CDC Injury Research Agenda - Introduction, NCIPC

Injuries have a substantial impact on the lives of individual Americans, their families, and society. The consequences of injuries can be extensive and wide ranging. They are physical, emotional, and financial; in the case of disabling injuries, the consequences are enduring.

The mission of the National Center for Injury Prevention and Control (Injury Center) at the Centers for Disease Control and Prevention (CDC) is to prevent premature death and disability and to reduce the human suffering and medical costs caused by injuries. To prevent injuries and minimize their consequences when they occur, the Injury Center uses the public health approach—a systematic process to:

The Injury Center is the only organization in the federal government with the responsibility to address all phases of the injury research framework—from foundational research through dissemination research—for all major causes of injury among all age groups. To reach its goal of translating science into effective programs and policies, the Injury Center collaborates with other federal agencies and partners to document the incidence and impact of injuries, understand the causes, identify effective interventions, and promote their widespread adoption.

The importance of research in diminishing the problem of injuries has been described before. For example, the 1985 Institute of Medicine (IOM) report Injury in America concluded that supporting injury research is necessary to substantially reduce injury rates; the Injury Center’s formation was, in part, a result of this IOM finding. Fourteen years later, another IOM report, Reducing the Burden of Injury, re-emphasized the importance of a scientific foundation for injury prevention and called on the Injury Center to work with foundations, states and communities, businesses, and other federal agencies to stimulate and facilitate investment in injury research activities. Publishing this research agenda is a step toward that goal.

In 1999 in the United States, nearly 150,000 people died from injuries, and 1 in 10 people experienced a nonfatal injury serious enough to require a visit to the emergency department. Injuries—including unintentional injuries, homicide, and suicide—are the leading cause of death for people ages 1 to 44 (table 1). Injury is the leading cause of years of potential life lost before age 65.

For people ages 1 to 34, unintentional injuries alone claim more lives than any other cause. In 1999, motor vehicle traffic fatalities accounted for 42% of unintentional fatal injuries, representing more than 40,000 deaths (table 2). Poisoning, suffocation, drowning, falling, and fire each accounted for a substantial proportion of unintentional injury deaths. Adverse effects in medical settings caused an additional 2,540 fatalities.

The impact of injuries resulting from violence is also great. Homicide is the second leading cause of death for people ages 15 to 24 and the third or fourth leading cause for every other group between the ages of 1 and 34. Suicide is not only the eleventh leading cause of death across all ages but ranks second for people ages 25 to 34 and third for people ages 15 to 24.

Many injuries do not result in death but nevertheless place a considerable burden on individuals and society. Approximately one third of all emergency department visits and 8% of all hospital stays are due to injuries. Data from the National Electronic Injury Surveillance System indicate that falls account for an estimated 7.43 million emergency department visits annually, or 25% of all injury visits (table 3). Another 4.95 million visits (17%) are transportation related, and 1.67 million (5.7%) result from assaults. In addition, many injuries have consequences well beyond the initial need for medical attention. For instance, it is estimated that 5.3 million people in the U.S. have long-term disabilities from traumatic brain injury and 200,000 from spinal cord injury. The topic-specific chapters that follow present more detailed data, but clearly, injuries constitute a major burden on the public’s health.

Unintentional Injury Deaths, 1999
All Ages, All Races, Both Sexes
Cause of Death ^a	Number of Deaths	Percentage of Deaths
Motor vehicle traffic	40,965	41.9
Falls	13,162	13.5
Poisoning	12,186	12.5
Suffocation	5,503	5.6
Drownings ^b	3,529	3.6
Fires and burns	3,471	3.6
Natural disasters, animals, and environmental exposures	1,923	2.0
Pedestrian ^c	1,502	1.5
Struck by or against a person or object	894	0.9
Firearms	824	0.8
Machinery	622	0.6
Pedal cyclist ^c	185	0.2
Cut or pierced by sharp object	74	0.07
Overexertion	21	0.02
Other transport	3,725	3.3
Other and unspecified causes	9,724	9.9
Total Deaths	97,860	100.0

a. From Centers for Disease Control and Prevention. Recommended framework for presenting injury mortality data. MMWR 1997; 46(RR-14).
b. An Additional 501 water transprotation-related drownings are included in Other transport.
c. An additional 4,545 pedestrian fatalities and 615 pedal cyclist fatalities are included in Motor vehicle traffic.

Produced by: Office of Statistics and Programming, National Center for Injury Prevention and Control, CDC
Data Source: National Center for Health Statistics, Vital Statistics System

**Table 3**
**Leading Causes of Nonfatal Injuries Treated in Hospital Emergency Departments, United States, 2000**
**All Ages, All Races, Both Sexes**
Mechanism ^a	Number	Percent	Rate
Total (overall)	29,549,711	100.0	10,752.6
Unintentional	27,550,181	93.2	10,025.0
Falls	7,434,032	25.2	2,705.1
Struck by or against a person or object	4,970,710	16.8	1,808.7
Transport ^c	4,954,232	16.8	1,802.78
Overexertion	3,233,993	10.9	1,176.8
Cut or pierced by sharp object	2,364,651	8.0	860.5
Bite or sting other than dog bite	1,036,796	3.5	377.3
Foreign body	735,214	2.5	267.5
Fires and burns	539,423	1.8	196.3
Dog bites	345,563	1.2	125.7
Poisonings	334,652	1.1	121.8
Other	1,600,915	5.4	582.5
Assault	1,672,117	5.7	608.5
Sexual Assault	63,984	0.2	23.3
Struck by or against a person or object	1,294,597	4.4	471.1
Cut or pierced by sharp object	122,080	0.4	44.4
Bites	52,141	0.2	19.0
Firearms	48,570	0.2	17.7
Other	90,745	0.3	33.0
Self-harm	264,108	0.9	96.1
Poisonings	170,243	0.6	61.9
Cut or pierced by sharp object	65,256	0.2	23.7
Other	28,609	0.0	10.4
Legal Intervention ^d	63,304	0.2	23.0

a. From Centers for Disease Control and Prevention. National estimates of nonfatal injuries treated in hospital emergency departments--United States 2000. MMWR 2001: 50(17): 340-6.
b. Annual rates are expressed on a number of injuries per 100,000 of population.
c. The number, percentage, and rate of Transport injuries consist of the following subcategories combined: Motor vehicle occupant, Motorcyclist, Pedal cyclist, Pedestrian, and Other transport.
d. Injuries inflicted by law enforcement personnel in the course of official duties.

Produced by: Office of Statistics and Programming, National Center for Injury Prevention and Control, CDC.
Data Source: National Electronic Injury Surveillance System (NEISS), U.S. Consumer Product Safety Commission.

CDC’s Injury Center works to prevent unintentional and violence-related injuries and to minimize the consequences of injuries when they do occur. Its public health approach draws on such sciences as epidemiology and other biomedical sciences, biomechanics and other engineering sciences, social sciences, and economics in seven topic areas:

Research about occupational injury, an important part of the injury field, is addressed by CDC’s National Institute for Occupational Safety and Health (NIOSH). NIOSH and its partners established the National Occupational Research Agenda (NORA) to address occupational injuries. NORA can be viewed at http://www.cdc.gov/niosh/nora. However, research conducted in occupational settings that has important implications for nonoccupational injury prevention and control is also within the scope of the Injury Center research agenda.

Far beyond the borders of the U.S., injuries remain an important cause of death and disability. The Injury Center is committed to working with the research community to better understand and prevent injuries worldwide. However, because Injury Center funds for global health are limited, this research agenda focuses on domestic issues.

To ensure consideration of a broad range of research, the Injury Center invited a wide array of constituents to participate in developing the research agenda. At the beginning of the agenda-setting process, Injury Center staff gathered input from key partner organizations and agencies that represented researchers, practitioners, and policy makers. Staff then drafted materials and presented them to topic-specific work groups consisting of 10 to 15 members, including relevant federal partners, invited experts outside of the federal government, and Injury Center staff. Each work group met for two days to identify, discuss, and prioritize potential research needs.

The Injury Center posted a draft of the agenda on the Internet and announced its posting in the Federal Register, inviting public comment. Through correspondence with all current grantees, relevant federal agencies, researchers, practitioners, and professional organizations, the Injury Center solicited input from the injury prevention community. The Injury Center also offered to mail copies of the draft research agenda to groups and individuals without Internet access.

Throughout the process, the Injury Center relied on guidance from members of its Research Agenda Steering Committee, which consisted of six leaders in injury control and public health with an encompassing variety of perspectives. Additionally, members of the Secretary’s Advisory Committee on Injury Prevention and Control commented on the content of the draft research agenda and provided advice about its implementation.

To organize the body of potential research about injury prevention and control for this agenda, the Injury Center used a model for the phases of research that extends from work by Holder and his colleagues (figure 1). Building on other health research, the approach suggests that research moves along a continuum: from basic and descriptive research to intervention development and testing to research about disseminating and maintaining effective intervention strategies. The research priorities in the chapters that follow address all of these phases.

Foundational
Foundational research covers the basic studies and public health surveillance approaches that define and quantify the extent of an injury problem. These activities establish the causes of injuries, create causal models for injury prevention, and provide a foundation for developing theory-based interventions.

Developmental
Developmental research supports the design and preliminary testing of potential strategies to prevent and control injuries. Included are risk-factor research and pilot and feasibility studies that measure how interventions affect key variables in the causal chain.

Efficacy and Effectiveness
Efficacy and effectiveness research assesses whether a given intervention actually reduces injuries. These studies establish whether an intervention has the desired effect, estimate the effect size under optimal and real-world conditions, measure the costs of the intervention, and identify unintended consequences. Ideally, efficacy should first be established under conditions that optimize both the intensity of implementation and the study population’s acceptance of the intervention.

Dissemination
Dissemination research examines the robustness of intervention effectiveness given variations in implementation and/or acceptance of the intervention. Studies focus on methods to encourage practitioners and policy makers to adopt science-based programs, policies, and laws that reduce intentional and unintentional injuries and on factors that increase organizational and community capacity for tailoring, implementing, and sustaining effective interventions.

This agenda defines a research priority as an important injury problem that can be meaningfully addressed with a modest number of research studies (approximately 10 to 20) and that can include several related research questions. Figure 2 shows an example of a research priority for the topic Preventing Injuries at Home and in the Community.

Figure 2
Example of Topic, Priority, and Research Questions
Topic	Priority	Research Question
Preventing Injuries at Home and in the Community	Evaluate strategies for widespread dissemination and implementation of effective interventions to reduce injuries at home and in the community	1) What are the barriers to disseminating effective home injury prevention programs in indigent urban populations? 2) How can effective community smoke alarm installation programs be extended inexpensively to large populations?

To identify research needs for each topic, Injury Center staff reviewed the current state of knowledge in the field and noted the most critical research gaps. Then, work group members generated many priorities, revised them, and identified those the Injury Center should address in the near term. The work group process fostered debate and created a forum where ideas and suggestions could be introduced to broaden the Injury Center’s perspective. This breadth is reflected in the priorities enumerated in the topic-specific chapters.

Three criteria guided the selection of Injury Center research priorities: institutional mission, public health burden, and research opportunity (figure 3). Above all, the research priorities had to match the Injury Center’s mission of reducing the incidence, severity, and adverse outcomes of injury through the application of public health methods. Thus, research that applies directly to public health practice received primary emphasis. Consideration of the public health burden ensured inclusion of research about the major types and causes of injuries. An emphasis on research opportunity encouraged further focus on risk factors and interventions associated with a large, preventable fraction as well as on interventions that will soon be ready for widespread dissemination.

Every research priority in this agenda is important. After considering input from experts in the field, Injury Center staff identified the most important priorities, those that warrant the greatest attention and intramural and extramural resources from the Injury Center over the next three to five years. They are designated with asterisks in each topic-specific chapter. Staff also identified research priorities that span topics. These cross-cutting research priorities are described in the section that follows.

NOTE: For all priorities in this agenda, special attention should be paid to vulnerable populations that experience disparate, elevated risks. Such groups include racial and ethnic minorities, persons with disabilities, the youngest and oldest Americans, recent immigrants, and rural residents.