attempt, and 29.5% had disclosed an intent to commit suicide (Table 34).

Legal Intervention

The 16 NVDRS states included in this report collected data on 127 legal-intervention incidents in 2009 resulting in 125 single-victim deaths, and five deaths in which the legal-intervention victim had recently committed a homicide. Of the 130 legal-intervention decedents, 56.9% were non-Hispanic whites and 29.2% were non-Hispanic blacks. With respect to location, 44.6% of legal-intervention deaths occurred in a house or apartment, 29.2% on a street or highway, and 7.7% in a motor vehicle (Table 35). The majority of decedents were aged 30–54 years (Table 36). Of the 92.3% of decedents from legal-intervention deaths who were tested for alcohol, 40.1% were positive for alcohol, and 79.6% of these decedents had a BAC of ≥0.08 g/dL (Table 37). The percentage of victims tested for other substances varied (range: 47.7%–80.0%). The presence of other drugs for which tests were positive also varied: 17.7% of those tested for marijuana, 15.5% of those tested for antidepressants, 10.8% of those tested for opiates, 10.6% of decedents tested for cocaine, and 4.0% of those tested for amphetamines were positive for these substances (Table 37).

Suicides Among Persons Aged ≥60 Years

In 2009, NVDRS collected data for 2,034 persons aged ≥60 years who died by suicide. Of those, rates of suicide were nearly identical among those aged 60–69 years, 70–79 years, and ≥80 years old (14.1–14.2 per 100,000 population). Male rates increased with age from 23.3 per 100,000 population for those aged 60–69 years, 26.8 for those aged 70–79 years, and 35.6 for those aged ≥80 years (Table 38). The opposite pattern occurred among females; for the same age groups, female rates decreased from 5.8 to 4.2 and 2.7, respectively. Among persons aged ≥60 years, rates were approximately 5.5 times higher among males than among females (26.2 and 4.6 per 100,000 population, respectively). Rates were highest among non-Hispanic whites (16.1 per 100,000 population), followed by A/PIs (8.4), Hispanics (5.8), and non-Hispanic blacks (4.2). At the time of death, persons aged 60–69 years most often were either married or divorced. Those aged 70–79 years and ≥80 years most often were either married or widowed (Table 38).

The majority (84.5%) of suicide decedents aged ≥60 years died in a house or apartment followed by natural areas (2.8%) or a street or highway (1.7%). Among suicide decedents aged ≥60 years, firearms accounted for 70.3% of deaths (9.9 per 100,000 population), poisoning for 14.5% (2.0 per 100,000 population), and hanging/strangulation/suffocation for 10.6% (1.5 per 100,000 population) (Table 38).

Precipitating circumstances were identified for approximately 87.0% of older adult suicides. Current depressed mood (37.4%), current mental health problem (35.2%), and physical health problems (46.2%) were the most commonly identified circumstances; 30.7% left a suicide note, and 23.4% disclosed their intent to commit suicide (Table 39).

Discussion

Violent deaths occur among men and women and among persons of all ages, races, and ethnicities. NVDRS can help identify populations particularly affected by violence. Furthermore, the system not only provides details on specific manners of violent deaths but also identifies common factors that span multiple domains of violence. These details can increase understanding about the nature of various forms of violence and help direct violence prevention efforts so they are more effective.

NVDRS continues to show that relationship problems, particularly with an intimate partner, are common circumstances preceding suicides, homicides, and homicide-suicides (i.e., suicide after homicide). These findings support the potential value of programs that help improve communication skills, social problem-solving, conflict resolution, and individual coping skills. The Safe Dates Program, a school-based program aimed at reducing dating violence among adolescents has shown promise with reducing long-term physical and sexual dating violence (7). Furthermore, primary prevention strategies designed to teach skills that reduce aggressive behavior toward others and improve social skills, emotional well-being and self-esteem can be targeted toward preadolescents and early adolescents before violent behaviors and patterns begin (8,9). Many universal school-based prevention programs have been found to reduce youth violence (9). These programs focus on promoting positive development of children and adolescents with a goal of creating long-term reductions in violence.

Use of alcohol and other substances often precedes both self-directed and interpersonal violent behavior (4,10–13). Intoxication can increase impulsivity (14), which has been linked to suicidal behavior (15) and aggression (16). Intoxication can also reduce physical control and awareness of surrounding risks making individuals more vulnerable to victimization (17). Even though information on alcohol and drug use in NVDRS was limited to victims and homicide-suicide perpetrators, the data still provide some evidence that violence prevention efforts might benefit from strategies intended to prevent and reduce alcohol and other substance abuse.

Most of the undetermined deaths in 2009 resulted from use of multiple substances. Although opioids, either heroin or prescription opioid analgesics, were the most common substances detected by toxicology tests, alcohol was also involved in many of these deaths, which complicates understanding of the intentions of the decedent. In addition, antidepressants were present at the time of death for many decedents, suggesting they had accessed mental health treatment and were prescribed these medications. More research is needed to assess the role prescription medications play in undetermined poisoning deaths. These findings also suggest that efforts are needed to help identify those with co-occurring substance abuse problems so that precautions can be taken by providers when prescribing opioid analgesics and antidepressants.

Mental health problems were the most common circumstances among suicide decedents. Depression was the most common diagnosis among those who were considered to have a current mental health problem. Although efforts are still needed to overcome barriers to seeking mental health services (e.g., financial barriers, lack of available services, and fear of social stigma), the findings in this report show that many suicide victims recently received mental health treatment, suggesting that additional strategies are needed to prevent suicide. Providers need to closely monitor and continually assess the risk for suicide among persons who are receiving mental health services, especially if they have other acute stressors and are using alcohol or other substances. In addition, this report showed that a large proportion of suicide decedents had disclosed their suicide intentions to others, and many had made previous suicide attempts. Both findings support the importance of treatment and monitoring for those who attempt suicide, as well as education for the general public on how to respond and seek help for persons expressing suicidal intentions (4,10–12,18).

Financial distress was also a common factor preceding death both from suicide and homicide. In addition, many homicides were precipitated by robberies and burglaries, criminal activities that have been found to be more common among those who are receiving low wages or are unemployed (19). Job training, counseling, and placement services for those facing difficult financial times might help reduce maladaptive responses to this type of strain (10–12,20–22).

In addition to demonstrating the importance of addressing individual stressors, a focus on broader factors, such as those stressors occurring at the community or society level, are needed. For example, escalating interpersonal and intimate partner problems often preceded the violent death. These findings underscore the importance of addressing contextual factors that condone or support the use of violence as a means of resolving conflict. For example, social and economic conditions within communities can create inequities in the distribution of and access to resources and opportunities, which can create community conflict and violence. Strategies that provide residents in distressed communities with better access to services that help reduce the stressors that exacerbate violence can be explored for effectiveness. Strategies that help communities plan, implement, and monitor prevention activities that are based on the best available evidence can facilitate prevention. For example, the CDC initiative Striving to Reduce Youth Violence Everywhere provides communities with information, training, and tools to help them identify effective strategies and put them into practice before violence occurs. (Additional information is available at http://www.vetoviolence.org/stryve.)

Limitations

The findings in this report are subject to several limitations. First, NVDRS data are available only from a limited number of states and therefore are not nationally representative. Second, the availability, completeness, and timeliness of data depend on partnerships among state health department NVDRS teams, CMEs, and law enforcement personnel. Data sharing and communication among partners is particularly challenging when states have independent county coroner systems rather than a centralized CME 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 developed fully. Third, toxicology data are not collected consistently across all states or for all alcohol and drug categories. The percentage of decedents testing positive might be affected by selective testing biases in medical examiner or coroner offices (23). Fourth, abstractors are limited to the data included in the reports they receive. Reports might not fully reflect all information known about an incident, particularly in the case of homicides, when data are less readily available until after prosecutions are complete. Fifth, case definitions present challenges when a single death is classified differently in different documents (e.g., "unintentional" in a police report, "homicide" in a CME report, and "undetermined" on the death certificate). NVDRS abstractors reconcile these cases using standardized NVDRS case definitions and select a single manner of death on the basis of all source documents. Sixth, although extensive coding training is conducted and help desk support is available daily, coding might vary depending on the abstractor's level of experience. For this reason, states regularly conduct blinded reabstraction of cases to test consistency and identify training needs. Seventh, the medical and mental health information (e.g., type of conditions, whether the victim was currently receiving treatment) are not often captured directly from medical records but from CME reports, family members, and friends of the victims. Therefore, the completeness of this information is 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, CME records, and law enforcement reports, which typically contain only circumstances associated with risk factors.

Conclusion

Accurate, timely, and comprehensive surveillance data can be used to monitor the occurrence of violence-related fatal injuries and assist public health and other authorities in the development, implementation, and evaluation of programs and policies that reduce and prevent violent deaths and injuries at the national, state, and local levels (24,25). Continued development and expansion of NVDRS is critical to the public health and criminal justice communities at the federal, state, and local levels that work to reduce the personal, familial, and societal costs of violence. Additional efforts are needed to increase the number of states participating in NVDRS, with the ultimate goal of full national representation, including all 50 states, the District of Columbia, and U.S. territories.

Acknowledgments

Contributors to this report included participating state Violent Death Reporting Systems; participating state agencies, including state health departments, vital registrars' offices, coroners' and medical examiners' offices, crime laboratories, and local and state law enforcement agencies; partner organizations, including the Safe States Alliance (formerly STIPDA), National Violence Prevention Network, National Association of Medical Examiners, National Association for Public Health Statistics and Information Systems, Council of State and Territorial Epidemiologists, and Association of State and Territorial Health Officials; federal agencies, including the Department of Justice (Bureau of Justice Statistics and the Federal Bureau of Investigation), the Department of the Treasury (Bureau of Alcohol, Tobacco, and Firearms); the International Association of Chiefs of Police; other stakeholders, researchers, and foundations, including Harvard University School of Public Health and the Joyce Foundation; and the National Institute for Occupational Safety and Health and the National Center for Health Statistics, CDC.

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