Epidemiologic Reviews Vol.

25, 2003
Copyright © 2003 by the Johns Hopkins Bloomberg School of Public Health Printed in U.S.A.
All rights reserved DOI: 10.1093/epirev/mxg010

Injury Surveillance

John M. Horan1 and Sue Mallonee2

1 Division of Applied Public Health Training, Epidemiology Program Office, Centers for Disease Control and Prevention, Atlanta, GA.
2 Injury Prevention Service, Oklahoma State Department of Health, Oklahoma City, OK.

Received for publication July 24, 2002; accepted for publication April 23, 2003.

Abbreviations: CDC, Centers for Disease Control and Prevention; EMS, emergency medical services; ICD, International
Classification of Diseases; NEISS, National Electronic Injury Surveillance System; NHTSA, National Highway Traffic Safety
Administration.

INTRODUCTION priorities, support prevention activities, and evaluate preven-

Public health surveillance is the ongoing, systematic
collection, analysis, interpretation, and dissemination of data
on health-related events for use in public health action to
reduce morbidity and mortality and to improve health (1).
More simply put, surveillance is about translating informa-
tion into action. In the United States, much of the focus of
public health surveillance has traditionally been on preven-
tion and control of infectious diseases, an area where surveil-
lance has been used to identify outbreaks, monitor emerging
problems, and assess the impact of prevention measures (2–
5). Another essential role of public health surveillance is
monitoring causes of death, including premature mortality.
In that context, injuries clearly emerge as a major public
health problem. In 1999, unintentional injuries were the fifth
leading cause of death in the United States and were the
leading cause for persons in the age group 1–34 years (6).
Unintentional injury, together with homicide and suicide,
accounted for nearly 60 percent of all deaths among persons
aged 1–34 years (6).
Following Congressional authorization in 1983, the
National Research Council and the Institute of Medicine
(National Academy of Sciences) produced the 1985 report
Injury in America (7), which documented the burden of
injury and became a major impetus for developing support
for research and programs to address this important problem.
A 1988 review of public health surveillance in the United
States (8) noted that recognition of intentional and uninten-
tional injuries as major public health problems had led to the
need for developing systems of public health surveillance for
injuries. Additionally, as injury research and prevention
programs have evolved, so has the need for surveillance data
to identify populations at risk, determine programmatic
tion efforts. While there have been substantial advances in
injury surveillance in recent years, there are still many chal-
lenges and needs. In this paper, focusing primarily on the
United States, we provide an overview of current injury
surveillance data sources and systems, and we review their
use for surveillance of major categories of injury. We also
present several new developments in injury surveillance and
comment on some of the new challenges facing injury
surveillance in an era of rapidly changing information tech-
nology and growing recognition of the need for effective
integration of information systems.
DATA SOURCES AND SURVEILLANCE SYSTEMS
The book Principles and Practice of Public Health
Surveillance identifies three sources of health-related infor-
mation: individuals, health care providers, and other entities
(9). All three make important contributions to injury surveil-
lance. Through telephone surveys or other means, individ-
uals are a source of data on injury incidence, risk-taking
behaviors, and use of preventive measures. Health care
providers at different levels of the medical care system are a
source of data on outcomes of injury events, including the
terminal event of injury-related mortality. Additionally, a
variety of agencies and institutions that collect data for other
purposes, such as police reports on traffic crashes and
crimes, fire department records, insurance claims, and
worker’s compensation files, are sources of important infor-
mation on the circumstances and sequelae of injury events.
The primary responsibility for public health surveillance
in the United States resides at the state level. Within state
health departments, injury prevention has struggled for

Correspondence to Dr. John M. Horan, Mailstop D-18, Division of Applied Public Health Training, Epidemiology Program Office, Centers for
Disease Control and Prevention, Atlanta, GA 30333 (e-mail: jhoran@cdc.gov).

24 Epidemiol Rev 2003;25:24–42


recognition as a critical component of public health practice.
Development of injury surveillance capacity has been vari-
able across states. Even in states with relatively advanced
capacity, surveillance priorities have not been consistently
based on public health criteria such as premature mortality
and preventable morbidity; they have also depended on the
level of popular and political interest in bringing certain
conditions under surveillance. The need for a coordinated
approach to state-based injury surveillance served as the
motivation to form an injury surveillance work group in
1998. This cooperative undertaking by state, federal, and
academic injury prevention organizations produced the
Consensus Recommendations for Injury Surveillance in
State Health Departments (10). This document recom-
mended putting 14 injuries and injury risk factors under
surveillance by all states. Basic surveillance of most of the
14 recommended conditions is achievable through the use of
data sets that are present in most states. To begin imple-
menting the recommendations, 12 states contributed to the
first State Injury Indicators Report, a summary report of
1997 and 1998 data for 12 of the recommended conditions
(11). The second annual summary report, based on 1999
data, is expected to include more than 20 states, with even-
tual expansion to include all US states and territories within
several years.
The capacity for national-level injury surveillance has
grown in recent decades. For example, in a 1998 review of
national data systems useful for firearm-related injury
surveillance, Annest and Mercy (12) noted that seven of the
13 systems they reviewed either did not exist or did not have
the capacity to capture information on firearm-related inju-
ries 10 years previously. In 1996, the federal Centers for
Disease Control and Prevention (CDC) published the Inven-
tory of Federal Data Systems in the United States for Injury
Surveillance, Research, and Prevention Activities (13).
These systems cover a broad range, including mortality,
morbidity, risk factors, and preventive factors.
Brief summaries of various data sources and systems for
surveillance of injury mortality, morbidity, and risk factors
are presented below. Sources and systems that are related to
specific causes of injury (traffic injury, occupational injury,
violence, etc.) are described in later sections of the paper.
Mortality data
Vital records. In the United States, state laws require
completion of death certificates for all deaths. State offices
of vital records maintain death certificate files and provide
regular summary reports based on these data. Through coop-
eration between all 50 states, the territories, the District of
Columbia, and the CDC, death certificate data are compiled
into the National Vital Statistics System (http://
www.cdc.gov/nchs/nvss.htm) (14), which produces public
access data tapes that enumerate deaths for the United States
by state, county, and Metropolitan Statistical Area (US
Census). All injury deaths are assigned codes indicating the
nature of the injury and the external cause of the injury.
Medical examiner and coroner records. Medical exam-
iner and coroner systems offer a rich source of data on injury
deaths that are complementary to vital statistics data. For
Epidemiol Rev 2003;25:24–42
Injury Surveillance 25
example, computerized systems or records may include data
that are unavailable on death certificates, such as the dece-
dent’s alcohol and drug use, the premise of injury, the type of
firearm involved, a description of injuries incurred, and a
narrative on the circumstances resulting in death (15).
Physician-oriented medical examiner systems began replacing
the older, more political lay coroner systems around 1950, but
this trend stalled; currently, only 18 states have a centralized,
statewide medical examiner’s office (16), and not all of these
states have computerized data systems. In addition, compara-
bility among states or even among counties within states is
problematic because there is no standardized, national coding
system for medical examiner or coroner data.
Morbidity data
Hospital inpatient records. Hospital discharge records are
important sources for injury morbidity data because they
include injuries severe enough to warrant hospitalization,
and when linked to vital statistics data or medical examiner
data, they provide a more complete picture of serious
trauma. Forty-four states collect hospital inpatient data for
various purposes through voluntary or mandatory health
reporting requirements (17). These data are usually collected
from hospital records that are intended primarily to serve
administrative and management purposes (such as billing
files). Moreover, collection of hospital discharge data varies
across states and within states over time, and most state
systems exclude federal (military and Indian Health Service)
facilities. A 1997 survey showed that 36 states and the
District of Columbia were routinely collecting data on
external causes of injury in their statewide hospital discharge
data systems (18), yet the completeness of external-cause
coding in hospital discharge data has been shown to vary
substantially among states (11). To use these data for injury
incidence surveillance, it is necessary to avoid double-
counting patients transferred from one facility to another and
patients readmitted for the same injury. Adding an additional
field in hospital discharge systems that reflects readmission
for a previous injury, a transfer from another hospital, and
the date of injury has been recommended to improve this
data source (19). Thus, while these systems can be very
useful for injury surveillance, they have limitations, and their
data elements may have limited relevant information. To
promote and improve the use of hospital discharge data, the
State Injury Prevention Directors’ Association, in collabora-
tion with partner organizations, published recommendations
for using hospital discharge data for injury surveillance (20).
At the national level, data are available through the
National Hospital Discharge Survey, which is conducted by
the CDC (http://www.cdc.gov/nchs/about/major/hdasd/
nhds.htm). Begun in 1965, the survey collects information
from a probability sample of discharges from nonfederal
short-stay hospitals with six or more beds in the United
States. While these data specify types of injuries, external-
cause coding for injuries in the National Hospital Discharge
Survey is limited but improving; in 2000, 70 percent of
discharges with a principal injury diagnosis had at least one
external-cause-of-injury code.
26 Horan and Mallonee
Trauma registries. Forty-four US states collect either
statewide or regional trauma registry data (21). The Amer-
ican College of Surgeons established the National Trauma
Data Bank as a national repository of trauma data in 1994;
over 430,000 records from 130 trauma centers in 28 states
and US territories were voluntarily submitted between 1994
and 2001 (22). Trauma registry data provide detailed infor-
mation on the nature and severity of the injury, the treatment,
and the outcome upon discharge from the hospital. While
trauma registries are a potential part of the data needed for
comprehensive injury surveillance, the data are collected
primarily to monitor and evaluate trauma care, and they have
limitations (23, 24). Most state or regional trauma registries
are limited to trauma center hospitals and are not population-
based (25); few are statewide, and few include all hospitals
(26). In addition, the case criteria of most trauma registries
exclude some causes of injury (i.e., same-level falls, poison-
ings, drownings, etc.), include only severely injured persons
(persons with “major trauma” or persons hospitalized for
more than 24 or 48 hours, etc.), and exclude prehospital
deaths (25). Thus, trauma registries may be incomplete and
nonrepresentative sources of injury surveillance data (27).
Outpatient care records and reports. Surveillance based
on outpatient records can address the substantial proportion
of injuries severe enough to require medical care but not
resulting in hospitalization. Seventeen states currently
collect emergency department data, and an additional seven
states are actively planning to collect emergency department
encounter data within the next 2 years (17). In addition,
several states are collecting ambulatory surgical data from
hospitals and free-standing clinics. These data have limita-
tions for injury surveillance similar to those of inpatient
records.
The National Electronic Injury Surveillance System
(NEISS) obtains data on all consumer product-related injury
cases from a nationally representative sample of approxi-
mately 100 hospital emergency departments
(http://www.cpsc.gov/CPSCPUB/PUBS/3002.html). The
NEISS was started in the early 1970s by the Consumer
Product Safety Commission. In 1999, the Institute of Medi-
cine recommended expanding the system to include all
nonfatal injuries (19), and in July 2000 the NEISS All Injury
Program was initiated to collect data on all types and causes
of treated injuries in a nationally representative subset of 65
of the NEISS hospital emergency departments (28). These
data may be accessed through the World Wide Web-based
Injury Statistics Query and Reporting System (29).
Several national surveys conducted by the CDC collect
data on outpatient care that are useful for injury surveillance.
The National Ambulatory Medical Care Survey was begun
in 1973 and has been conducted annually since 1989 (http://
www.cdc.gov/nchs/about/major/ahcd/ahcd1.htm). The sur-
vey is based on sampling of patient visits to non-federally-
employed office-based physicians who are primarily
engaged in direct patient care. Each participating physician
is randomly assigned to a 1-week reporting period, during
which data are recorded for a systematic random sample of
visits. The patient record form includes fields for informa-
tion on injury-related visits. Annual data collection for the
National Hospital Ambulatory Medical Care Survey began
in 1992. The survey comprises a national probability sample
of visits to emergency and outpatient departments of general,
nonfederal hospitals (http://www.cdc.gov/nchs/about/major/
ahcd/ahcd1.htm). Data included in the survey include
alcohol- and drug-relatedness and, for injury-related visits,
codes for reason for the visit, up to three diagnoses and
external causes, and place and intent of injury. The National
Health Interview Survey has collected self-reported informa-
tion from approximately 38,000–40,000 US household inter-
views annually since 1957 (http://www.cdc.gov/nchs/
nhis.htm). The survey provides estimates of injuries and
poisonings for which medical attention was obtained within
3 months of the interview date. The National Health Inter-
view Survey was redesigned in 1997; it now includes
detailed injury-specific questions for all members of the
family as part of the core survey.
Emergency medical services records. Most states collect
emergency medical services (EMS) data for persons who are
transported to a hospital by an ambulance. These data have
been utilized for injury surveillance (30) or integrated into
existing categorical injury surveillance systems (31, 32).
While the National Highway Traffic Safety Administration
(NHTSA) has developed a set of 81 uniform prehospital data
elements (33), EMS systems vary in their ability to collect
and use injury-related data. In over 90 percent of states,
complete EMS data are missing at the regional or state level
(34). EMS systems within cities, regions, and states should
continue to refine and systematize data collection (35). The
National Association of State EMS Directors is working
with the NHTSA and the Trauma/EMS Systems program of
the Health Resources and Services Administration to
develop a national EMS database (36).
Post-acute-care data. Data systems describing the dura-
tion of rehabilitative care and outcomes beyond hospital
mortality and morbidity are rare (37). It has been recom-
mended that more efforts be made to extend trauma regis-
tries to determine long-term outcomes and to develop norms
for these outcomes (19). The Uniform Data System for
Medical Rehabilitation was developed with support from the
National Institute of Disability and Rehabilitation to capture
the severity of patient disability and the outcomes of rehabil-
itation (19). Registries such as Model Systems of Care,
established for the treatment of traumatic brain injury (38)
and spinal cord injuries (39), have collected data on patients
through rehabilitation, community reintegration, and long-
term follow-up. However, these registries are costly, are
labor-intensive, and only follow select patient groups after
specialized care; thus, findings cannot be interpreted widely.
The CDC has funded population-based surveillance of trau-
matic brain injury outcomes in two states and the National
Study on Costs and Outcomes of Trauma Care. The latter
will examine the relation between treatment and outcome for
up to 12 months postinjury (40). There is a need for further
development of outcome registries, including practical tools
that can be applied routinely at low cost, effective and effi-
cient patient tracking systems, and standardized guidelines
for developing and maintaining such registries (19).
Epidemiol Rev 2003;25:24–42

Risk factor data
Surveillance of preinjury risk or protective factors (e.g.,
bicycle helmet or seat-belt use, prevalence of smoke detec-
tors, etc.) can be a timely, efficient approach to providing
data for injury prevention. Two systems that provide state-
level data on risk factors are the Behavioral Risk Factor
Surveillance System and the Youth Risk Behavior Surveil-
lance System. The Behavioral Risk Factor Surveillance
System, established by the CDC in 1984, is a random-sample
household telephone survey that monitors self-reported
health behaviors in all 50 states, the District of Columbia,
and three territories (http://www.cdc.gov/brfss/). The
number of injury-specific risk and protective behaviors
about which all adult respondents are asked is limited, but
states can add injury-specific modules. Data from the survey
have proven useful for identifying and highlighting a broad
range of national and state-level injury prevention issues
(41–45). The Youth Risk Behavior Surveillance System,
developed by the CDC in 1989, includes national, state, terri-
torial, and local school-based surveys of US students in
grades 9–12 regarding risk behaviors associated with leading
causes of morbidity and mortality (http://www.cdc.gov/
nccdphp/dash/yrbs). Survey topics include behaviors related
to injury risk, such as lack of seat-belt use, drinking and
driving, weapon-carrying, and suicide attempts (46). Youth
Risk Behavior Surveillance System data are a source both
for summary national-level reports (46) and for targeted
investigations on state issues (47, 48).
Several systems are currently being used in the United
States for national surveillance of injury risk factors. The
Motor Vehicle Occupant Safety Survey and the National
Survey of Drinking and Driving Attitudes and Behavior are
nationally representative telephone surveys (49, 50). The
National Occupant Protection Use Survey is a nationally
representative observational survey that provides estimates
of shoulder belt and motorcycle helmet use and data on the
characteristics of belt users (51). The Injury Control and
Risk Survey was a random digit dialing telephone survey
sponsored by the CDC in 1994 for collection of injury risk
factor and demographic data from a nationally representative
sample of adult respondents (52–54). The Injury Control and
Risk Survey was a single survey, not an ongoing system of
surveillance. A subsequent similar survey, Injury Control
and Risk Survey 2, is currently under way. These and other
surveys are valuable sources of national-level estimates, but
they cannot provide state- or local-level data.
The widespread use of data from these various systems
and surveys is an indication of the importance and value of
surveillance that focuses on preinjury factors. However, the
diversity of these systems also reflects the absence of a
systematic, coordinated approach to addressing this issue.
CODES AND STANDARDS FOR INJURY SURVEILLANCE
In order for information about injury mortality, morbidity,
and risk factors to be efficiently accessed and used for
surveillance, it needs to be categorized under standard codes
and definitions. For injury prevention, the usefulness of
information being collected and coded is greatly enhanced if
Epidemiol Rev 2003;25:24–42
Injury Surveillance 27
the data include not only the nature or type of injury (e.g.,
fracture, poisoning) but also the external cause or mecha-
nism of injury (e.g., motor vehicle crash, unintentional
ingestion). Standard codes and definitions are required for
accurate comparison of state, local, or international data
regarding the magnitude and distribution of injuries as a
public health problem.
Mortality data on death certificates are coded using the
International Classification of Diseases (ICD). The Ninth
Revision of the ICD (ICD-9), the common standard since
1979, was replaced in the United States by the Tenth Revi-
sion (ICD-10) in 1999. In the ICD-9, coding of external
causes of death was done with a supplementary set of codes
commonly known as E-codes, and all deaths resulting from
an external cause of injury were assigned an E-code. The
external cause is the mechanism causing death (e.g., a motor
vehicle traffic crash), and the injuries resulting from the
external cause (e.g., fractures, open wounds, etc.) are listed
as contributing causes on the death certificate. In the ICD-
10, external causes are classified under a series of alpha-
numeric codes, V01–Y98 (55).
Morbidity data, for example, data in hospital discharge
and emergency department medical records, are currently
coded in the United States using the clinical modification of
the ICD-9 (ICD-9-CM). Coding of external causes has been
considerably less complete for morbidity data, and this has
limited the usefulness of sources such as hospital discharge
records for injury surveillance. A 1997 survey showed that,
on average, states with laws requiring E-coding had a higher
percentage of E-coded hospital discharges; however, it was
possible to achieve a high level without such a law (18).
LeMier et al. (56) have recently shown a high level of accu-
racy of computerized E-code data in Washington State for
reporting of injury mechanism and intent. The ICD-9-CM
system is expected to be replaced by the clinical modifica-
tion of the ICD-10 (ICD-10-CM) in the next few years.
Although major revisions such as the change from the
ICD-9 to the ICD-10 pose challenges for temporal compari-
sons of data, in general the ICD coding systems enhance
comparability and consistency in mortality and morbidity
statistics, helping decrease the costs of collecting, linking,
and using data. Similar benefits are potentially available
from standards for recording other essential health-related
information. In recent years, standards development work
has been under way in several areas of injury surveillance.
The Data Elements for Emergency Department Systems
(57), designed to conform to established formats for patient
data, is a recommended set of specifications for information
entered in emergency department records. Data Elements for
Emergency Department Systems is not intended as a
mandated essential or minimum data set; rather, it is
intended to foster uniformity among individual data
elements that are chosen for use. Similarly, recommended
uniform data elements have been developed for firearm-
related injury surveillance (58, 59) and central nervous
system injuries (60); definitions and recommended data
elements for surveillance of intimate partner violence (61)
have been developed and are being pilot-tested.
Just as standards for recording data can facilitate collec-
tion and analysis, standards for presentation can better
28 Horan and Mallonee
enable data dissemination and display. Development and
publication of the Recommended Framework for Presenting
Injury Mortality Data (62) has provided a widely accepted
systematic approach for the display of standard ICD-9 E-
code groupings in a matrix of mechanism/cause by manner/
intent; a similar framework has been developed for
morbidity data (63). In addition, the International Collabora-
tive Effort on Injury Statistics has recently developed and
published an injury diagnosis matrix, known as the Barell
Matrix, as a recommended approach for displaying data on
the nature of the injury (fracture, amputation, burn, etc.) by
body region (head and neck, torso, etc.) (64).
SURVEILLANCE OF MAJOR CATEGORIES OF INJURIES
Transportation injuries
According to the National Vital Statistics System, trans-
portation-related injuries are the leading cause of injury-
related death in the United States, accounting for over
46,000 deaths in 1999 (14). Transportation injuries were the
leading cause of all deaths for persons of every age from age
4 years to age 33 years (65). The NHTSA provides the most
comprehensive surveillance system for transportation-
related injuries in the United States. Detailed data regarding
the circumstances of transportation fatalities are collected in
the Fatality Analysis Reporting System in all 50 states and
the District of Columbia (66). The Fatality Analysis
Reporting System is a powerful tool for uncovering new
epidemiologic information on crashes and injury risks (67).
Since 1988, crash and injury statistics have been based on
data from the General Estimates System. The General Esti-
mates System is a probability-based sample of police-
reported crashes from 60 locations across the country, gener-
ating national estimates of crashes and injuries (68). In 2000,
there were an estimated 6,394,000 police-reported traffic
crashes resulting in 41,821 deaths and over three million
injuries (69). Vehicle occupants accounted for nearly 90
percent (over 36,000) of these deaths, followed by 4,739
pedestrians and nearly 700 pedal cyclists (69).
Until late 1991, the NHTSA’s 19-city survey was used to
track national use of seat belts. In 1991, the 19-city survey
was replaced with an aggregate of individual statewide
observational surveys weighted by each state’s population
(70). In addition to the state belt-use surveys, the National
Occupant Protection Use Survey has conducted observation
surveys since 1994, using a multistage probability sample to
estimate occupant protection in the United States (70); the
prevalence of seat-belt use in 1998 was found to be 68.9
percent (71).
The Crash Outcome Data and Evaluation System is a state-
based surveillance system initially funded by the NHTSA in
seven states to determine the benefits of use of seat belts and
motorcycle helmets in motor vehicle crashes (72). The
system utilizes a probabilistic computer algorithm (73) to
link crash data from police reports, medical data from EMS,
hospital emergency department, and discharge files, and
claims data from third-party payors to evaluate injuries and
their associated costs from motor vehicle crashes. A strength
of the linked system is that person-level data are available for
uninjured, injured, and killed persons, and these data provide
a more comprehensive assessment of the consequences of
safety behaviors (e.g., use of belts and helmets) and counter-
measures (e.g., air bags) (70). At least 26 states have
received funding from the Crash Outcome Data and Evalua-
tion System for numerous applications through 1999 (32).
In addition to measuring the magnitude of the problem,
injury surveillance systems have been instrumental in docu-
menting the effects of state legislation in reducing the burden
of transportation-related injuries and in measuring adverse
consequences of safety measures. Some types of legislation
that have been evaluated include: establishing 21 years as the
minimum age for the purchase of alcoholic beverages (74,
75); safety-belt primary enforcement laws (76, 77); child
safety seat laws (78); sobriety checkpoints (79); graduated
licensing of teenage drivers (80, 81); and administrative
license revocation and lower blood alcohol concentration
laws (75, 82, 83). Analysis of a combination of data from
risk factor surveillance systems and survey data has also
been used to show relations that have policy implications
(84).
Determining unanticipated adverse outcomes of preven-
tion strategies is an important use of surveillance. Motor
vehicle injury surveillance documented the adverse conse-
quences (including death from air bags) that have occurred
among unrestrained children under age 13 years, small-
statured adults, and infants in rear-facing car seats in the
vehicle front seat (85, 86). In addition, an insurance-based
crash and injury database demonstrated significant injury risks
associated with restraining young children (age 2–5 years) in
regular seat belts as compared with child restraint systems
(87); these data have led to educational efforts and policy
changes throughout the country. Efforts in utilizing surveil-
lance systems to support and evaluate motor-vehicle-related
safety legislation and policies should serve as a model for
supporting and evaluating policy for other causes of injury.
Residential injuries
Burn and fire-related injuries. Per capita, the fire problem
in the United States, including fatal injuries due to fire, is one
of the worst in the industrialized world. Injuries from fire
and burns are the seventh leading cause of injury death in the
United States, accounting for 3,910 deaths in 1999 (14).
According to the National Health Interview Survey, over one
million burn injuries are reported annually in the United
States (88); this number of injuries has declined significantly
from the two million annual injuries estimated in the first
report of the National Health Interview Survey, drawn from
1957–1961 data.
In 2000, public fire departments responded to nearly two
million fires in the United States, according to estimates
based on data received by the National Fire Protection Asso-
ciation from fire departments responding to the 2000 annual
National Fire Experience Survey; these fires resulted in over
4,000 and 22,000 civilian deaths and injuries, respectively,
and over $11 billion in property loss (89). In 2000, residen-
tial fires accounted for approximately 80 percent of the fire
injury problem, including nearly 400,000 residential fires,
3,445 civilian deaths, 17,400 injuries, and almost $6 billion
Epidemiol Rev 2003;25:24–42

in direct property damage (89). The National Fire Incident
Reporting System is a voluntary reporting system that has
been overseen by the US Fire Administration (Federal Emer-
gency Management Agency) since 1976. This database
collects information on one million fires (approximately one
half of all reported fires) from 14,000 fire departments in 42
states and the District of Columbia (90), including data on
causes, locations, and temporal and geographic trends in
fires and injuries.
An important risk factor for death or serious injury during
a residential fire is the lack of a functioning smoke alarm
(31, 91). According to surveillance for smoke-alarm owner-
ship in US households conducted by the Behavioral Risk
Factor Surveillance System, the prevalence of smoke alarms
in the United States is nearly 94 percent (42); however, in-
home surveys by the Consumer Product Safety Commission
and others have shown that 25–30 percent of household
smoke alarms are not functional (92–94).
The utility of linking (manually or electronically) popula-
tion-based morbidity data (fire/burn injury surveillance
systems, emergency department or hospital discharge data,
ambulance run reports), mortality data (medical examiner,
vital statistics, and coroner data), and fire department data in
determining risk factors and high-risk populations and in
evaluating targeted interventions has been demonstrated (31,
95, 96). However, published reports to date have only linked
these data on a community, city, or county basis rather than
on a statewide basis. The Federal Fire Partnership—the US
Fire Administration, the Consumer Product Safety Commis-
sion, and the CDC—has set a goal of eliminating residential
fire-related deaths by 2020 (Christine Branche, CDC,
personal communication, 2002). State efforts to achieve this
goal could benefit from systematic data linkage to enhance
surveillance capacity.
Fall injuries. Falls were the fourth leading cause of injury
death in the United States in 1999 (14) and the leading cause
of medically attended injuries, accounting for 11.3 million
fall episodes (97), including eight million emergency depart-
ment visits (98). Age-specific rates of hospital-treated falls
are highest in the youngest and oldest populations, but the
proportions of these falls that require hospitalization are very
different (3 percent in persons aged less than 25 years vs. 33
percent for person aged 75 years or older) (98). Elderly
persons have the highest fall mortality rates (99).
State or local surveillance for falls is typically based on
existing E-coded systems such as emergency department or
hospital discharge data systems. While data on patient
descriptive factors (age, sex, race/ethnicity, etc.) are avail-
able in these systems, external-cause coding only offers a
description that the person slipped or tripped or fell on the
same level or at a distance. The data often do not provide
specific details about how the fall occurred (98), and E-codes
do not provide sufficient detail regarding risk factors (envi-
ronmental hazards, medication use, etc.) (100). With an
aging US population, fall rates appear to be increasing, and
prevention efforts could benefit substantially from expanded
surveillance systems that collect more detailed information
on the causes and outcomes of fall injuries.
Epidemiol Rev 2003;25:24–42
Injury Surveillance 29
Occupational injuries
The International Labor Organization has estimated that
work-related injuries kill approximately 335,000 persons
annually, resulting in a worldwide rate of 14.0 deaths per
100,000 workers, with developing nations having the highest
injury fatality rates (101, 102). In the United States, occupa-
tional injury deaths are routinely reported by three sources.
The National Safety Council has estimated work-related
deaths and injuries for the US population since 1933 (103).
The CDC’s National Institute for Occupational Safety and
Health, utilizing death certificates from all 50 states and the
District of Columbia (104), has collected data in the National
Traumatic Occupational Fatalities Surveillance System
since 1980. In 1992, the Bureau of Labor Statistics devel-
oped a federal-state partnership, the national Census of Fatal
Occupational Injuries, in all 50 states and the District of
Columbia that cross-references multiple sources of data (i.e.,
death certificates, medical examiner certificates, worker’s
compensation records, and federal and state agency reports)
(105). Fatality counts from the Census of Fatal Occupational
Injuries have exceeded those of the National Traumatic
Occupational Fatalities Surveillance System annually by
approximately 20 percent (104, 106).
Discrepancies between the different reporting sources
occur because of differences in methods of case identifica-
tion and case definition (107, 108). Although existing
systems are discrepant and may undercount the number of
deaths (108–110), these surveillance systems have docu-
mented a large public health problem, high-risk occupations,
and temporal trends (102) and have greatly improved the
availability of data in the United States. This has led to
expanded research on and policy changes regarding newly
recognized issues such as prevention of workplace violence
(111, 112). Other surveillance systems around the world
have noted similar surveillance problems (113) and
improvements in surveillance data (114).
There is no single surveillance system capable of
capturing the majority of nonfatal occupational injuries in
the United States (115). The Survey of Occupational Injuries
and Illnesses is a federal/state program in which private-
sector employer reports are collected and processed by state
agencies in collaboration with the Bureau of Labor Statistics
(116). This system underestimates nonfatal injuries nation-
ally, since it excludes the self-employed, farms with fewer
than 11 employees, private households, and federal, state,
and local agencies (109, 116). Surveillance of nonfatal occu-
pational injuries by the Bureau of Labor Statistics’ annual
survey and state-based worker’s compensation systems
provides general estimates of the burden of nonfatal injuries
in states but lacks detail for characterizing injuries beyond
broad diagnostic classifications and the number of workdays
lost. Additionally, national data are collected for injuries
serious enough to be treated at a hospital emergency depart-
ment in the NEISS and the National Hospital Ambulatory
Medical Care Survey (115, 117, 118); however, self-
reporting from the National Health Interview Survey has
suggested that only 34 percent of persons with occupational
injuries are treated in an emergency department (119).
30 Horan and Mallonee
State-based occupational surveillance systems are impor-
tant for determining state and local patterns and priorities for
prevention. Many state surveillance systems have reported
state-specific mortality data and trends (120–122). State
population-based surveillance systems for nonfatal occupa-
tional injuries are incomplete and fragmented. There are
several factors that restrict data collection. First, there are no
multiple case-level data systems that can be linked at the
state level (i.e., labor, worker’s compensation, hospital
emergency department or discharge data). Second, external-
cause coding of hospital data does not separately identify
“injury at work” (123). Third, using worker’s compensation
coding as the source of payment on hospital data under-
counts work-related injuries (124). The Alaska Trauma
Registry is a rare example of a system capable of assessing
all occupational injuries involving admission to an acute-
care hospital (125).
Trade-specific analyses of surveillance systems have been
found to be useful in determining potential areas for further
work-based prevention programs (126–128). Other popula-
tion-based systems have utilized worker’s compensation
claims (129), telephone surveys (130), trauma registry data
(131), and police and employers’ reports (132). Finally,
comprehensive company-wide injury surveillance systems,
such as those implemented by the Ford Motor Company
(Dearborn, Michigan), have proven useful for occupational
injury prevention activities (133).
Surveillance for occupational injury in the United States
has improved substantially in the past two decades, but it
could be improved further (107). The use of free text anal-
ysis as a source of case-finding and improving surveillance
data has been demonstrated to be promising by the National
Traumatic Occupational Fatalities Surveillance System and
other surveillance systems (133–136). Surveillance at the
state level needs considerable attention and improvement.
State-level hospital data collection systems could enhance
the utility of such data for injury surveillance for the more
severe injuries by mandating a field denoting injury at work
(123). States could also add collection of work-related inju-
ries to the statewide Behavioral Risk Factor Surveillance
System. The collection of case-level data from multiple
sources (including labor, worker’s compensation, hospital,
and vital statistics data) that could be linked, in a manner
similar to data on transportation-related injuries in some
states (32), should be explored.
Injuries related to violence and firearms
In 1999, violent deaths from suicide and homicide
combined accounted for approximately 29,000 deaths
among persons aged 1–44 years in the United States, ranking
as the second leading cause of death in this age group behind
unintentional injuries (29). For the age groups 15–24 years
and 25–34 years, suicide and homicide ranked as the second
or third leading causes of death after unintentional injury
(29).
Suicide and suicidal behavior. The National Vital Statis-
tics System is the major source for national surveillance data
on suicide (137), documenting more than 29,000 suicide
deaths in 1999 (99). The overall age-adjusted rate of suicide
reported in the United States has been fairly stable for
decades, but there are important differences by age, sex,
race/ethnicity, and region (138–141). In 1999, The Surgeon
General’s Call to Action to Prevent Suicide (142) proposed
a national suicide prevention strategy, with a series of
recommendations for a nationwide collaborative effort to
reduce suicidal behaviors and premature deaths due to
suicide.
One of the strongest predictors for suicide is a previous
attempt (143). Thus, local or state surveillance of nonfatal
suicidal behavior can play a key role in prevention. The
recent expansion of the NEISS offers the potential to
generate national estimates of suicide attempts requiring
emergency medical treatment (144). The Youth Risk
Behavior Surveillance System has also been used to provide
national and state-level estimates of suicidal thoughts and
behavior among youth in schools (145, 146). Together with
vital statistics, data from these systems can provide informa-
tion on a range of suicidal behaviors, from thoughts to
completion. Continued and improved suicide surveillance
using these data will be important in measuring the impact of
the National Strategy for Suicide Prevention.
Homicide. In 1999, there were nearly 17,000 reported
homicides in the United States (99). For surveillance of
homicides, death certificate information from the National
Vital Statistics System provides basic information on the
underlying cause of death, the injuries sustained, and the
date and place of occurrence (147). However, death certifi-
cate data generally do not report important details, such as
the decedent’s relationship to the perpetrator or other key
information—for example, for firearm-related deaths, the
type of firearm involved. That information is included in the
supplemental homicide reports that are part of the Federal
Bureau of Investigation’s Uniform Crime Reporting
Program. These reports include information on the relation-
ship between the victim and the offender, the circumstances
surrounding the incident, the type of weapon used, and the
demographics of victim and offender. The supplemental
homicide report data are used in the Bureau of Justice Statis-
tics’ publication Homicide Trends in the United States (148).
A recent summary report on surveillance of intimate partner
homicides (149) used supplemental homicide report data to
document a steady decrease in rates of intimate partner
homicide during 1981–1998; these decreases were noted to
be temporally associated with social programs and legal
measures implemented to curb intimate partner violence. To
provide more comprehensive and detailed crime statistics,
the Bureau of Justice Statistics and the Federal Bureau of
Investigation have designed the National Incident Based
Reporting System to supplant the Uniform Crime Reporting
Program (150).
Child Fatality Review teams, first formed in Los Angeles
County, California, in 1978 (151), are an important source of
data on child homicides. An estimated 2,000 child deaths
due to abuse and neglect occur in the United States annually;
the majority of victims are younger than age 5 years (152).
Local Child Fatality Review teams generally include
members from coroners’ offices and from law enforcement,
child protective services, and public health agencies. Varia-
tion in definitions and data elements used by different teams
Epidemiol Rev 2003;25:24–42

limits the current potential for national surveillance, but state
and local teams can provide information to promote effective
child health and safety policies (153).
National Violent Death Reporting System. The 1999 Insti-
tute of Medicine report, Reducing the Burden of Injury,
noted that “an ongoing federally sponsored system of
surveillance for all intentional injuries (homicides and
suicides) is conspicuously absent from the array of data
systems available on a national level” (19, p. 73). The report
recommended development of a fatal intentional injury
surveillance system for collection of data on all homicides
and suicides. In 2001, Congress appropriated $1.5 million to
the CDC to begin implementing the National Violent Death
Reporting System. In collaboration with federal and state
partners, the CDC has produced an outline for the National
Violent Death Reporting System that proposes the develop-
ment of state-based systems to routinely link data already
being collected by four sources: death certificates, medical
examiner or coroner reports, police reports, and crime labo-
ratory reports. Death certificates indicate the cause of
death and whether the death was work-related. The
medical examiner/coroner data include information on the
decedent’s blood alcohol level and other toxicology
screening; police reports include data on the victim-
perpetrator relationship and other circumstances of the
event; and crime laboratory reports provide detailed infor-
mation on the type of firearm used in firearm-related deaths
(e.g., caliber, barrel length, type). In the proposed system,
each state health department would collect and link data
from these sources in a state-level system, and together the
states’ data would form the basis for national surveillance
(154).
Surveillance of nonfatal violence. For every death due to
homicide, it has been estimated that there are over 100
nonfatal injuries due to violence (155). National data on
nonfatal violence are collected in two systems administered
by the US Department of Justice. The Uniform Crime
Reporting Program, operated by the Federal Bureau of
Investigation, collects law enforcement reports on violent
crimes, including rape and aggravated assault. Reporting by
local enforcement agencies is voluntary, but participation is
widespread, and the program has been estimated to represent
over 95 percent of the US population (156). The Bureau of
Justice Statistics’ National Crime Victimization Survey is an
ongoing nationally representative sample survey of house-
holds that collects data on rape, assault, and other crimes.
The Uniform Crime Reporting Program and the National
Crime Victimization Survey are complementary systems
with different strengths and limitations. Uniform Crime
Reporting Program reports can provide national, regional,
state, and local data based on incidents reported to law
enforcement authorities. The National Crime Victimization
Survey includes incidents that may have gone unreported to
authorities; however, the data are self-reported and the
system is designed to provide only national estimates.
Recent expansion of the NEISS to include surveillance of all
injuries may provide an opportunity to improve national-
level surveillance for these conditions (157). Other survey-
based surveillance systems, such as the Youth Risk Behavior
Epidemiol Rev 2003;25:24–42
Injury Surveillance 31
Surveillance System, are additional potential sources of
important data on nonfatal violence (158).
In 1995, the National Institute of Justice and the CDC
sponsored the National Violence Against Women Survey
(159). The survey estimated annual intimate partner victim-
ization rates higher than those reported in the National Crime
Victimization Survey; however, there were important meth-
odological differences between these surveys (160). Subse-
quently, in 1998, the Department of Health and Human
Services and the Department of Justice sponsored a work-
shop, “Building Data Systems for Monitoring and
Responding to Violence Against Women” (161). The
summary report recommended using uniform definitions to
define and measure violence against women, and it identi-
fied the need for guidelines for intimate partner violence
surveillance on local levels. In recent years, the CDC has
supported several states in developing pilot projects on
surveillance of intimate partner violence (162), and it is
currently developing a pilot project for possible ongoing
periodic national surveys.
Surveillance of firearm-related injury. From the late 1960s
through the early 1990s, the number of firearm-related
deaths in the United States increased by more than 50
percent, and in 1991, firearms equaled or surpassed motor
vehicle crashes as the leading cause of injury death in seven
states and the District of Columbia (163). With growing
awareness of this public health issue, the capacity for
surveillance of firearm-related injuries and risk factors has
improved. In the early 1990s, Massachusetts implemented
the first statewide reporting system for gunshot wounds
resulting in death, hospitalization, or emergency department
treatment (164). National surveillance for nonfatal injuries
was enhanced in 1992 by the addition of firearm-related
injuries to the data collected in the NEISS (165). To further
advance development of state-level firearm-related injury
surveillance, in 1994 the CDC provided funding for seven
states to develop, implement, and evaluate systems (166).
These projects demonstrated both the feasibility and the
value of state-level surveillance for firearm-related injuries.
They also illustrated several important challenges, including
the resource-intensive nature of the endeavor (167). The
experience gained and lessons learned from these projects
have provided important context for the development of the
National Violent Death Reporting System (see above),
which is envisioned as the future basis of state- and national-
level surveillance of firearm-related mortality.
Other major categories
Poisoning. In 1995, poisoning ranked as the third leading
cause of injury mortality in the United States, following
deaths from motor vehicle traffic injuries and firearm inju-
ries (168). The number of poisoning deaths increased 24
percent from 1995 (n = 16,307) to 2000 (n = 20,230) (29).
Several surveillance systems address different aspects of
poisoning morbidity and mortality. Virtually all poison
control centers in the United States participate voluntarily in
the Toxic Exposure Surveillance System maintained by the
American Association of Poison Control Centers (169). The
annual reports of the Toxic Exposure Surveillance System
32 Horan and Mallonee
are published each year in the American Journal of Emer-
gency Medicine; the report for 2000 includes over 2.1
million poison exposure cases (170). In addition, data from
individual poison control centers can help in identifying and
characterizing problems at a state or local level (171).
The Drug Abuse Warning Network, sponsored by the
Substance Abuse and Mental Health Services Administra-
tion, is an ongoing drug abuse data collection system that
provides data on morbidity and mortality from abuse of
illegal drugs or use of legal drugs for nonmedical purposes.
Recent evaluation and redesign of the Drug Abuse Warning
Network system has produced several reporting changes,
including semiannual reports of morbidity data, annual
reports of mortality data, and periodic short publications
(The DAWN Report) on selected topics (172). The
Hazardous Substances Emergency Events Surveillance
system is maintained by the Agency for Toxic Substances
and Disease Registry to provide information for partici-
pating states with which to reduce morbidity and mortality
from releases of hazardous substances. Sixteen state health
departments participate in the Hazardous Substances Emer-
gency Events Surveillance system; annual summary reports
are available on the World Wide Web (173).
Disaster events. During the last quarter of the 20th
century, natural disasters such as floods, earthquakes, hurri-
canes, tornadoes, fires, and volcanic eruptions claimed
approximately three million lives worldwide and adversely
affected the lives of another 800 million persons (174). In
addition, disasters may be caused by deliberate or uninten-
tional human actions (175). Terrorism throughout the world
is widely reported in the media, and events in the United
States (176–179) and abroad (180–182) have suggested that
mass casualties associated with domestic and international
terrorism among US citizens and military personnel are
increasing. In fact, in the United States alone, from 1988 to
1997, the number of actual and attempted bombings
increased by 127 percent (183).
Disaster surveillance can help determine the magnitude
and nature of health/injury problems, identify groups at high
risk for adverse health effects, optimize relief responses,
evaluate the effectiveness of relief efforts, and recommend
ways of decreasing the consequences of future disasters
(184). Public health surveillance for disasters presents many
challenges: 1) data must be collected under highly adverse
conditions; 2) multiple sources of information must be inte-
grated in a cohesive fashion; 3) circumstances and forces
may exist that impede surveillance (incomplete documenta-
tion of adverse effects, restricted or prohibited access to
records); and 4) data collection and postdisaster action must
be completed rapidly, accurately, and repeatedly in order to
rescue persons at risk or prevent further adverse conse-
quences (185).
Standardized reporting methods, including case defini-
tions, reporting procedures, and standardized data collection
tools that could be easily modified to determine disaster-
related injuries and deaths, do not exist and should be devel-
oped (185–187). After the World Trade Center attack of Sep-
tember 11, 2001, the National Center for Health Statistics
convened an ad hoc working group and developed a set of
new codes within the framework of the ICD-10 and ICD-9-
CM that will allow the identification of deaths from ter-
rorism reported on death certificates through the National
Vital Statistics System, as well as the identification of inju-
ries and illnesses from terrorism reported in medical rec-
ords (http://www.cdc.gov/nchs/about/otheract/icd9/terrorism_
code.htm; also see reference 250). In addition, a recent (April
2003) ad hoc working group was convened by the National
Center for Injury Prevention and Control to develop stan-
dardized data collection tools and methods for bombings or
explosions. Finally, it has been recommended that experi-
enced public health disaster surveillance teams, similar to
National Transportation Safety Board investigators in the
United States, be established and rapidly deployed to assist
communities experiencing disasters (187).
Patient safety. Although injuries related to medical care
have not traditionally been included in public health surveil-
lance of injuries, some investigators have commented that
iatrogenic injuries may account for more deaths than all
other accidents combined (188). The Institute of Medicine
addressed the issue of injuries related to medical care and
medications in its report To Err Is Human: Building a Safer
Health System (189), which called for a comprehensive
approach to improving patient safety. In response to the
recommendations of the Institute of Medicine, the federal
government’s Quality Interagency Coordination Task Force
issued a report in February 2000 (190) that proposed the
establishment of error reporting systems in all states. The
report proposed to foster an environment of support for these
systems by implementing mandatory reporting in Depart-
ment of Defense medical facilities. It also proposed to imple-
ment a voluntary reporting system nationwide in Veterans
Administration hospitals and to integrate federal voluntary
systems with data collection activities by states and private
organizations. Concurrently, the CDC is developing the
National Healthcare Safety Network for reporting of infor-
mation on patient and health care worker safety. The patient
safety component focuses on infectious and noninfectious
adverse events associated with health care delivery, and the
health care worker component focuses on adverse events
associated with vaccines, vaccine-preventable diseases, and
exposure to bloodborne pathogens (e.g., from needlestick
injuries).
Traumatic central nervous system injuries. Traumatic brain
injury has been estimated to cause 50,000 deaths, over
200,000 hospitalizations, and one million emergency depart-
ment visits annually in the United States (191–193). Among
survivors of traumatic brain injury, over 80,000 people per
year are left with subsequent disabilities (194). The age-
specific incidence of traumatic spinal cord injury is highest
among adolescents and young adults, and some of the most
common causes are potentially preventable (195, 196). To
support state-based surveillance of traumatic brain injury
and traumatic spinal cord injury, the CDC has developed the
Guidelines for Surveillance of Central Nervous System
Injury (60) and has provided financial support to some states
to conduct surveillance of the incidence, risk factors, and
causes of these injuries. States have used this surveillance for
highlighting urban-rural differences in rates of traumatic
brain injury (197) and risk factors or risk groups specific to a
state (198). However, evaluation of traumatic spinal cord
Epidemiol Rev 2003;25:24–42

injury surveillance has demonstrated a positive predictive
value below 70 percent for diagnoses from hospital
discharge data (196, 199). Furthermore, vital records
systems have low sensitivity for detecting traumatic spinal
cord injury. Recognizing the importance and difficulty of
conducting surveillance for traumatic spinal cord injury,
representatives of the State and Territorial Injury Prevention
Directors’ Association, the Council of State and Territorial
Epidemiologists, and the CDC have begun planning a
working group to develop pragmatic approaches for trau-
matic spinal cord injury surveillance by state health depart-
ments.
IMPROVING INJURY SURVEILLANCE—LINKAGE,
INTEGRATION, EVALUATION
Data linkage
Linking data elements from more than one data set has
many advantages over the use of a single data set. Many
types of databases have been linked for public health surveil-
lance and found to be useful in understanding injury risk
factors and outcomes. The Crash Outcome Data and Evalua-
tion System funded by the NHTSA is an example of the
utility and application of linking multiple data sets (traffic
collision, EMS, hospital discharge, and vital statistics data)
at the state and national levels (32). The Crash Outcome
Data and Evaluation System has allowed states to more
accurately assess the occurrence, costs, and outcomes of
transportation-related injuries and to evaluate the efficacy
and cost savings associated with highway safety initiatives.
By aggregating these data from multiple states, policy-
makers can be provided with extensive scientific informa-
tion for their consideration regarding public safety and
health care cost containment (72).
Police and traffic collision reports have also been linked to
trauma registries or death certificates to demonstrate the
association of type, severity, and outcome of injury with
crash type, to advance the understanding of crash biome-
chanics and the design of vehicle occupant protection
systems (200), and to evaluate current recommendations on
the use of seat belts during pregnancy (201). Other examples
include linking driver’s license data with trauma registry
data to compare police assessment of alcohol use with blood
alcohol measurements (202) or with hospital discharge data
to examine the possibly decreased ability to drive following
traumatic brain injury (203). Linkage of hospital discharge
data with death certificate data has shown that discharge
status has limitations as an outcome measure among injured
persons (204) and that death certificate cause-of-death
coding is sometimes incompatible with the main conditions
of decedents while hospitalized (205). Thus, linking data sets
used for surveillance can facilitate prevention research and
permit evaluation of existing data sources.
Integration of surveillance systems
Surveillance of injuries should be viewed as one compo-
nent of the larger system of public health surveillance. A
1994 report by Thacker and Stroup (206) commented on the
Epidemiol Rev 2003;25:24–42
Injury Surveillance 33
fragmented approach to surveillance and the development
over time of a collection of poorly coordinated systems that
evolved in response to various needs. They proposed that a
comprehensive public health surveillance system be struc-
tured as a network of compatible health information systems
linked electronically and readily accessible to public health
practitioners. Major efforts have begun to reorganize public
health surveillance along such lines. In 1994, the Council of
State and Territorial Epidemiologists called for the creation
of a national public health surveillance system to expand,
coordinate, prioritize, and standardize approaches to public
health surveillance (207). Subsequently, the CDC, in
collaboration with the Council of State and Territorial Epide-
miologists and other key partners, began the development
and implementation of the National Electronic Disease
Surveillance System to promote the use of information
system and data standards for integrated surveillance at the
local, state, and national levels (208). Thus far, progress is
real but slow. Although the concept of integration is compel-
ling, functional implementation is proving to be an expen-
sive and difficult task that may take many additional years to
complete.
Evaluation
In 1963, Alexander Langmuir observed that “good surveil-
lance does not necessarily ensure the making of the right
decisions, but it reduces the chances of wrong ones” (209, p.
191). Thus, surveillance has limitations, even when done
well. Assessing surveillance systems’ performance can be
accomplished through periodic evaluations. In 1988, the
CDC published a set of guidelines for evaluating surveil-
lance systems (210). The guidelines focused on basic, prac-
tical issues such as the public health importance of the
condition(s) under surveillance and the usefulness and costs
of a surveillance system. These guidelines have been widely
accepted and used in public health practice. An updated
version published in 2001 (1) reiterates the original approach
and principles and also addresses several issues of growing
importance, including integration of information systems,
establishment and use of data standards, and protection of
confidentiality in the electronic exchange of health data.
Evaluations of injury surveillance systems have proven
useful in identifying important strengths and shortcomings.
Results from evaluation of a pediatric injury surveillance
system in Canada indicated that data from the system might
be representative of “general youth injury patterns” in the
country, even though the system was not originally designed
to include a nationally representative sample (211). Evalua-
tions of newspapers as a potential source for injury surveil-
lance have found that a substantial proportion of fatal cases
and cases requiring hospitalization are not identified by
newspaper reports (110, 212). In 1994, the CDC sponsored
the development and evaluation of several state-based
firearm injury surveillance systems. Summary reports
included both surveillance data and system evaluations, thus
providing a fuller picture of the strengths, limitations, bene-
fits, and costs of these systems (166). Evaluation of the
quality of injury surveillance data is necessary if prevention
activities based on the data are to be appropriate and effec-
34 Horan and Mallonee
tive (213). Assessing the usefulness of surveillance systems
is a key element in evaluation; reports demonstrating the
practical use of data (26, 95, 214) provide examples that the
systems are serving their intended purposes. In general, the
time and effort spent in evaluation can provide information
assuring that the resources being put into surveillance are
well invested.
INTERNATIONAL INJURY SURVEILLANCE
Injuries are a major cause of mortality worldwide, causing
more than five million deaths each year (215). As in many
other areas of public health, major differences exist in coun-
tries’ capacities for injury surveillance, generally corre-
sponding to their overall economic development. A
comprehensive review of injury surveillance in countries
other than the United States is beyond the scope of this
report. We present instead several examples to illustrate the
spectrum of injury surveillance activities internationally. In
addition, the World Wide Web page of the CDC-sponsored
International Collaborative Effort on Injury Statistics
provides access to information on many countries’ injury
prevention programs and injury surveillance activities (http:
//www.cdc.gov/nchs/about/otheract/ice/links.htm).
Injury surveillance in some developed countries
The European Union’s Home and Leisure Accident
Surveillance System was designed for use in emergency
departments for collection of data on the causes of home and
leisure injuries, including consumer products involved in
those injuries. Approximately 85 hospital emergency depart-
ments in all but three European Union countries participate
in the Home and Leisure Accident Surveillance System.
Germany, Luxembourg, and Spain participate through
household surveys that use the same key variables as the
emergency department recording system. The data are used
for generating national summary statistics (216) as well as
for highlighting specific injury issues (217, 218). In the
Netherlands, a key participant in the Home and Leisure
Accident Surveillance System, the Dutch Consumer Safety
Institute has conducted emergency department-based
surveillance for home and leisure injuries since 1984. In
1997, the Dutch Injury Surveillance System was initiated in
a sample of hospital emergency departments for ongoing
surveillance of injuries from all causes (219). The Dutch
Injury Surveillance System provides a basis for priority-
setting in injury control in the Netherlands (220), for
obtaining information on the direct medical costs of injury
(221), and for identifying research priorities.
In Canada, the Canadian Hospitals Injury Reporting and
Prevention Program (222) collects and analyzes data on inju-
ries and poisonings from the emergency departments of 10
children’s hospitals and five general hospitals across
Canada. The primary focus is on children and adolescents.
Data collection is accomplished using standard forms that
are forwarded to the Injury Section at Health Canada for
computer entry into the database of the Canadian Hospitals
Injury Reporting and Prevention Program. The program
serves as a valuable source of summary statistics and a
resource for surveillance information on specific injury
conditions (223). In Australia, the National Injury Surveil-
lance Unit of the Australian Institute of Health and Welfare
uses mortality statistics and hospital discharge data to
produce reports on major causes of injury morbidity and
mortality (224, 225), and the National Injury Surveillance
Unit has worked in conjunction with injury surveillance and
prevention practitioners in Australia to develop a set of
national data standards for injury surveillance. In addition,
Australia recently developed the National Coroners Informa-
tion System, an Internet-based data storage and retrieval
system for coroner cases (226). A state-based system, the
Victorian Injury Surveillance and Applied Research System,
accesses data from death certificates, coroner records,
hospital admissions, and emergency department visits to
conduct statewide surveillance of injury mortality and
morbidity (227, 228). In New Zealand, the Injury Prevention
Research Unit was established in 1990 (229). The Injury
Prevention Research Unit uses data files on deaths and
public hospital discharges from the National Minimum Data
Set compiled by the New Zealand Health Information
Service to publish fact sheets and results of descriptive and
evaluative studies on priority injury prevention issues (230–
234). The Injury Prevention Research Unit also maintains
the National Injury Query System, an Internet-accessible,
menu-driven source of information on injury mortality and
morbidity statistics (235).
Comparability across national borders is important for
effective international surveillance. The International
Collaborative Effort on Injury Statistics is a multinational
effort, sponsored by the CDC, to improve the quality and
comparability of international injury data. Participants
include representatives from the World Health Organization,
from countries in Western Europe and North America, and
from Australia, New Zealand, and Israel. The International
Collaborative Effort on Injury Statistics has investigated
international differences in injury mortality rates (236) and
has held symposia to identify problems and propose solu-
tions for international injury statistics (237). A major current
project in which members of the International Collaborative
Effort on Injury Statistics are participating is the Interna-
tional Classification of External Causes of Injury, a multi-
axial classification system for coding data on external
causes, developed in response to a perceived need for more
detailed information about injury circumstances than is
available through the ICD classification system. The first
version of the International Classification of External Causes
of Injury was released in 2001 and is presently undergoing
the requisite procedures for acceptance in the World Health
Organization family of international classifications. A short
version intended for use in emergency department-based
surveillance has been pilot-tested in the United States (238).
Injury surveillance in developing and underdeveloped
countries
In The Global Burden of Disease, Murray and Lopez noted
that “still very little is reliably known about causes of death
in much of the developing world” (239, p. 191). Although
injury mortality and morbidity have been identified as major
Epidemiol Rev 2003;25:24–42

problems in some underdeveloped countries (240), injury
surveillance is problematic because of the dearth of
resources for public health activities in general. The World
Health Organization and the CDC have recently developed a
manual to help design, establish, and maintain injury surveil-
lance systems, aimed in particular at persons working in
settings with severe constraints on the capacity to keep
records or assemble data into statistics (215).
In Asia, some countries have begun or are beginning to
establish national systems for injury surveillance. In other
countries without such systems, surveys and studies have
used existing data sets to describe and quantify data on
important injury issues. The People’s Republic of China has
developed a sentinel system of disease surveillance points in
lieu of a nationwide system of vital records and public health
surveillance. The disease surveillance points system covers
approximately 10 percent of the population (241). Disease
surveillance points data have been used to estimate the
overall injury mortality rate in China and to identify leading
causes and high-risk groups (241, 242). Thailand initiated a
provincial injury surveillance system in 1993, with reporting
from five large hospitals located in Bangkok and four
regions of the country. The data have been useful in docu-
menting the large proportion of injuries from transport acci-
dents and the large proportion of deaths occurring prior to
hospitalization. The latter may indicate a need for improved
prehospital transport and care. Hospital-based sentinel
surveillance is being considered for a larger national injury
surveillance system for the country (243). In Vietnam, which
does not have a formal national system of injury surveil-
lance, the Vietnam Multi-center Injury Survey was
conducted in 2001. This nationally representative survey of
over 127,000 respondents demonstrated that injuries are the
leading cause of years of potential life lost. Drowning was
the leading cause of years of potential life lost nationally,
and road traffic injury was second. The high prevalence of
personal transportation via motorcycle rather than via auto-
mobile or bicycle has important implications for the inci-
dence and prevention of transport-related injuries (244).
In some underdeveloped countries in Africa and other areas,
monitoring causes of death has been done by “verbal autopsy”
interviews of the deceased person’s relatives or associates.
Trained field-workers can perform these interviews, with
subsequent review by clinicians to assign a cause of death
(245). The latter step can be costly, and a study in Ghana and
Tanzania using computer algorithms in lieu of physician
review to assign cause-of-death diagnoses demonstrated that
this might be an effective and less expensive alternative (246).
Hospital-based surveillance can provide data on injury
morbidity, although it does not identify the many patients who
do not seek formal medical care (247). While acknowledging
this important limitation, a study in Uganda demonstrated the
feasibility of a hospital-based system using a minimum data
set and a simple standard index of injury severity (248). The
Caribbean Epidemiology Center of the World Health Organi-
zation is working with several member countries to develop
emergency department-based injury surveillance. Recog-
nizing the limited resources (money, personnel, etc.) avail-
able, the designers have emphasized simplicity, but they
Epidemiol Rev 2003;25:24–42
Injury Surveillance 35
acknowledge that “even if the system is simple and flexible,
sustainability will be difficult to achieve” (249, p. 246).
CONCLUSIONS
In recent decades, great strides have been made in injury
surveillance. The systematic collection and use of data on
risk factors, incidence, severity, outcomes, and costs has
assisted practitioners and researchers in identifying popula-
tions at risk, implementing and evaluating prevention
programs, and formulating and evaluating policy. These
efforts have already improved the health of the population,
and they will continue to do so.
In the United States, surveillance for the leading cause of
injury fatality, motor vehicle-related injuries, has included
linking multiple data sets in which data were collected for
disparate purposes. This has supported innovative public
health applications, such as evaluation of the effectiveness of
state and national legislation or regulations. In some
respects, motor vehicle-related injury surveillance has been
further advanced than surveillance for other classes of
injury, but important developments are under way in other
areas. Surveillance systems are being designed for major
issues in injury such as violent death and patient safety. Stan-
dards are being developed and used to facilitate consistency
and comparability in data collection and dissemination.
Federal, state, and academic partners are collaborating to
promote and improve state-level injury surveillance
capacity. Progress in injury surveillance can be fostered by
developing systematic approaches to the access and use of
existing data sources, as has recently been done in the
Consensus Recommendations for Using Hospital Discharge
Data for Injury Surveillance (20).
The growth and development of injury surveillance also
presents important challenges. With more systems that can
provide more data, there is a greater need for integration.
Integration of information systems is a multidimensional
issue encompassing data on risk factors, morbidity, and
mortality for both intentional and unintentional injuries,
involving local, state, national, and international levels, and
including systems that are intended to serve not only public
health but also clinical, administrative, and other functions.
In addition, injury surveillance and public health surveil-
lance in general face the challenge of integration during a
time of increasing capacity for electronic access to and trans-
mission of health-related information. The tools and systems
at our disposal provide tremendous opportunity, but they
also require responsible use, including the provision of data
security and the protection of confidentiality.
Finally, a continuing challenge for injury surveillance is
making effective use of the data. No matter how important
the condition under surveillance, data collection is not an end
in itself, as reflected in the observation by former CDC
Director William H. Foege: “The reason for collecting,
analyzing, and disseminating information on a disease is to
control that disease. Collection and analysis should not be
allowed to consume resources if action does not follow.”
This is true for injury surveillance as well as disease surveil-
lance. In that context, the public health investment in surveil-
lance—whether it be in continuing or enhancing existing
36 Horan and Mallonee
systems, developing new ones, or committing effort and
resources to systems integration—needs to be service-
oriented, supporting programs by providing data for deci-
sions and information for action.
ACKNOWLEDGMENTS
The authors acknowledge Lois Fingerhut, Dawn Castillo,
and Drs. Lee Annest, Jim Mercy, and David Sleet for their
comments and feedback. They thank Diana Lambert for
assistance in preparing the manuscript.
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