Injuries and violence end more lives by age 30 in the U.S. than any other cause, and infectious disease remains a challenge for the nation as well, according to a review of the state of the nation's health.
The top three causes of death in the first 3 decades of life -- unintentional injury, suicide, and homicide -- together accounted for 79% of deaths in that age bracket, Tamara Haegerich, PhD, and colleagues at the CDC's National Center for Injury Prevention and Control in Atlanta found.
Overall mortality from infectious causes has dropped over the past 2 decades worldwide, but mainly in lower-income countries, Rima Khabbaz, MD, of the CDC's Office of Infectious Diseases, and colleagues at the agency noted in a second review.
Emerging diseases, outbreaks of vaccine-preventable disease, and antimicrobial resistance present significant risks in the U.S., they concluded.
"Priority actions to meet these challenges include addressing high-burden diseases such as HIV and chronic hepatitis, foodborne diseases, and healthcare-associated infections; targeting outbreaks of vaccine-preventable diseases; and controlling endemic and emerging vector-borne and zoonotic infections," Khabbaz's group wrote.
Both reviews appeared online in The Lancet in a series entitled "The health of Americans."
Other papers in the series highlighted:
- The slowdown in healthcare expenditure in the country over the past decade, though those costs remain the highest per person among nations
- The potential public health and prevention benefits of the Affordable Care Act's mandate to serve as a bridge between the U.S. public health system and private healthcare
- Chronic disease as a key challenge in the U.S., where half of all adults have diabetes, heart disease, obesity, or some other chronic condition, despite the fact that most of these stem from just a few, largely preventable risk factors, like smoking, a poor diet, and physical inactivity
Injury, Violence, and Accidents
"Injuries and violence are not accidents and are not inevitable," Haegerich's group noted. "They can be prevented."
CDC data from the Web-Based Injury Statistics Query and Reporting System showed that per 100,000 people of all ages, 37.9 people died from unintentional injuries and 17.5 from violence in 2010.
The most frequent causes in 2010 were:
- Violence (55,000 deaths)
- Motor vehicle crashes (33,687)
- Poisoning (33,041)
- Falls (26,009)
- Suffocation (6,165)
- Drowning (3,782)
- Fires (2,845)
"The number of deaths tells only part of the story," the reviewers noted. They pointed to 2.3 million people treated in U.S. emergency departments due to assault or self-harm; while about one in 10 people had a nonfatal unintentional injury that prompted a visit to the emergency department.
"The results extend beyond injury affliction," Haegerich and colleagues pointed out. "Injuries and violence can have other physical, mental, sexual, and reproductive health consequences that can become chronic and result in substantial health burden and costs."
The estimated annual cost was more than $513 billion in medical care and lost productivity across the lifespan of victims.
There is strong evidence to support prevention interventions, they noted.
Those that address social and economic factors to make the default decision a healthy one can have a bigger impact than those that require intensive, one-on-one counseling, they said.
For prevention of youth violence, the independent Community Preventive Services Task Force recommends early childhood home visitation, school-based violence prevention, and therapeutic foster care.
During a child's first 2 years of life, home visitation programs for high-risk families that provide training -- such as on parenting and life skills -- as well as education and work opportunities, community service linkage, or other assistance, can reduce child maltreatment by 39%.
Programs at school to help kids build social problem-solving skills and to promote regulation of emotions can reduce violent behavior by 15% overall and by 29% among high-school students.
Intensive therapeutic foster care for chronically delinquent adolescents was associated with 72% more reduction in violent crime than standard residential treatment in one study.
However, too often these strategies aren't available, affordable, or used, Haegerich and colleagues noted.
"The Affordable Care Act provides an opportunity to integrate injury and violence prevention into healthcare delivery systems," they wrote.
"The law includes coverage of recommended preventive services that health insurance has traditionally not covered, and requires the meaningful use of electronic health records. Opportunity now exists to advance injury prevention through screening and referral for injury risk factors such as depression, domestic violence (for women of child-bearing age), alcohol misuse, and behavioral problems (for children). As new evidence emerges, opportunity might arise for coverage for other types of screening, such as for fall risk among older adults."
The Affordable Care Act also provides new opportunities for control of infectious disease through expanded access to care and better healthcare coordination for underserved populations, Khabbaz and colleagues said.
Priorities for prevention highlighted by the group were "measures with broad-reaching effects such as vaccines, multifaceted approaches to decrease antimicrobial resistance, and testing and education to reduce the further spread of preventable infections."
"In the USA, the largest gains will be achieved through focused efforts to reduce high burden and high consequence diseases and to strengthen efforts to promote early detection of and rapid response to emerging infections," they wrote.
With globalization, though, efforts within the country won't be enough to tackle emerging infections -- such as Middle East respiratory syndrome (MERS), dengue fever, and chikungunya -- that can rapidly emerge and spread from anywhere in the world, they noted.
In February, the U.S. joined other countries and the World Health Organization and other international organizations in a global health security agenda with objectives for antimicrobial resistance, biosafety and biosecurity, global disease detection and response networks, and emergency response.
Closer to home, physicians can focus on keeping up vaccination rates and communicating their importance to patients and families as well as stemming healthcare-associated infections, Khabbaz's group noted.
Feedback reports from the National Nosocomial Infections Surveillance System have shown a 41% decrease in central line-associated bloodstream infections, a 17% drop in surgical-site infections, and a 7% decline in catheter-associated urinary tract infections from 2008-2009 to 2011.
More effective implementation of antibiotic stewardship programs to restrict the use of these drugs for appropriate indications will be crucial, and enhanced surveillance and laboratory networks with advanced molecular diagnostic capacities can help too, the reviewers suggested.
The reviewers disclosed no relevant relationships with industry.
- Reviewed by F. Perry Wilson, MD, MSCE Instructor of Medicine, Perelman School of Medicine at the University of Pennsylvania and Dorothy Caputo, MA, BSN, RN, Nurse Planner
The LancetSource Reference: Haegerich TM, et al "Prevention of injury and violence in the USA" Lancet 2014; DOI: 10.1016/S0140-6736(14)60074-X.
The LancetSource Reference: Khabbaz RF, et al "Challenges of infectious diseases in the USA" Lancet 2014; DOI: 10.1016/S0140-6736(14)60890-4.