Variation in pediatric and adolescent firearm mortality rates in rural and urban US counties

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 23 649 pediatric firearm deaths (15 190 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 mosturban 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.