title: Variation in pediatric and adolescent firearm mortality rates in rural and urban US counties.
abstract: OBJECTIVE
  We examined whether firearm mortality rates among children varied across US counties along a rural-urban continuum.
  
  
  METHODS
  US vital statistics data were accessed for all pediatric (age: 0-19 years) firearm deaths from 1999 through 2006. Deaths were analyzed according to a modified rural-urban continuum code (based on population size and proximity to metropolitan areas) assigned to each county (3141 counties).
  
  
  RESULTS
  In the 8-year study period, there were 23649 pediatric firearm deaths (15190 homicides, 7082 suicides, and 1377 unintentional deaths). Pediatric nonfirearm mortality rates were significantly higher in the most-rural counties (adjusted rate ratio: 1.36 [95% confidence interval [CI]: 1.13-1.64]), compared with the most-urban counties. The most-rural counties demonstrated virtually identical pediatric firearm mortality rates (adjusted rate ratio: 0.91 [95% CI: 0.63-1.32]), compared with the most-urban counties. The most-rural counties had higher rates of pediatric firearm suicide (adjusted rate ratio: 2.01 [95% CI: 1.43-2.83]) and unintentional firearm death (adjusted rate ratio: 2.19 [95% CI: 1.27-3.77]), compared with the most-urban counties. Pediatric firearm homicides rates were significantly higher in the most-urban counties (adjusted rate ratio: 3.69 [95% CI: 2.00-6.80]), compared with the most-rural counties.
  
  
  CONCLUSIONS
  Children in the most-rural US counties had firearm mortality rates that were statistically indistinguishable from those for children in the most-urban counties. This finding reflects a greater homicide rate in urban counties counterbalanced by greater suicide and unintentional firearm death rates in rural counties. Nonfirearm mortality rates were significantly greater outside the most-urban US counties.
authors.affiliation: Children's Hospital of Philadelphia, Department of Surgery, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104-4227, USA. nance@email.chop.edu
authors.forename: Michael L
authors.initials: ML
authors.lastname: Nance
authors.forename: Brendan G
authors.initials: BG
authors.lastname: Carr
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Kallan
authors.forename: Charles C
authors.initials: CC
authors.lastname: Branas
authors.forename: Douglas J
authors.initials: DJ
authors.lastname: Wiebe
mesh_terms: D000293:Adolescent; D002648:Child; D005260:Female; D005389:Firearms; D006708:Homicide / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D012424:Rural Population; D013405:Suicide / Q000706:statistics & numerical data*; D014481:United States / Q000453:epidemiology; D014505:Urban Population / Q000706:statistics & numerical data*; D014948:Wounds, Gunshot / Q000401:mortality*