Differences in State Traumatic Brain Injury–Related Deaths, by Principal Mechanism of Injury, Intent, and Percentage of Population Living in Rural Areas — United States, 2016–2018

Weekly / October 15, 2021 / 70(41);1447–1452

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Jill Daugherty, PhD1; Hong Zhou, MS, MPH1; Kelly Sarmiento, MPH1; Dana Waltzman, PhD1 (View author affiliations)

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Summary

What is already known about this topic?

Traumatic brain injuries (TBIs) have contributed to approximately one million U.S. deaths during the last 2 decades. Rates of TBIs vary by state.

What is added by this report?

During 2016–2018, states in the Northeast had the lowest TBI–related death rates (12.8 per 100,000), whereas rates were highest in the South (19.2). Suicide and unintentional falls contributed the highest number of TBI-related deaths in most states. States with a large proportion of residents living in rural areas had higher TBI-related death rates.

What are the implications for public health practice?

Expanding evidence-based prevention strategies that address TBI-related deaths is warranted, especially among states with high rates due to suicide, unintentional falls, and motor vehicle crashes.

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Related Materials

Traumatic brain injuries (TBIs) have contributed to approximately one million deaths in the United States over the last 2 decades (1). CDC analyzed National Vital Statistics System (NVSS) mortality data for a 3-year period (2016–2018) to examine numbers and rates of TBI-related deaths, the percentage difference between each state’s rate and the overall U.S. TBI-related death rate, leading causes of TBI, and the association between TBI and a state’s level of rurality. During 2016–2018, a total of 181,227 TBI-related deaths (17.3 per 100,000 population per year) occurred in the United States. The percentage difference between state TBI-related death rates and the overall U.S. rate during this period ranged from 46.2% below to 101.2% above the overall rate. By state, the lowest rate was in New Jersey (9.3 per 100,000 population per year); the states with the highest rates were Alaska (34.8), Wyoming (32.6), and Montana (29.5). States in the South and those with a higher proportion of residents living in rural areas had higher rates, whereas states in the Northeast and those with a lower proportion of residents living in rural areas had lower TBI-related death rates. In 43 states, suicide was the leading cause of TBI-related deaths; in other states, unintentional falls or unintentional motor vehicle crashes were responsible for the highest numbers and rates of TBI-related deaths. Consistent with previous studies (2), differences in TBI incidence and outcomes were observed across U.S. states; therefore, states can use these findings to develop and implement evidence-based prevention strategies, based on their leading causes of TBI-related deaths. Expanding evidence-based prevention strategies that address TBI-related deaths is warranted, especially among states with high rates due to suicide, unintentional falls, and motor vehicle crashes.

NVSS collects data on all deaths that occur among U.S. residents. For this study, data from NVSS’s multiple cause-of-death files for 2016–2018 were combined to estimate the incidence of TBI-related deaths. An established surveillance definition was used to classify TBI-related deaths with codes from the International Classification of Diseases, Tenth Revision (ICD-10)* if 1) the single underlying cause of death was listed as an injury, consistent with previous reports (1), and 2) any of the multiple codes for causes of deaths listed in the death record indicated a TBI-related diagnosis. National Death Index record axis condition codes were used (both Part I and Part II of entity axis cause of death condition codes) (3). Data on TBI-related deaths were stratified by state and principal mechanism of injury (cause). Injuries were grouped first by intent (intentional, unintentional, or undetermined intent). Intentional injuries were further categorized as suicides or homicides. Unintentional injuries were categorized by mechanism of injury (including motor vehicle crash, fall, being struck by or against an object, or unspecified). Principal mechanism of injury was determined based on the CDC-recommended external cause of injury mortality matrix for ICD-10 codes (4) and reported as the average of the 3-year grouping. U.S. Census Bureau data were used to determine the percentage of each state’s population that lived in rural areas. Urban areas encompass at least 2,500 persons, at least 1,500 of whom live outside institutional group quarters; rural areas encompass all population, housing, and territory not included within an urban area†

Each state’s TBI-related death rates and corresponding 95% confidence interval (CI) were based on U.S. bridged-race population estimates of the resident population (5). U.S. Census population estimates for the year 2000 were used as the standard for age-adjusted rates by the direct method (6). The percentage difference between the overall TBI-related death rate for the United States and each state’s TBI-related death rate was calculated. Nonoverlapping CIs were used to analyze between-group differences for rates of TBI-related deaths. Because the use of nonoverlapping CIs is a conservative approach for determining statistically significant differences, a t-test was conducted if the 95% CI of two groups overlapped to determine whether there was a statistically significant difference. A Pearson correlation was calculated to determine the association between a state’s level of rurality and its TBI-related death rate. SAS (version 9.4; SAS Institute) was used for all analyses. This activity was reviewed by CDC and was conducted consistent with applicable federal law and CDC policy.§

During 2016–2018, a total of 181,227 TBI-related deaths occurred in the United States. The overall U.S. TBI-related death rate was 17.3 per 100,000 population per year (Table 1). The Northeast Census region had the lowest TBI-related death rate (12.8), followed by the West (16.8), and Midwest (18.1); the highest rate (19.2) was in the South. The lowest state TBI-related death rate was in New Jersey (9.3); the highest rates were in Alaska (34.8), Wyoming (32.6), and Montana (29.5) (t-tests, p-value<0.05). State-specific TBI-related death rates were lower than the overall U.S. rate in 13 states and the District of Columbia (DC), higher in 35 states, and very close to the national average in one state (Pennsylvania). New Jersey’s TBI-related death rate was 46.2% lower than the overall U.S. rate, and Alaska’s rate was 101.2% higher.

States with higher percentages of rural residents had higher rates of TBI-related deaths (r = 0.65, p<0.0001) (Supplementary Figure, https://stacks.cdc.gov/view/cdc/110372). Overall, more than two in five (44.4%) TBI-related deaths were attributable to intentional causes (suicide and homicide). Suicide was the leading category or tied for the leading category of TBI-related deaths in 43 states (Table 2). In states where suicide was not the leading category of TBI-related deaths, unintentional falls were often responsible for the highest rate of TBI-related deaths (Table 3); unintentional falls were the second most common cause of TBI-related deaths in many states. Unintentional motor vehicle crashes and homicide were the third and fourth most common categories of TBI-related deaths, respectively, in the United States during 2016–2018.

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Discussion

During 2016–2018, approximately 180,000 TBI-related deaths occurred in the United States. Rates of TBI-related deaths rates differed considerably by state during this period. The four states with the lowest rates were in the Northeast; the rates in these states were at least 35% lower than the overall U.S. rate. The three states with the highest rates were in the West and were at least 70% higher than the overall U.S. rate. This pattern occurred both for intentional and unintentional causes of TBI-related deaths.

Level of rurality might play a role in the incidence of TBI-related deaths in states with higher rates. Residents in rural areas experience a higher incidence of TBI (2) and might face barriers to accessing emergency medical care (including Level I trauma centers) (7) and specialized TBI care (8). Disparate TBI-related death rates might also result from risk differences in mechanisms of injury and implementation of state injury prevention policies. Although seat belt use is associated with a 50% reduction in deaths from a motor vehicle crash, legislation and enforcement vary among states (9). CDC’s Motor Vehicle Prioritizing Interventions and Cost Calculator for States (MVPICCS) tool identifies effective motor vehicle injury prevention strategies that states can implement.**

Approximately 40% of TBI-related deaths examined were categorized as intentional injuries (i.e., homicides or suicides). Suicide was responsible for the highest number and the highest rate of TBI-related deaths for most states. The rates of TBI-related deaths due to homicide in some southern jurisdictions (e.g., Louisiana, DC, and South Carolina) were nearly double those in many states in the Northeast. A previous report found that nearly all TBI-related deaths from suicide had firearm injury as the underlying mechanism of injury (1). These patterns correspond with regional analyses indicating that firearm-related homicide rates are highest in the South and firearm-related suicide rates are highest in the South and West (10). State and community implementation of a multipronged approach, including evidence-based violence prevention strategies, such as those identified in CDC’s technical packages on violence and suicide prevention,†† could be considered to reduce suicides and homicides, including those that are TBI-related.

Unintentional falls were the second most common cause of TBI-related deaths in many states. Evidence-based, cost-effective prevention efforts could be implemented to decrease fall-related injuries and deaths, most commonly experienced by older adults. CDC’s Stopping Elderly Accidents, Deaths and Injuries (STEADI) initiative includes resources and tools for health care providers that are designed to improve identification of patients at risk for a fall and support implementation of effective strategies to treat or reduce the risk for fall-related injuries, including TBI.§§

The findings in this report are subject to at least three limitations. First, incomplete reporting or misclassification of cause of death (i.e., deaths from other causes or deaths indirectly caused by TBI) on death certificates might bias estimates of TBI-related deaths. For example, NVSS data might not include all TBI-related deaths, especially if a TBI was not explicitly documented in death records. Second, data were combined across multiple years; therefore, a trend analysis was not possible; different patterns have emerged over time. Finally, data presented in this report are from the years 2016–2018, and might not reflect more recent differences. The COVID-19 pandemic, in particular, might have had an impact on more recent estimates.

Expanding evidence-based prevention strategies that address TBI-related deaths is warranted, especially among states with high rates attributable to suicide, unintentional falls, and motor vehicle crashes. States can employ a number of evidence-based strategies (such as those identified in CDC’s technical packages on violence and suicide prevention) to reduce the leading causes of TBI-related deaths, including those for suicide,¶¶ unintentional falls,*** and motor vehicle crashes.†††

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Corresponding author: Jill Daugherty, [email protected], 404-498-1830.

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1Division of Injury Prevention, National Center for Injury Prevention and Control, CDC.

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All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.

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* Traumatic brain injuries are defined by the following ICD-10 diagnosis codes: S01, S02.0, S02.1, S02.3, S02.7-S02.9, S04.0, S06, S07.0, S07.1, S07.8, S07.9, S09.7-S09.9, T90.1, T90.2, T90.4, T90.5, T90.8, and T90.9. https://www.cdc.gov/injury/wisqars/mapping_help/injury_type.html

† https://www.census.gov/programs-surveys/geography/guidance/geo-areas/urban-rural/2010-urban-rural.html

§ 45 C.F.R. part 46, 21 C.F.R. part 56; 42 U.S.C. Sect. 241(d); 5 U.S.C. Sect. 552a; 44 U.S.C. Sect. 3501 et seq.

https://www2.census.gov/geo/pdfs/maps-data/maps/reference/us_regdiv.pdf

** https://www.cdc.gov/transportationsafety/calculator/index.html

†† https://www.cdc.gov/violenceprevention/communicationresources/pub/technical-packages.html

§§ www.cdc.gov/STEADI

¶¶ https://www.cdc.gov/suicide/index.html

*** https://www.cdc.gov/transportationsafety/index.html

††† https://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html

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References

  1. Daugherty J, Waltzman D, Sarmiento K, Xu L. Traumatic brain injury-related deaths by race/ethnicity, sex, intent, and mechanism of injury—United States, 2000–2017. MMWR Morb Mortal Wkly Rep 2019;68:1050–6. https://doi.org/10.15585/mmwr.mm6846a2 PMID:31751321
  2. Bazarian JJ, McClung J, Shah MN, Cheng YT, Flesher W, Kraus J. Mild traumatic brain injury in the United States, 1998–2000. Brain Inj 2005;19:85–91. https://doi.org/10.1080/02699050410001720158 PMID:15841752
  3. Redelings MD, Wise M, Sorvillo F. Using multiple cause-of-death data to investigate associations and causality between conditions listed on the death certificate. Am J Epidemiol 2007;166:104–8. https://doi.org/10.1080/02699050410001720158 PMID:15841752
  4. CDC. ICD framework: external cause of injury mortality matrix for ICD-10. Atlanta, GA: US Department of Health and Human Services, CDC; 2010. https://www.cdc.gov/nchs/injury/ice/matrix10.htm
  5. National Center for Health Statistics. U.S. census populations with bridged race categories. Hyattsville, MD:US Department of Health and Human Services, CDC; 2019. https://www.cdc.gov/nchs/nvss/bridged_race.htm
  6. Faul M, Xu L, Wald MM, Coronado VG. Traumatic brain injury in the United States: emergency department visits, hospitalizations and deaths 2002–2006. Atlanta, GA: US Department of Health and Human Services, CDC; 2010. https://www.cdc.gov/traumaticbraininjury/pdf/blue_book.pdf
  7. American Trauma Society. Find your local trauma center—courtesy of the 2019 ATS-TIEP. Falls Church, VA: American Trauma Society; 2020. https://www.amtrauma.org/page/FindTraumaCenter
  8. Yue JK, Upadhyayula PS, Avalos LN, Cage TA. Pediatric traumatic brain injury in the United States: rural-urban disparities and considerations. Brain Sci 2020;10:135. https://doi.org/10.3390/brainsci10030135 PMID:32121176
  9. National Highway Traffic Safety Administration. Traffic safety facts 2015 data: rural/urban comparison of traffic fatalities. Washington, DC: US Department of Transportation, National Highway Traffic Safety Administration; 2017. https://www.nhtsa.gov/document/traffic-safety-facts-2015-data
  10. Fowler KA, Dahlberg LL, Haileyesus T, Annest JL. Firearm injuries in the United States. Prev Med 2015;79:5–14. https://doi.org/10.1016/j.ypmed.2015.06.002 PMID:26116133

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TABLE 1. Estimated number,* age-adjusted rates,† and percentage difference§ from overall U.S. rate of traumatic brain injury–related deaths,,** by state — United States, 2016–2018Return to your place in the text
Region††/State No. Rate (95% CI) % Difference from overall U.S. rate
U.S. total 181,227 17.3 (17.2–17.4)      NA
Northeast 24,550 12.8 (12.6–12.9)      −26.0
Midwest 40,272 18.1 (17.9–18.3)      4.6
South 75,361 19.2 (19.1–19.4)      11.0
West 41,044 16.8 (16.6–17.0)      −2.9
Alabama 3,235 21.2 (20.5–22.0)      22.5
Alaska 752 34.8 (32.2–37.3)      101.2
Arizona 4,691 20.3 (19.7–20.9)      17.3
Arkansas 2,314 24.3 (23.3–25.3)      40.5
California 15,264 12.3 (12.1–12.4)      −28.9
Colorado 3,776 21.9 (21.2–22.6)      26.6
Connecticut 1,984 16.2 (15.4–16.9)      −6.4
Delaware 396 12.4 (11.1–13.6)      −28.3
District of Columbia 239 11.3 (9.8–12.7)      −34.7
Florida 13,647 18.4 (18.1–18.7)      6.4
Georgia 6,400 20.3 (19.8–20.8)      17.3
Hawaii 662 12.8 (11.8–13.8)      −26.0
Idaho 1,380 26.4 (25.0–27.8)      52.6
Illinois 5,395 13.0 (12.6–13.3)      −24.9
Indiana 3,835 18.3 (17.7–18.9)      5.8
Iowa 1,933 18.2 (17.3–19.0)      5.2
Kansas 1,985 21.3 (20.3–22.2)      23.1
Kentucky 3,232 23.2 (22.3–24.0)      34.1
Louisiana 3,109 21.6 (20.9–22.4)      24.9
Maine 1,069 22.5 (21.0–23.9)      30.1
Maryland 2,484 12.7 (12.2–13.2)      −26.6
Massachusetts 2,507 10.4 (10.0–10.9)      −39.9
Michigan 5,234 15.7 (15.3–16.2)      −9.2
Minnesota 2,754 14.8 (14.3–15.4)      −14.5
Mississippi 2,244 24.3 (23.2–25.3)      40.5
Missouri 4,818 24.8 (24.1–25.6)      43.4
Montana 993 29.5 (27.6–31.4)      70.5
Nebraska 1,290 20.9 (19.7–22.0)      20.8
Nevada 1,875 20.1 (19.2–21.1)      16.2
New Hampshire 856 18.6 (17.3–19.9)      7.5
New Jersey 2,752 9.3 (9.0–9.7)      −46.2
New Mexico 1,690 25.3 (24.1–26.6)      46.2
New York 6,714 10.1 (9.8–10.3)      −41.6
North Carolina 6,339 19.4 (18.9–19.9)      12.1
North Dakota 576 23.8 (21.7–25.8)      37.6
Ohio 7,787 20.5 (20.0–21.0)      18.5
Oklahoma 2,880 23.2 (22.4–24.1)      34.1
Oregon 2,919 21.3 (20.5–22.0)      23.1
Pennsylvania 7,688 17.4 (17.0–17.8)      0.6
Rhode Island 426 10.9 (9.8–12.0)      −37.0
South Carolina 4,310 27.3 (26.5–28.2)      57.8
South Dakota 690 25.0 (23.1–26.9)      44.5
Tennessee 4,392 20.6 (19.9–21.2)      19.1
Texas 13,546 16.2 (16.0–16.5)      −6.4
Utah 1,851 21.7 (20.7–22.7)      25.4
Vermont 554 26.2 (24.0–28.5)      51.4
Virginia 5,330 19.8 (19.3–20.4)      14.5
Washington 4,601 19.4 (18.9–20.0)      12.1
West Virginia 1,264 20.9 (19.7–22.1)      20.8
Wisconsin 3,975 20.4 (19.8–21.1)      17.9
Wyoming 590 32.6 (29.9–35.3)      88.4

Abbreviations: CI = confidence interval; ICD-10 = International Classification of Diseases, Tenth Edition; NA = not applicable.
* Deaths with missing age were excluded.
† Per 100,000 population per year. Age-adjusted to the 2000 U.S. standard population. Adjustments made by 12 age groups: 0–4, 5–9, 10–14, 15–19, 20–24, 25–34, 35–44, 45–54, 55–64, 65–74, 74–84, and ≥85 years.
§ Differences in any two rates were considered statistically significant if their confidence intervals were not overlapping.
Traumatic brain injuries are defined by the following ICD-10 diagnosis codes: S01, S02.0, S02.1, S02.3, S02.7-S02.9, S04.0, S06, S07.0, S07.1, S07.8, S07.9, S09.7-S09.9, T90.1, T90.2, T90.4, T90.5, T90.8, and T90.9.
** Record-Axis Condition codes were used (usually included both Part I and Part II of Entity-Axis Condition codes). Death estimates were obtained from CDC’s National Vital Statistics System.
†† https://www2.census.gov/geo/pdfs/maps-data/maps/reference/us_regdiv.pdf

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TABLE 2. Estimated number* and age-adjusted rates† of intentional traumatic brain injury–related deaths,§ by state and mechanism of injury — United States, 2016–2018Return to your place in the text
Region**/State Intentional total Suicide†† Homicide Other§§
No. Rate (95% CI) No. Rate (95% CI) No. Rate (95% CI) No. Rate (95% CI)
U.S. total 80,479 8.0 (7.9–8.0) 62,985 7.1 (7.1–7.2) 17,494 1.8 (1.8–1.9) 2,571 0.3 (0.2–0.3)
Northeast 8,510 4.8 (4.7–4.9) 6,463 4.1 (4.0–4.2) 2,047 1.2 (1.2–1.3) 448 0.2 (0.2–0.3)
Midwest 17,009 8.1 (8.0–8.2) 13,322 7.3 (7.1–7.4) 3,687 1.9 (1.8–1.9) 517 0.2 (0.2–0.3)
South 36,156 9.4 (9.3–9.5) 27,869 8.4 (8.3–8.5) 8,287 2.3 (2.2–2.3) 923 0.2 (0.2–0.3)
West 18,804 7.8 (7.7–7.9) 15,331 7.4 (7.2–7.5) 3,473 1.5 (1.4–1.5) 683 0.3 (0.3–0.3)
Alabama 1,807 12.1 (11.5–12.7) 1,328 10.1 (9.6–10.7) 479 3.4 (3.1–3.7) 49 0.3 (0.2–0.4)
Alaska 395 17.7 (15.9–19.5) 302 15.7 (13.9–17.5) 93 4.3 (3.4–5.2) 29 1.3 (0.8–1.7)
Arizona 2,513 11.2 (10.8–11.7) 2,137 11.0 (10.5–11.5) 376 1.8 (1.6–2.0) 120 0.6 (0.5–0.7)
Arkansas 1,174 12.7 (11.9–13.4) 906 11.2 (10.4–11.9) 268 3.1 (2.7–3.4) 34 0.4 (0.3–0.5)
California 6,149 5.0 (4.9–5.1) 4,466 4.2 (4.1–4.3) 1,683 1.4 (1.3–1.5) 217 0.2 (0.2–0.2)
Colorado 1,859 10.7 (10.2–11.2) 1,596 10.6 (10.1–11.2) 263 1.6 (1.4–1.8) 59 0.3 (0.2–0.4)
Connecticut 483 4.2 (3.8–4.6) 368 3.6 (3.2–4.0) 115 1.1 (0.9–1.3) 42 0.4 (0.3–0.5)
Delaware 198 6.7 (5.7–7.7) 150 5.7 (4.8–6.7) 48 1.8 (1.3–2.3) —¶¶ —
District of Columbia 113 5.1 (4.1–6.0) 25 1.2 (0.7–1.6) 88 4.1 (3.2–5.0) — —
Florida 6,024 8.7 (8.5–8.9) 4,819 7.8 (7.6–8.1) 1,205 2.0 (1.9–2.1) 115 0.2 (0.1–0.2)
Georgia 3,113 9.8 (9.4–10.1) 2,380 8.6 (8.2–8.9) 733 2.4 (2.2–2.6) 62 0.2 (0.2–0.3)
Hawaii 136 3.0 (2.5–3.6) 95 2.4 (1.9–2.9) 41 1.0 (0.7–1.3) 16 —
Idaho 693 13.4 (12.4–14.5) 639 14.4 (13.3–15.6) 54 1.1 (0.8–1.4) 13 —
Illinois 2,137 5.4 (5.2–5.6) 1,469 4.2 (4.0–4.5) 668 1.8 (1.6–1.9) 77 0.2 (0.1–0.2)
Indiana 1,881 9.3 (8.9–9.7) 1,422 8.0 (7.6–8.5) 459 2.4 (2.2–2.6) 52 0.3 (0.2–0.3)
Iowa 672 6.9 (6.4–7.5) 586 7.0 (6.4–7.6) 86 0.9 (0.7–1.1) 19 —
Kansas 892 10.2 (9.5–10.9) 747 9.9 (9.2–10.6) 145 1.7 (1.4–2.0) 30 0.3 (0.2–0.4)
Kentucky 1,557 11.5 (10.9–12.0) 1,223 10.3 (9.7–10.9) 334 2.6 (2.3–2.9) 49 0.4 (0.3–0.5)
Louisiana 1,714 12.1 (11.5–12.7) 1,160 9.4 (8.8–10.0) 554 4.1 (3.7–4.4) 32 0.2 (0.1–0.3)
Maine 407 9.2 (8.2–10.1) 380 9.9 (8.8–10.9) 27 0.7 (0.4–0.9) 13 —
Maryland 990 5.3 (5.0–5.6) 654 3.9 (3.6–4.2) 336 1.9 (1.7–2.1) 40 0.2 (0.1–0.3)
Massachusetts 595 2.7 (2.5–2.9) 433 2.2 (2.0–2.5) 162 0.8 (0.7–0.9) 42 0.2 (0.1–0.3)
Michigan 2,360 7.5 (7.2–7.9) 1,914 7.0 (6.7–7.3) 446 1.5 (1.4–1.7) 68 0.2 (0.2–0.3)
Minnesota 1,045 6.1 (5.7–6.5) 931 6.3 (5.9–6.7) 114 0.7 (0.6–0.8) 47 0.3 (0.2–0.4)
Mississippi 1,053 11.6 (10.9–12.3) 753 9.4 (8.8–10.1) 300 3.5 (3.1–3.9) 41 0.5 (0.3–0.6)
Missouri 2,421 13.1 (12.5–13.6) 1,800 11.0 (10.5–11.6) 621 3.6 (3.3–3.9) 48 0.3 (0.2–0.3)
Montana 522 16.2 (14.8–17.7) 480 17.3 (15.7–18.9) 42 1.3 (0.9–1.8) 17 —
Nebraska 403 6.9 (6.2–7.6) 347 6.9 (6.1–7.6) 56 1.0 (0.7–1.3) 22 0.4 (0.2–0.5)
Nevada 1,122 12.1 (11.4–12.9) 934 11.6 (10.9–12.4) 188 2.2 (1.8–2.5) 48 0.5 (0.4–0.6)
New Hampshire 385 8.9 (8.0–9.8) 358 9.6 (8.5–10.6) 27 0.7 (0.4–1.0) — —
New Jersey 920 3.4 (3.1–3.6) 538 2.2 (2.0–2.4) 382 1.5 (1.3–1.6) 46 0.2 (0.1–0.2)
New Mexico 888 13.6 (12.7–14.5) 694 12.1 (11.2–13.1) 194 3.2 (2.7–3.6) 50 0.8 (0.6–1.0)
New York 2,100 3.4 (3.3–3.6) 1,461 2.7 (2.5–2.8) 639 1.1 (1.0–1.2) 190 0.3 (0.3–0.3)
North Carolina 2,795 8.8 (8.4–9.1) 2,132 7.7 (7.3–8.0) 663 2.2 (2.0–2.3) 64 0.2 (0.2–0.3)
North Dakota 236 10.2 (8.9–11.6) 214 10.8 (9.3–12.3) 22 0.9 (0.5–1.3) — —
Ohio 3,300 9.2 (8.9–9.5) 2,490 7.9 (7.6–8.2) 810 2.4 (2.2–2.6) 93 0.3 (0.2–0.3)
Oklahoma 1,500 12.5 (11.8–13.1) 1,233 11.9 (11.2–12.5) 267 2.3 (2.0–2.6) 36 0.3 (0.2–0.4)
Oregon 1,327 10.0 (9.5–10.6) 1,188 10.4 (9.8–11.0) 139 1.1 (0.9–1.3) 24 0.2 (0.1–0.3)
Pennsylvania 3,316 8.2 (7.9–8.5) 2,659 7.5 (7.2–7.8) 657 1.8 (1.7–1.9) 82 0.2 (0.2–0.2)
Rhode Island 98 2.8 (2.3–3.4) 80 2.7 (2.1–3.3) 18 0.5 (0.3–0.8) 15 —
South Carolina 1,841 11.9 (11.3–12.4) 1,333 9.8 (9.2–10.3) 508 3.5 (3.2–3.8) 35 0.2 (0.1–0.3)
South Dakota 270 10.6 (9.3–11.8) 226 10.2 (8.9–11.6) 44 1.8 (1.2–2.3) — —
Tennessee 2,192 10.6 (10.1–11.0) 1,753 9.7 (9.2–10.2) 439 2.2 (2.0–2.5) 78 0.4 (0.3–0.5)
Texas 7,038 8.3 (8.1–8.5) 5,589 7.7 (7.5–7.9) 1,449 1.7 (1.6–1.8) 202 0.2 (0.2–0.3)
Utah 967 11.0 (10.3–11.7) 878 11.6 (10.9–12.4) 89 1.0 (0.8–1.2) 34 0.4 (0.2–0.5)
Vermont 206 10.5 (9.0–12.0) 186 10.9 (9.2–12.5) 20 1.2 (0.6–1.7) — —
Virginia 2,330 8.8 (8.4–9.2) 1,828 7.9 (7.6–8.3) 502 2.0 (1.8–2.2) 58 0.2 (0.2–0.3)
Washington 1,944 8.3 (7.9–8.7) 1,658 8.2 (7.8–8.6) 286 1.3 (1.1–1.4) 54 0.2 (0.2–0.3)
West Virginia 717 12.6 (11.6–13.5) 603 12.1 (11.1–13.1) 114 2.2 (1.8–2.6) 22 0.4 (0.2–0.5)
Wisconsin 1,392 7.7 (7.3–8.2) 1,176 7.5 (7.0–7.9) 216 1.3 (1.2–1.5) 50 0.3 (0.2–0.4)
Wyoming 289 16.4 (14.5–18.4) 264 17.4 (15.2–19.5) 25 1.5 (0.9–2.1) — —

Abbreviation: CI = confidence interval.
* Deaths with missing age were excluded.
† Per 100,000 population per year. Age-adjusted to the 2000 U.S. standard population. Adjustments made by 12 age groups: 0–4, 5–9, 10–14, 15–19, 20–24, 25–34, 35–44, 45–54, 55–64, 65–74, 74–84, and ≥85 years.
§ Record-Axis Condition codes were used (usually included both Part I and Part II of Entity-Axis Condition codes). Death estimates obtained from CDC’s National Vital Statistics System.
Differences in any two rates were considered statistically significant if their confidence intervals were not overlapping.
** https://www2.census.gov/geo/pdfs/maps-data/maps/reference/us_regdiv.pdf
†† Suicides reported in persons aged <10 years were excluded; whether children aged <10 years are able to form suicidal intent is unclear.
§§ Other indicates that no intent or mechanism was specified in the record and includes traumatic brain injuries in which the intent was not determined, falls of undetermined intent, and those because of legal intervention or war.
¶¶ Dashes indicate values suppressed for counts ≤10 and rates based on <20 count.

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TABLE 3. Estimated number* and age-adjusted rates† of unintentional traumatic brain injury–related deaths,§ by state and mechanism of injury — United States, 2016–2018Return to your place in the text
Region**/State Total Motor vehicle crashes Falls†† Struck by or against an object Other§§
No. Rate (95% CI) No. Rate (95% CI) No. Rate (95% CI) No. Rate (95% CI) No. Rate (95% CI)
U.S. total 98,177 9.1 (9.0–9.1) 33,152 3.3 (3.3–3.4) 51,903 4.5 (4.5–4.5) 992 0.1 (0.1–0.1) 12,130 1.1 (1.1–1.2)
Northeast 15,592 7.7 (7.6–7.9) 4,411 2.5 (2.5–2.6) 9,267 4.2 (4.1–4.3) 156 0.1 (0.1–0.1) 1,758 0.9 (0.9–0.9)
Midwest 22,746 9.8 (9.6–9.9) 7,078 3.4 (3.3–3.5) 12,449 4.9 (4.8–5.0) 253 0.1 (0.1–0.1) 2,966 1.3 (1.3–1.4)
South 38,282 9.5 (9.5–9.6) 14,723 3.9 (3.9–4.0) 18,427 4.3 (4.3–4.4) 380 0.1 (0.1–0.1) 4,752 1.2 (1.2–1.2)
West 21,557 8.7 (8.6–8.8) 6,940 2.9 (2.9–3.0) 11,760 4.6 (4.5–4.7) 203 0.1 (0.1–0.1) 2,654 1.1 (1.0–1.1)
Alabama 1,379 8.8 (8.3–9.2) 615 4.3 (3.9–4.6) 435 2.5 (2.2–2.7) 13 —¶¶ 316 1.9 (1.7–2.2)
Alaska 328 15.8 (14.0–17.6) 148 6.6 (5.5–7.7) 105 5.8 (4.6–6.9) — — 72 3.3 (2.5–4.1)
Arizona 2,058 8.5 (8.1–8.9) 575 2.7 (2.5–2.9) 1,254 4.8 (4.5–5.1) — — 221 1.0 (0.9–1.1)
Arkansas 1,106 11.3 (10.6–12.0) 491 5.5 (5.0–6.0) 461 4.2 (3.8–4.6) 20 0.2 (0.1–0.3) 134 1.4 (1.2–1.6)
California 8,898 7.1 (6.9–7.2) 2,812 2.3 (2.2–2.4) 4,832 3.8 (3.7–3.9) 86 0.1 (0.1–0.1) 1,168 0.9 (0.9–1.0)
Colorado 1,858 10.8 (10.3–11.3) 543 3.1 (2.9–3.4) 1,049 6.2 (5.8–6.6) 12 — 254 1.4 (1.3–1.6)
Connecticut 1,459 11.6 (11.0–12.2) 623 5.7 (5.2–6.1) 632 4.4 (4.0–4.7) 12 — 192 1.4 (1.2–1.6)
Delaware 194 5.5 (4.7–6.3) 37 1.2 (0.8–1.7) 131 3.5 (2.9–4.1) — — 26 0.7 (0.5–1.0)
District of Columbia 124 6.1 (5.0–7.2) 23 1.0 (0.6–1.5) 81 4.0 (3.1–4.9) — — 20 1.0 (0.5–1.4)
Florida 7,508 9.5 (9.3–9.7) 2,613 4.1 (4.0–4.3) 4,128 4.3 (4.2–4.5) 31 0.0 (0.0–0.1) 736 1.0 (0.9–1.1)
Georgia 3,225 10.4 (10.0–10.7) 1,491 4.7 (4.5–4.9) 1,299 4.3 (4.1–4.6) 36 0.1 (0.1–0.1) 399 1.3 (1.1–1.4)
Hawaii 510 9.4 (8.5–10.3) 132 3.0 (2.5–3.6) 327 5.3 (4.7–5.9) — — 49 1.0 (0.7–1.3)
Idaho 674 12.7 (11.7–13.6) 299 5.9 (5.2–6.6) 297 5.3 (4.7–5.9) — — 68 1.3 (1.0–1.6)
Illinois 3,181 7.4 (7.1–7.6) 908 2.3 (2.2–2.5) 1,895 4.2 (4.0–4.4) 30 0.1 (0.0–0.1) 348 0.8 (0.7–0.9)
Indiana 1,902 8.7 (8.3–9.1) 689 3.4 (3.2–3.7) 904 3.9 (3.6–4.1) 29 0.1 (0.1–0.2) 280 1.3 (1.1–1.4)
Iowa 1,242 11.0 (10.4–11.7) 330 3.4 (3.1–3.8) 762 6.1 (5.7–6.6) 15 — 135 1.3 (1.1–1.5)
Kansas 1,063 10.7 (10.1–11.4) 314 3.6 (3.1–4.0) 599 5.6 (5.1–6.0) — — 140 1.5 (1.2–1.7)
Kentucky 1,626 11.3 (10.8–11.9) 711 5.3 (4.9–5.7) 625 4.1 (3.7–4.4) 28 0.2 (0.1–0.3) 262 1.8 (1.6–2.1)
Louisiana 1,363 9.3 (8.8–9.8) 556 4.0 (3.7–4.3) 590 3.8 (3.5–4.1) 14 — 203 1.4 (1.2–1.6)
Maine 649 13.0 (12.0–14.1) 206 5.2 (4.5–6.0) 385 6.4 (5.8–7.1) — — 52 1.2 (0.9–1.6)
Maryland 1,454 7.2 (6.8–7.6) 265 1.4 (1.3–1.6) 1,038 5.0 (4.7–5.3) 23 0.1 (0.1–0.2) 128 0.6 (0.5–0.8)
Massachusetts 1,870 7.5 (7.2–7.9) 421 1.9 (1.7–2.1) 1,270 4.8 (4.6–5.1) 10 — 169 0.7 (0.6–0.8)
Michigan 2,806 8.0 (7.7–8.3) 631 2.1 (1.9–2.2) 1,529 4.1 (3.9–4.3) 28 0.1 (0.1–0.1) 618 1.8 (1.6–1.9)
Minnesota 1,662 8.4 (8.0–8.9) 234 1.4 (1.2–1.6) 1,235 6.0 (5.7–6.3) 11 — 182 1.0 (0.8–1.1)
Mississippi 1,150 12.2 (11.5–12.9) 532 6.0 (5.5–6.5) 464 4.5 (4.1–5.0) — — 146 1.6 (1.3–1.9)
Missouri 2,349 11.5 (11.0–12.0) 1,009 5.4 (5.1–5.8) 1,017 4.5 (4.2–4.7) 32 0.2 (0.1–0.2) 291 1.5 (1.3–1.6)
Montana 454 12.8 (11.6–14.0) 187 5.9 (5.0–6.7) 199 5.0 (4.3–5.7) — — 65 1.9 (1.4–2.4)
Nebraska 865 13.6 (12.6–14.5) 355 6.2 (5.5–6.8) 385 5.4 (4.9–6.0) — — 117 1.8 (1.5–2.2)
Nevada 705 7.5 (7.0–8.1) 147 1.6 (1.3–1.9) 465 4.9 (4.5–5.4) — — 89 0.9 (0.7–1.1)
New Hampshire 462 9.5 (8.6–10.3) 149 3.4 (2.8–4.0) 262 5.0 (4.4–5.6) — — 46 0.9 (0.7–1.2)
New Jersey 1,786 5.8 (5.5–6.1) 525 1.9 (1.8–2.1) 993 3.0 (2.8–3.2) — — 259 0.8 (0.7–0.9)
New Mexico 752 10.9 (10.1–11.7) 224 3.7 (3.2–4.2) 429 5.7 (5.2–6.3) — — 92 1.4 (1.1–1.6)
New York 4,424 6.4 (6.2–6.6) 1,239 2.0 (1.9–2.1) 2,608 3.5 (3.4–3.7) 50 0.1 (0.1–0.1) 527 0.8 (0.7–0.9)
North Carolina 3,480 10.5 (10.1–10.8) 1,307 4.2 (4.0–4.5) 1,705 4.8 (4.6–5.1) 37 0.1 (0.1–0.1) 431 1.3 (1.2–1.4)
North Dakota 333 13.3 (11.8–14.8) 162 6.9 (5.8–8.0) 122 4.2 (3.4–4.9) — — 44 2.0 (1.4–2.6)
Ohio 4,394 11.0 (10.7–11.4) 1,581 4.5 (4.3–4.7) 2,236 5.1 (4.8–5.3) 50 0.1 (0.1–0.2) 527 1.4 (1.2–1.5)
Oklahoma 1,344 10.4 (9.9–11.0) 318 2.6 (2.3–2.9) 842 6.3 (5.8–6.7) — — 175 1.4 (1.2–1.7)
Oregon 1,568 11.0 (10.5–11.6) 564 4.4 (4.0–4.7) 835 5.4 (5.1–5.8) 28 0.2 (0.1–0.3) 141 1.0 (0.8–1.2)
Pennsylvania 4,290 9.0 (8.7–9.2) 1,080 2.8 (2.6–2.9) 2,701 5.0 (4.8–5.2) 57 0.1 (0.1–0.2) 452 1.0 (0.9–1.1)
Rhode Island 313 7.7 (6.8–8.6) 46 1.4 (1.0–1.8) 236 5.4 (4.7–6.1) — — 30 0.9 (0.5–1.2)
South Carolina 2,434 15.2 (14.6–15.8) 1,352 8.9 (8.5–9.4) 820 4.7 (4.3–5.0) 20 0.1 (0.1–0.2) 242 1.5 (1.3–1.7)
South Dakota 416 14.3 (12.9–15.7) 139 5.3 (4.4–6.2) 225 7.2 (6.2–8.1) — — 47 1.7 (1.2–2.2)
Tennessee 2,122 9.6 (9.2–10.0) 623 3.1 (2.8–3.3) 1,102 4.7 (4.4–5.0) 28 0.1 (0.1–0.2) 369 1.7 (1.5–1.8)
Texas 6,306 7.7 (7.5–7.9) 2,367 2.8 (2.7–2.9) 3,096 3.9 (3.8–4.1) 56 0.1 (0.0–0.1) 787 0.9 (0.9–1.0)
Utah 850 10.4 (9.6–11.1) 346 3.8 (3.4–4.2) 391 5.2 (4.7–5.7) — — 104 1.2 (1.0–1.5)
Vermont 339 15.2 (13.5–16.9) 122 6.4 (5.2–7.6) 180 7.2 (6.1–8.3) — — 31 1.4 (0.9–1.9)
Virginia 2,942 10.8 (10.4–11.2) 1,283 4.9 (4.7–5.2) 1,310 4.6 (4.4–4.9) 42 0.2 (0.1–0.2) 307 1.1 (1.0–1.2)
Washington 2,603 10.9 (10.5–11.3) 830 3.7 (3.4–3.9) 1,446 5.9 (5.6–6.2) 27 0.1 (0.1–0.2) 300 1.2 (1.1–1.4)
West Virginia 525 7.9 (7.2–8.7) 139 2.5 (2.0–2.9) 300 4.0 (3.6–4.5) 15 — 71 1.2 (0.9–1.5)
Wisconsin 2,533 12.4 (11.9–12.9) 726 4.0 (3.7–4.3) 1,540 7.0 (6.6–7.3) 30 0.1 (0.1–0.2) 237 1.3 (1.1–1.4)
Wyoming 299 16.1 (14.2–18.0) 133 7.9 (6.5–9.2) 131 6.5 (5.4–7.7) — — 31 1.5 (1.0–2.1)

Abbreviation: CI = confidence interval.
* Deaths with missing age were excluded.
† Per 100,000 population per year. Age-adjusted to the 2000 U.S. standard population. Adjustments made by 12 age groups: 0–4, 5–9, 10–14, 15–19, 20–24, 25–34, 35–44, 45–54, 55–64, 65–74, 74–84, and ≥85 years.
§ Record-Axis Condition codes were used (usually included both Part I and Part II of Entity-Axis Condition codes). Death estimates obtained from CDC’s National Vital Statistics System.
Differences in any two rates were considered statistically significant if their confidence intervals were not overlapping.
** https://www2.census.gov/geo/pdfs/maps-data/maps/reference/us_regdiv.pdf
†† Excluded falls of undetermined intent.
§§ External cause of injury codes specify that the injury was unintentional but do not specify the actual mechanism of injury.
¶¶ Dashes indicate values suppressed for counts ≤10 and rates based on <20 count.

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Suggested citation for this article: Daugherty J, Zhou H, Sarmiento K, Waltzman D. Differences in State Traumatic Brain Injury–Related Deaths, by Principal Mechanism of Injury, Intent, and Percentage of Population Living in Rural Areas — United States, 2016–2018. MMWR Morb Mortal Wkly Rep 2021;70:1447–1452. DOI: http://dx.doi.org/10.15585/mmwr.mm7041a3.

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