The Status of Legal Authority for Injury Prevention Practice in State Health Departments

Abstract

Despite the potential for public health strategies to decrease the substantial burden of injuries, injury prevention infrastructure in state health departments is underdeveloped. We sought to describe the legal support for injury prevention activities at state health departments.

We searched the Lexis database for state laws providing authority for those activities, and categorized the scope of those laws. Only 10 states have authority that covers the full scope of injury prevention practice; in the others, legal authority is piecemeal, nonspecific, or nonexistent.

More comprehensive legal authority could help health departments access data for surveillance, work with partners, address sensitive issues, and garner funding. Efforts should be undertaken to enhance legal support for injury prevention activities across the country.

APPROXIMATELY 50 MILLION nonfatal injuries¹ and 180 000 deaths from injury occur each year in the United States. Lifetime costs associated with medical expenses and lost productivity from all injury types are estimated to exceed $400 billion.² The public health approach to injury prevention, based on the core public health functions of assessment, policy development, and assurance,³ includes surveillance to define the scope of the problem, identification of risk and protective factors, development and testing of prevention and control strategies, and assurance of widespread adoption of those strategies that prove to be effective.⁴ This approach could have a large positive impact on the public’s health.

Although injuries impose a substantial public health burden, and effective public health strategies could decrease that burden, public health practice has been relatively slow to take on injury prevention. In recognition that public health needed to increase its focus on injury prevention, the Centers for Disease Control and Prevention created its National Center for Injury Prevention and Control in 1992 (although injury and violence work at the agency dates back to the late 1970s and early 1980s). State and local health department infrastructure to address injuries has been growing since that time as well, but the injury prevention infrastructure in most health departments, if it exists at all, remains small and underfunded relative to the magnitude of the injury problem.

Government public health agencies function within an authorizing environment defined by statute and sometimes clarified by rule or regulation.⁵ Although broad statutory authority allows agency leaders some freedom to define their activities, if the agency moves into a new arena without unambiguous legal authority, its activities may be open to challenge, particularly if they involve regulation or are fraught with political implications, as are so many issues in public health, including injury prevention. Clear authority to engage in injury prevention activities is essential if public health agencies are to engage robustly in this area.

We investigated laws in all 50 states that pertain to authorizing health departments to undertake a robust slate of injury prevention activities. We found that the scope of legal authority for injury prevention activities varies widely across the country regarding which kinds of injuries are addressed and which legal tools an injury prevention program is explicitly authorized to use. If state health departments are to fully realize their potential to prevent injuries, efforts to make the legal basis for the full range of injury prevention activities more comprehensive across the country should be undertaken.

METHODS

We conducted a 50-state online review of selected state laws relating to injury surveillance and prevention. Our data came from Lexis searches conducted between March 2007 and April 2008. Search terms were collect and report injury data; injury surveillance; injury prevention program; reportable injuries; violence; injury in combination with 1 or more of the following terms: reporting, collection, patient, retrieving, collected, funded, financial, inpatient, health service, retrieval, injury; head and spinal; brain injury; trauma registry; injury program; injury prevention; and injury within 5 words of the term report.

For study purposes, we defined laws as both statutes enacted by legislatures and regulations or rules having the force of law promulgated by agencies pursuant to delegated legislative authority. Consistent with statutory grants of authority, rules or regulations may clarify ambiguous statutory authority, provide specificity, or fill gaps left by the legislature. Our analysis excluded the following kinds of laws:

• Laws related to or enforced by non–public health agencies, such as highway safety laws or environmental regulations, unless those laws surfaced in the application of our search terms;

• General public health or welfare laws that implicitly authorized injury surveillance or prevention activities;

• Provisions defining injury prevention terms, unless those provisions otherwise assisted in understanding the scope of legal authority or other relevant factor;

• Provisions creating injury victim funds or grants for development of nonprofit or employer injury prevention programs;

• Provisions relating to injury data systems’ quality control;

• Laws that only mandated promotion of injury prevention activities⁶; and

• Specialized areas of injury prevention laws, which have appropriately been the subjects of research and analysis in their own right (e.g., child, domestic, and intimate partner abuse and workers’ compensation or employer-focused risk management programs).

A law classified as providing authority for a full scope of activities authorized work on a broad range of intentional and unintentional injuries, established the program within the state’s department of health, and delineated particular duties or areas of activity touching on all of the core governmental public health functions of assessment, policy development, and assurance as defined by the Institute of Medicine.⁷

We characterized the laws found in our search by whether they provided authority for a full scope of injury prevention activities or were restricted in any of the following respects:

• Mandates and grants of authority for injury prevention programs administered by agencies other than departments of health;

• Location at which the injury occurred, such as amusement parks, school grounds, or swimming pools;

• Intent, such as violence-related injuries, suicide, or unintentional injuries;

• Mechanism or cause, such as firearms or pesticides;

• Activity during which the injury occurred, such as hunting or boating;

• Authority assigned to emergency medical services or trauma systems;

• Brain and spinal cord injuries; and

• Occurrence in children.

RESULTS

Overall, 10 states had authority for a full-scope injury prevention program. The health departments in 7 states were mandated to administer such a program, and the departments in 3 additional states were authorized, but not required, to do so. Forty states only had authority for activities related to specific injury prevention activities, which were limited to specific types or causes of injury.

Mandates for Full-Scope Programs

Seven states had full-scope mandates for injury prevention programs: Connecticut,⁸ Florida,⁹ Missouri,¹⁰ North Carolina,¹¹ Texas,¹² Utah,¹³ and Wisconsin.¹⁴ North Carolina law, for example, provided that

the Department shall establish and administer a comprehensive statewide injury prevention program. The Department shall designate the Division of Public Health as the lead agency for injury prevention activities. The Division of Public Health shall: (1) Develop a comprehensive State plan for injury prevention; (2) Maintain an injury prevention program that includes data collection, surveillance, and education and promotes injury control activities; and (3) Develop collaborative relationships with other State agencies and private and community organizations to establish programs promoting injury prevention.¹⁵

Statutes in 6 of the 7 states expressly required injury surveillance. Although Missouri did not use the term, we elected to include that state in the full-scope rather than the limited-scope category because its law directed that the “powers, functions and duties” of the Division of Injury Prevention, Head Injury Rehabilitation, and Local Health Services must include sponsorship of research into the causes and prevention of injuries, among other elements. Missouri’s law varied slightly from the others by not only providing authority for injury prevention generally, but also specifically addressing head injuries and access to support services. Accordingly, it mandated slightly different obligations, such as

[the] responsibility, subject to appropriations, of ensuring that injury prevention and brain injury rehabilitation evaluation, service coordination, treatment, rehabilitation, and community support services are accessible, wherever possible.¹⁶

Discretionary Authority for Full-Scope Programs

Three states (Alaska, Georgia, and Ohio)¹⁷ had laws providing discretionary authority to state agencies to engage in the full scope of injury prevention activities. The Alaska legislature adopted the Turning Point Model State Public Health Act in 2005.¹⁸ It provides that the health department may

identify, assess, prevent, and ameliorate conditions of public health importance through surveillance; epidemiological tracking, program evaluation, and monitoring; testing and screening programs; treatment; administrative inspections; or other techniques.¹⁹

A condition of public health importance is defined as

a disease, syndrome, symptom, injury, or other threat to health that is identifiable on an individual or community level and can reasonably be expected to lead to adverse health effects in the community.²⁰

In Georgia, the health department

is empowered to declare certain diseases, injuries, and conditions to be diseases requiring notice and to require the reporting thereof to the county board of health and the department in a manner and at such times as may be prescribed.²¹

The State Board of Emergency Medical Services in Ohio may establish an injury prevention program.²²

Authority for Limited-Scope Programs

All states had at least 1 law authorizing injury prevention activity with limited scope. States with authority for a full-scope injury prevention program also had laws authorizing a particular subset of injury prevention activities. Authorized activities covered a wide range of causes of injuries, some common and others unusual or relevant to only a small part of the population (Table 1). The specific types of injuries covered in each state also differed (Table 2). These laws primarily related to unintentional injuries, with a few exceptions (e.g., violence- and firearm-reporting laws).

TABLE 1—

Laws Authorizing Injury Prevention Activity of Limited Scope: United States, 2007–2008

Scope of Law	States	No.
Location
Nonspecific workplace	AL, AK, AZ, CA, CT, DC, HA, IA, ME, MD, MA, MI, NV, NH, NJ, NM, NC, OH, OK, OR, PA, SC, TN, TX, UT, WA, WY	27
Public utility workplace	CA, DE, ID, MT, PA, WI	6
Health care workplace/needlestick	AR, GA, OK, RI, WV	5
Institution or prison	AL, CA, DE, DC, HA, KS, OK	7
Otherab	AL, AZ, HA, KY, NH, NJ, NY, OK, SC, TN, TX, UT	12
Intent
Violence	AK, AZ, CA, CO, DE, ID, IL, IA, MS, NE, NC, ND, OH, TN, UT, WA	16
Otherac	GA	1
Activity
Amusement park	AR, CA, GA, IA, LA, ME, MI, MO, NE, NJ, NY, NC, PA, SC, TX	16
Boating	CT, FL, GA, ID, MD, MN, MS, MO, NH, NJ, TN, UT, WA	13
Hunting	IL, IA, MS, NY, PA, RI, WV, WI	8
Boxing	CA, MA, NY, OR, PA	5
Otherad	ME	1
Mechanism
Motor vehicle	CA, DE, FL, GA, IL, IA, KS, LA, MD, MI, MN, MT, NE, NV, NH, NJ, OR, RI, TX, VT, VI, WI	22
Firearm	AZ, DC, FL, LA, MD, MI, MN, NE, SD, WI	10
Burn	FL, IA, NV, OH, WV, WI	6
Tanning bed/ultraviolet radiation	GA, NC, OR, SC, TX, WI	6
Otherae	AR, CO, CT, FL, HA, LA, ME, MN, MS, MT, NV, NY, NC, PA, TN, WV	16
Other focus
Injury prevention within trauma or emergency medical service programs	AZ, CO, ID, IN, LA, MD, MI, MS, MO, MT, NE, NM, NC, OH, UT, WA, WI, WY	20
Injury prevention programs in agencies other than departments of health	AK, CA, GA, IA, NJ, OK	6
Brain or spinal cord injury registries	AL, AR, CT, FL, IA, LA, MN, MS, MO, NE, NH, NJ, NC, OH, RI, SC, WV	17
Child injuryf	AL, AR, DE, DC, IN, NJ, OH, OR, TN	10
General injury surveillance	UT	1

^aCategories specifically targeted by law in fewer than 5 states.

^bParks (4 states); school grounds (4 states); beach/pool, camps, dental, horse racing, mining, greyhound training (1 state each).

^cSuicide (1 state).

^dTransportation of hazardous materials (1 state)

^eAircraft, pesticides (3 states each); all-terrain vehicles (2 states); liquefied gas, environmental injury, captive wildlife, anesthesia related, exotic species, aerosols, prescription drug related, motor carrier, elevator, dog attack, general drug related (1 state each).

^fNonspecific injuries to children, injuries occurring in day care centers, toy related.

TABLE 2—

Laws Mandating or Authorizing Injury Prevention Activity (Full or Limited Scope), by State: United States, 2007–2008

State	Scope of Law	Legal Citation
Alabama	Brain and spinal cord injury registry	Ala. Code § 22–11C-3 and 11C-5
	Child injury	Ala. Code § 26–16-94
	School grounds injury	Ala. Code § 16–1-24
	Work injury	Ala. Code § 25–5-4; Ala. Code § 36–21-13; Ala. Admin. Code r. 480–3-3–0.37 and r. 480–3-4–0.29
	Dental injury	Ala. Code § 34–9-65
	Institutional/prison injury	Ala. Admin. Code r. 580–2-13–0.18 and r. 580–2-13–0.19
Alaska	Full-scope injury prevention program (discretionary)	Alaska Stat. § 18.05.010 and § 18.05.070
	Injury prevention program in agency other than department of health	Alaska Stat. § 18.60.030
	Work injury	Alaska Stat. § 18.60.058 and § 18.60.066
	Violence-related injury	Alaska Stat. § 08.64.369
Arizona	Injury prevention within trauma or EMS programs	Ariz. Rev. Stat. § 36–2225
	School grounds injury	Ariz. Rev. Stat. § 15–341
	Work injury	Ariz. Rev. Stat. § 23–427
	Pool injury	Ariz. Rev. Stat. § 36–1681
	Violence-related injury	Ariz. Rev. Stat. § 46–454
	Drug-related injury	Ariz. Rev. Stat. § 36–1661
	Firearm injury	Ariz. Rev. Stat. § 17–311
Arkansas	Brain and spinal cord injury registry	Ark. Code Ann. § 20–8-206 and § 20–14-703
	Child injury	Ark. Code Ann. § 20–27-1701; Ark. Code Ann. § 20–27-1704
	Work injury (health care/needlestick)	Ark. Code Ann. § 20–9-311
	Amusement park injury	Ark. Code Ann. § 20–27-1704
	Pesticide injury	Ark. Code Ann. § 20–20-216
	Injury related to fire prevention equipment and fires	Ark. Code Ann. § 20–22-601
California	Injury prevention program in agency other than department of health	Calif. [Health & Safety] Code § 104325
	Work injury	Calif. Lab Code § 6409, § 6409.1 and § 9104; Calif. Code Regs. 8 CCR § 14001 and 8 CCR § 14300.35
	Amusement park injury	Calif. Lab Code § 7914
	Public utility injury	Calif. Pub Util Code § 315
	Prison injury	Calif. Lab Code § 6413; Calif. Code Regs. 8 CCR § 14900
	Violence-related injury	Calif. Pen Code § 11161
	Motor vehicle injury	Calif. Veh Code § 2900
	Horse-racing injury	Calif. Bus & Prof Code § 19441.2
	Boxing injury	Calif. Code Regs. 4 CCR § 307
Colorado	Injury prevention within trauma or EMS programs	Colo. Rev. Stat. § 25–3.5–704
	Injury related to liquefied petroleum gas	Colo. Rev. Stat. § 8–20-407
	Violence	Colo. Rev. Stat. § 12–36-135
Connecticut	Full-scope injury prevention program (mandatory)	Conn. Gen. Stat. § 19a-4i
	Brain injury registry	Conn. Gen. Stat. § 19a-6e
	Work injury	Conn. Gen. Stat. § 31–374
	Aircraft injury	Conn. Gen. Stat. § 15–104;
	Boating injury	Conn. Gen. Stat. § 15–149b
Delaware	Public utility injury	26 Del. Code Ann. § 213; Del. Code Regs. § 10–800-026
	Violence-related injury	24 Del. Code Ann. § 1762
	Motor vehicle injury	21 Del. Code Ann. § 4203
	Child injury	Del. Code Regs. § 9–100-101
	Institution injury	Del. Code Regs. § 40–625-105
District of Columbia	Work injury	D.C. Code Ann. § 1–623.20
	Institution injury	D.C. Code Ann. § 7–1305.10
	Firearm injury	D.C. Code Ann. § 7–2601
	Child injury	22 D.C. Code Mun. Regs. § 2801
Florida	Full-scope injury prevention program (mandatory)	Fla. Stat. § 401.243
	Brain and spinal cord injury registry	Fla. Stat. § 381.74
	Burn injury	Fla. Stat. § 877.155
	Boating injury	Fla. Stat. § 310.111 and § 327.301
	Firearm injury	Fla. Stat. § 790.24
	Motor vehicle injury	Fla. Stat. § 316.066
	Pesticide injury	Fla. Stat. § 487.159
Georgia	Full-scope injury prevention program (discretionary)	Ga. Code Ann. § 31–12-2
	Injury prevention program in agency other than department of health	Ga. Code Ann. § 31–2-9
	Amusement park injury	Ga. Code Ann. § 34–12-13 and § 34–13-13
	Boating injury	Ga. Code Ann. § 52–7-14
	Tanning facility injury	Ga. Code Ann. § 31–38-8
	Suicide reporting	Ga. Code Ann. § 31–2-9
	Motor vehicle injury	Ga. Code Ann. § 40–6-278
	Work injury (health care/needlestick)	Ga. Comp. R. & Regs. 290–5-60–0.01 through 290–5-60–0.09
Hawaii	Work injury	Hawaii Rev. Stat. Ann. § 396–6
	Institution/prison injury	Hawaii Rev. Stat. Ann. § 338–22
	Environmental injury	Hawaii Rev. Stat. Ann. § 321–311
	Park injury	Hawaii Code R. § 13–104, § 13–130, § 13–146 and § 13–221
Idaho	Injury prevention within trauma or EMS programs	Idaho Code Ann. § 57–2001
	Public utility injury	Idaho Code Ann. § 61–517
	Violence-related injury	Idaho Code Ann. § 39–5303
	Boating injury	Idaho Code Ann. § 67–7027
Illinois	Violence-related injury	20 Ill. Comp. Stat. Ann. § 2310/2310–415 and § 2435/25; Ill. Admin. Code tit. 77, § 560.120
	Hunting injury	520 Ill. Comp. Stat. Ann. § 5/3.40
	Motor vehicle injury	625 Ill. Comp. Stat. Ann. § 5/18c-6502
Indiana	Injury prevention within trauma or EMS programs	Ind. Code Ann. §16–19-3–28
	Child injury	Ind. Code Ann. § 31–27-5–29
	Aircraft injury	Ind. Code Ann. § 8–21-3–3
Iowa	Injury prevention program in agency other than department of health	Iowa Admin. Code r. 641–76.5(135)
	Brain and spinal cord injury registry	Iowa Code § 135.22
	Burn injury	Iowa Code § 147.113A
	Work injury	Iowa Code § 88.6
	Amusement park injury	Iowa Code § 88A.3
	Violence-related injury	Iowa Code § 147.112
	Hunting injury	Iowa Code § 481A.18
	Motor vehicle injury	Iowa Code § 321.266
Kansas	Institution/prison injury	Kans. Stat. Ann. § 65–2425
	Motor vehicle injury	Kans. Stat. Ann. § 8–1611
Kentucky	Mining injury	Ky. Rev. Stat. Ann. § 352.180
Louisiana	Injury prevention within trauma or EMS programs	La. Rev. Stat. Ann. § 40:2845
	Brain injury registry	La. Rev. Stat. 40:1299.173
	Amusement park injury	La. Rev. Stat. Ann. § 40:1484.3 and § 40:1485.3
	Firearm injury	La. Rev. Stat. Ann. § 14:403.5
	Motor vehicle injury	La. Rev. Stat. Ann. § 32:871
	Injury caused by aerosols	La. Rev. Stat. Ann. § 40:1057.3
Maine	Work injury (caused by exposure to environmental agents)	Maine Rev. Stat. Ann. tit. 22, § 1491
	Injury related to transport of hazardous material	Maine Rev. Stat. Ann. tit. 25, § 2104-A
	Prescription drug–related injury	Maine Rev. Stat. Ann. tit. 32, § 13753
	Occupational injury in public sector	Maine Code R. § 12–179-006
	Amusement park injury	Maine Code R. § 16–219-028
Maryland	Injury prevention within trauma or EMS programs	Md. Code Regs. 30.08.04.04
	Work injury	Md. Code Ann., [Lab. & Empl.] § 5–206 and § 5–702
	Boating injury	Md. Code Ann., [Nat. Res.] § 8–724
	Firearm injury	Md. Code Ann., [Health-Gen.] § 20–703
	Motor vehicle injury	Md. Code Ann., [Transp.]§ 20–107
Massachusetts	Work injury	Mass. Ann. Laws ch. 30, § 46I; 452 Mass. Code Regs. 4.03
	Boxing injury	523 Mass. Code Regs. 1.03
Michigan	Injury prevention within trauma or EMS programs	Mich. Admin. Code R325.134
	Motor vehicle injury	Mich. Comp. Laws Serv. § 257.617a
	Firearm injury	Mich. Comp. Laws Serv. § 752.843
	Work injury	Mich. Admin. Code r. 408.12413
	Amusement park injury	Mich. Admin. Code r. 408.898
Minnesota	Brain and spinal cord injury registry	Minn. Stat. § 144.663 and § 144.664
	Boating injury	Minn. Stat. § 86B.341
	Firearm injury	Minn. Stat. § 626.52
	Motor vehicle injury	Minn. Stat. § 169.09
	Off-road/all-terrain vehicle injury	Minn. Stat. § 84.80 and § 84.924
Mississippi	Injury prevention within trauma or EMS programs	15–332-001 Miss. Code R. § 100–1400
	Brain and spinal cord injury registry	Miss. Code Ann. § 37–33-263
	Boating injury	Miss. Code Ann. § 59–21-51
	Violence-related injury	Miss. Code Ann. § 45–9-31
	Hunting injury	Miss. Code Ann. § 45–9-31
	Motor carrier injury	Miss. Code Ann. § 77–7-181
Missouri	Full-scope injury prevention program (mandatory)	Mo. Rev. Stat. § 199.003
	Injury prevention within trauma or EMS programs	Mo. Rev. Stat. § 190.176
	Brain and spinal cord injury registry	Mo. Rev. Stat. § 192.737
	Amusement park injury	Mo. Rev. Stat. § 316.206
	Boating injury	Mo. Rev. Stat. § 506.350
Montana	Injury prevention within trauma or EMS programs	Mont. Code Anno. § 50–6-412
	Public utility injury	Mont. Code Ann. § 69–3-107
	Motor vehicle injury	Mont. Code Anno., § 61–7-109
	Injury caused by exotic species	Mont. Admin. R. 12.6.2210
Nebraska	Injury prevention within trauma or EMS programs	Neb. Admin. Code tit. 185, Ch. 9 and legislative findings in Neb. Rev. Stat. Ann. § 71–2078
	Brain injury registry	Neb. Rev. Stat. § 81–655
	Amusement park injury	Neb. Rev. Stat. Ann. § 48–1808
	Violence-related injury	Neb. Rev. Stat. Ann. § 28–902
	Firearm injury	Neb. Rev. Stat. Ann. § 69–2442
	Motor vehicle injury	Neb. Rev. Stat. Ann. § 60–696
Nevada	Burn injury	Nev. Rev. Stat. Ann. § 629.045
	Work injury	Nev. Rev. Stat. Ann. § 618.378
	Motor vehicle injury	Nev. Rev. Stat. Ann. § 484.223
	Anesthesia-related injury	Nev. Admin. Code § 631.2241
New Hampshire	Brain and spinal cord injury registry	NH Rev. Stat. Ann. § 137-K:9
	Boating injury	N.H. Rev. Stat. Ann. § 270:1-a
	Motor vehicle injury	N.H. Rev. Stat. Ann. § 264:25
	Greyhound trainer injury	N.H. Code Admin. R. Ann. [Pari] 811.05
	Work injury	N.H. Code Admin. R. Ann. [Lab] 1403.46
New Jersey	Injury prevention program in agency other than department of health	N.J. Rev. Stat. § 26:2H-5.20
	Spinal cord injury registry	N.J. Stat. § 52:9E-8
	Child injury (related to toys)	N.J. Rev. Stat. § 52:17B-124.1
	Work injury	N.J. Rev. Stat. § 34:5–175
	Injury occurring at camps	N.J. Rev. Stat. § 26:12–9
	Amusement park injury	N.J. Rev. Stat. § 5:3–57; N.J. Admin. Code § 5:14A-10.5
	Boating injury	N.J. Rev. Stat. § 12:7–34.46
	Motor vehicle injury	N.J. Rev. Stat. § 39:4–130
New Mexico	Injury prevention within trauma or EMS programs	N.M. Code R. § 7.27.7.6, § 7.27.7.8, and § 7.27.7.10
	Work injury	N.M. Stat. Ann. § 50–9-19; N.M. Code R. § 1.18.805.655
New York	Work injury (specific to amusement parks)	N.Y. [Lab.] § 870-g
	Hunting injury	N.Y. [Envtl. Conserv.] § 11–0719
	All-terrain vehicle injury	N.Y. [Veh. & Traf.] § 2413
	Boxing injury	NY [Unconsol.] § 26
	Bathing beach/public pool injury	N.Y. Comp. Codes R. & Regs. tit. 10, § 6–1.7, § 6–2.7, and § 6–3.7
	Amusement park injury	N.Y. Comp. Codes R. & Regs. tit. 12, § 45–1.8
North Carolina	Full-scope injury prevention program (mandatory)	N.C. Gen. Stat. § 130A-224
	Injury prevention within trauma or EMS programs	10 N.C. Admin. Code § 13P.0902; and 10 N.C. Admin. Code § 13P.0903
	Brain injury registry	N.C. Gen. Stat. § 143B-216.65
	Pesticide injury	10A N.C. Admin. Code § 41F.0101; 10A N.C. Admin. Code § 41F.0102; 10A N.C. Admin. Code § 41F.0103
	Amusement park injury	N.C. Gen. Stat. § 95–111.10
	Elevator injury	N.C. Gen. Stat. § 95–110.9
	Violence-related injury	N.C. Gen. Stat. § 108A-102
	Tanning facility injury	15 N.C. Admin. Code § 11.1418
	Work injury	N.C. Gen. Stat. § 130A-456
North Dakota	Violence-related injury	N.D. Cent. Code § 43–17-41
	Tattooing/body piercing/branding injury	N.D. Cent. Code, § 23–01-35
Ohio	Full-scope injury prevention program (discretionary)	Ohio Rev. Code Ann. § 4765.10
	Injury prevention within trauma or EMS programs	Ohio Rev. Code Ann. § 4765–4-02
	Brain injury registry	Ohio Rev. Code Ann. 3304.23
	Child injury (reported to agency if child dies from injuries sustained at child care facility)	Ohio Rev. Code Ann. § 2919.227
	Burn injury	Ohio Rev. Code Ann. § 2921.22
	Work injury	Ohio Rev. Code Ann. § 4123.28
	Amusement park injury	Ohio Rev. Code Ann. § 1711.55
	Violence-related injury	Ohio Rev. Code Ann. § 5123.61
Oklahoma	Injury prevention program in agency other than department of health	Okla. Stat. Ann. tit. 63, § 315
	Work injury	Okla. Stat. Ann. tit. 40, § 403 and § 417
	Work injury (health care/needlestick)	Okla. Stat. Ann. tit. 63, § 1–539.1
	Public park injury	Okla. Admin. Code § 725:30–4-16
	Institution-related injury	Okla. Admin. Code § 340:100–3-34
Oregon	Child injury (related to toys)	Ore. Rev. Stat. § 677.491
	Motor vehicle injury	Ore. Rev. Stat. § 811.720
	Child injury (daycare to report to agency)	Ore. Admin. R. 414–300-0220
	Boxing injury	Ore. Admin. R. 230–020-0470
	Work injury	Ore. Admin. R. 437–001-0700
	Tanning facility injury	Ore. Admin. R. 333–119-0110
Pennsylvania	Work injury	43 Pa. Cons. Stat. § 12
	Amusement park injury	4 Pa. Cons. Stat. § 413
	Public utility injury	66 Pa. Cons. Stat. § 1508
	Injury caused by dog attack	3 Pa. Cons. Stat. § 459–505-A
	Boxing injury	58 Pa. Cons. Stat. § 21.14
	Hunting injury	34 Pa. Cons. Stat. § 2521
Rhode Island	Brain and spinal cord injury registry	R.I. Gen. Laws § 23–1-49
	Hunting injury	R.I. Gen. Laws § 20–13-12
	Motor vehicle injury	R.I. Gen. Laws § 31–26-9
	Work injury (health care/needlestick)	R.I. Gen. Laws § 23–1.11–8
South Carolina	Brain and spinal cord injury registry	S.C. Code § 44–38-10
	Amusement park injury	S.C. Code Ann. § 41–18-320; S.C. Code Ann. Regs. § 71–4400
	Work injury	S.C. Code Ann. Regs. § 71–335 and § 71–5550
	Tanning facility injury	S.C. Code Ann. Regs. § 61–106
	School grounds injury	S.C. Code Ann. § 59–63-55
South Dakota	Firearm injury	S.D. Codified Laws § 23–13-10 and § 23–13-11
Tennessee	Work injury	Tenn. Code Ann. § 50–3-702; Tenn. Comp. R. & Regs. 0800–1-3–0.04
	Boating injury	Tenn. Code Ann. § 69–9-210
	Violence-related injury	Tenn. Code Ann. § 38–1-101
	Injury caused by captive wildlife	Tenn. Code Ann. § 70–4-416
	Park injury	Tenn. Comp. R. & Regs. 0400–2-2–0.20
	Child injury	Tenn. Comp. R. & Regs. 0520–12-1–0.10
Texas	Full-scope injury prevention program (mandatory)	Tex. [Health and Safety] Code Ann. § 92.004 and § 92.007
	School grounds injury (bus accident)	Tex. [Educ.] Code Ann. § 34.015
	Work injury	Tex. [Health & Safety] Code Ann. § 84.005 and § 92.009
	Amusement park injury	Tex. [Occ.] Code Ann. § 2151.103
	Motor vehicle injury	Tex. [Transp.] Code Ann. § 601.004
	Tanning facility injury	25 Tex. Admin. Code § 229.355
Utah	Full-scope injury prevention program (mandatory)	Utah Code Ann. § 26–1-30
	Injury prevention within trauma or EMS programs	Utah Code Ann. § 26–8a-250
	Work injury	Utah Code Ann. § 34A-3–108
	Boating injury	Utah Code Ann. § 73–18-13
	Violence-related injury	Utah Code Ann. § 26–23a-2
	General injury surveillance	Utah Admin. Code r. 386–703-1
	Park injury	Utah Admin. Code r. 651–621-1
Vermont	Motor vehicle injury	Vt. Stat. Ann. tit. 23, § 1129
Virginia	Aircraft injury	Va. Code Ann. § 5.1–143
	Motor vehicle injury	Va. Code Ann. § 46.2–371
Washington	Injury prevention within trauma or EMS programs	Wash. Admin. Code § 246–976-420
	Boating injury	Wash. Rev. Code Ann. § 79A.60.220
	Violence-related injury	Wash. Rev. Code Ann. § 43.70.545 and § 74.34.035
	Work injury	Wash. Admin. Code § 296–27-02111, § 296–45-115, § 296–54-515, § 296–78-525, § 296–155-110, § 296–305-01501, § 296–305-01505, § 296–307-030, § 296–800-14005
West Virginia	Brain injury registry	W. Va. Code § 18–10A-15
	Burn injury	W. Va. Code Ann. § 61–2-27a
	Hunting injury	W. Va. Code Ann. § 20–2-57
	Work injury (health care/needlestick)	W. Va. Code Ann. § 16–36-2; W. Va. Code R. § 64–82-1
	Drug-related injury	W. Va. Code Ann. § 60A-10–9
	Commercial whitewater outfitter injury	W. Va. Code R. § 58–12-11
Wisconsin	Full-scope injury prevention program (mandatory)	Wis. Stat. § 255.20
	Injury prevention within trauma or EMS programs	Wis. Admin. Code [HFS] § 118.09
	Burn injury	Wis. Stat. § 146.995
	Public utility injury	Wis. Stat. § 195.34
	Tanning facility injury	Wis. Stat. § 255.08
	Hunting injury	Wis. Stat. § 29.345
	Firearm injury	Wis. Stat. § 146.995
	Motor vehicle injury	Wis. Stat. § 346.70
Wyoming	Injury prevention within trauma or EMS programs	048–210-001 Wyo. Code R. § 1–7; 048–210-003 Wyo. Code R. § 1–3
	Work injury	Wyo. Stat. Ann. § 27–2-105 and § 27–11-105

Note. EMS = emergency medical services.

Although restricted to particular types of injury, some of these laws articulated specific duties; others established a comprehensive approach to the law’s subject matter. California law, for example, provided that the state department of health “may maintain a program of accidental injury study and control, including but not limited to” 5 duties oriented toward research, such as studies of “human and environmental factors in the occurrence of accidental injury” and

development of control programs to reduce the frequency and severity of accidental injuries resulting from health and other human factors, either alone or in combination with environmental factors.²³

Likewise, a Georgia statute, although limited to suicide prevention, applied statewide and comprehensively articulated the duties to be performed by the program.²⁴ On the other hand, the Iowa maternal and child health regulation provided no specificity regarding the scope of injury prevention services to be performed by the contracting agency.²⁵

Nine states (Arizona, Colorado, Idaho, Louisiana, Mississippi, Montana, New Mexico, North Carolina, and Wyoming)²⁶ had statutes or regulations establishing mandatory injury prevention programs as components of statewide or district-wide trauma care or emergency medical services (among them, only North Carolina also mandated a comprehensive injury prevention program²⁷). Some programs addressed injuries with many different causes, but the placement of these programs suggested that they were limited to the acute injuries treated through the trauma system or emergency medical services and in that way differed from full-scope injury prevention authorizations. A provision in the emergency medical services chapter of Montana’s health and safety statutes, for instance, required that regional trauma care advisory committees “establish trauma education and injury prevention programs,” among other duties.²⁸ In other states, legislated criteria for designation of various trauma facilities (level 1, level 2, etc.) included a requirement that facilities develop injury prevention programs.²⁹

Closely related to provisions requiring establishment of programs were laws in 11 states (Indiana, Maryland, Michigan, Missouri, Nebraska, New Mexico, Ohio, Utah, Washington, Wisconsin, and Wyoming)³⁰ that listed injury prevention as a purpose or use of the statewide trauma system or emergency medical services or registry. For example, a Wisconsin regulation stated,

The purpose of the trauma registry is to collect and analyze trauma system data to evaluate the delivery of adult and pediatric trauma care, develop injury prevention strategies for all ages, and provide resources for research and education.³¹

Seventeen states (Alabama, Arkansas, Connecticut, Florida, Iowa, Louisiana, Minnesota, Mississippi, Missouri, Nebraska, New Hampshire, New Jersey, North Carolina, Ohio, Rhode Island, South Carolina, and West Virgina)³² required maintenance of registries of brain and spinal cord injuries. Florida and North Carolina were the only states in this group with a general injury prevention mandate. Unlike the broader injury prevention programs referenced in most trauma system laws we found, laws establishing brain and spinal injury programs (predictably) referred to prevention efforts aimed only at head and spinal cord injuries.

Despite our selection of search terms intended to eliminate laws relating to injury prevention programs administered by non–public health agencies, we nonetheless detected 6 states (Alaska, California, Georgia, Iowa, New Jersey, and Oklahoma)³³ with laws authorizing injury prevention programs to be administered by agencies other than departments of health. Laws in Alaska, Iowa, and New Jersey are examples. An Alaska statute required the state’s Department of Labor and Workforce Development to

study ways and means for prevention of accidents to persons on the streets and highways, in and on the water, in aircraft usage, in homes, on the farms, at schools, in industrial and commercial plants, and in public places.³⁴

The statute authorized activities typically found in the general-mandate statutes, such as providing education to the public and forming partnerships with other stakeholder organizations, but it also prescribed duties more directly related to employment contexts, such as

requir[ing] an employer to maintain records and submit reports appropriate for use in developing information regarding the causes and prevention of occupational accidents and illnesses.³⁵

An Iowa requirement that certain public health services, including injury prevention services, be purchased from contract agencies appeared to be directed to a special population, in that the requirement appeared in a regulation relating to the maternal and child health program.³⁶ Similarly, the New Jersey statute required establishment of violence prevention programs, but only in certain health care facilities.³⁷

DISCUSSION

We documented substantial variation in state laws relating to injury prevention and found gaps in the legal ability of state health departments to implement the full range of activities necessary for a comprehensive injury prevention program. Only 10 states had a general mandate or general discretionary authority for injury prevention programs. In the remaining states, legal authority for many critical injury prevention activities was piecemeal, nonspecific, or nonexistent.

By contrast, most state health departments had broad authority related to communicable disease control, which permits them to conduct public health surveillance, educate the public, promote prevention programs, undertake more coercive public health actions when the public’s health is threatened, and implement policies as necessary to protect the public’s health, among other activities. During tight budget times, the mandatory nature of communicable disease control also helps strengthen the case for funding for these activities.

The Turning Point National Collaborative on Public Health Statute Modernization³⁸ has led to modernization of many foundational public health statutes across the country. Similar efforts have been applied to public health laws related to privacy and emergency preparedness.³⁹ Although injury was included in the definition of conditions of public health importance in the model law used in the Turning Point effort,⁴⁰ this part of the model law appears not to have been widely adopted.

Why is explicit authority for injury prevention activities important? Governmental public health must function within the limits of its authorizing environment.⁴¹ A general mandate to protect the public’s health may be broadly interpreted in many states to cover injury prevention activities, but the lack of specificity in these authorities makes public health agencies potentially vulnerable to challenge should they undertake injury prevention activities; agencies may therefore be less proactive about addressing injury prevention issues, particularly when the issues are politically sensitive. In addition, other agencies involved in work related to injury prevention, such as law enforcement and transportation, may be reluctant to partner with public health agencies without a clear understanding of a public health mandate to work in this area.

Much of public health surveillance for injuries relies on data systems that draw on individual health care records, and unless public health agencies can clearly demonstrate that they are authorized to have access to these data, agency requests for access are likely to be questioned by health care systems that are responsible for ensuring that protected health information is only released for legitimate public health purposes permitted by law. Advances in health information technology may enhance the public health system’s access to these data, but because of the scale and ease of access that these changes make possible, increased scrutiny of whether public health agencies are authorized to access particular data is likely.

Finally, few states appear to invest substantially in injury prevention activities, and the lack of clear legal authority, although clearly not the only driver of funding allocation by state legislatures, may hinder efforts to advocate for appropriate funding to carry out these important efforts. The public discussion about giving injury programs explicit authority that necessarily accompanies efforts toward passing such legislation may raise awareness of the potential for injury prevention and thereby help support efforts to increase funding.

Although a comprehensive assessment of the impact of statutory authority for injury prevention was beyond the scope of our study, several specific examples help illustrate the importance of having solid authority for the full range of injury prevention activities. In North Carolina, the passage of a bill in 2007 providing full-scope authority helped the injury prevention program clarify with a wide range of partners that its program had responsibility to pull together these partners for several injury and violence prevention initiatives. Partners involved in these efforts included the Department of Insurance, the Injury Prevention Research Center at a local university, the Division of Mental Health, the Office of Emergency Medical Services, and domestic violence advocacy and service groups, among others. The passage of this authority helped identify the Injury Prevention Branch of the state health department as the clear go-to organization for development of a state plan for injury prevention, injury surveillance, and other activities. In addition, the process of passing this legislation provided a vehicle for discussions with partners about each of their roles and fostered engagement with the state injury prevention program. North Carolina's plan has been influential in advancing injury prevention agendas both within the state and nationally (Sharon Rhyne, programs manager, Chronic Disease and Injury Section, North Carolina Division of Public Health, written communication, February 2011).

In Oregon, where one author (M. A. K.) works, a lack of statutory authority has hindered the state injury prevention program. Working through concerns raised by health care systems about providing access to their data for injury prevention has required considerable staff effort and legal resources, which would otherwise have been available for more substantive work. Similarly, gaining access to law enforcement data, critical for understanding the circumstances of many violence-related injuries, has siphoned off staff resources in Oregon from other injury prevention activities because of the need to resolve questions about the program’s authority to work in this area.

The lack of external cause coding in hospital discharge, emergency room, and ambulatory care data sets also is a major obstacle to effective injury surveillance.⁴² These codes consist of 3 or 4 numbers and letters, derived from the International Classification of Diseases, 9th Revision, Clinical Modification,⁴³ that together describe various facets of a particular incident, such as the mechanism of injury.⁴⁴ It is typically the responsibility of medical records staff to enter the codes into data collection systems, according to their interpretation of information provided in patient medical records. The extent to which external cause coding is provided differs substantially across states, and a clear legal mandate for conducting injury surveillance may help strengthen the case for improving coding and enhancing public health surveillance for injuries.

Injuries create a substantial public health burden, yet most states lack unambiguous authority to address this health threat. The lack of clear authority to engage in a full scope of injury prevention activities is likely related in part to the relatively recent introduction of injury prevention into public health practice. Modern communicable disease control has been a focus for public health practice in states since at least the 19th century; by contrast, injury prevention as a discipline in modern public health practice began in the 1940s, and more widespread efforts in states began only in the 1980s.⁴⁵ The controversial nature of some injury prevention strategies (e.g., controlling firearms) may also have hindered states’ adoption of appropriate authorities for injury prevention programs. The patchwork laws providing authority only for specific subsets of injury prevention activity likely were passed in response to politically high-profile events or passionate advocacy (e.g., from the family of someone who died from a specific type of injury). These laws may be salutary, but they do not provide the necessary authority for a full scope of injury prevention practice at state health departments.

Limitations

It is possible that our decision to search only in the Lexis database resulted in missing some laws. Furthermore, because our research was limited exclusively to an online search of statutes and regulations, our findings and discussion do not reflect the impact that legal opinions on or interpretations of the statutes and regulations we studied or others we missed may have on the scope of legal authority to carry out various activities.

Although cities, counties, and other jurisdictions smaller than states conduct excellent injury prevention activities and can enact rules, laws, and ordinances related to injury prevention, resources did not permit us to review these legal tools. A similar review for those jurisdictions could be useful. We also did not examine the extent to which states acted on whatever authority they had to conduct injury prevention activities.

Conclusions

A mantra in the injury prevention field maintains that injuries are not accidents. Many injuries are predictable and preventable. What we lack is the political will to address injuries as a public health problem. One way to help create that political will would be to promulgate a model statute for a state-based injury prevention program that covers the full range of activities necessary for an effective program. The North Carolina statute mandating a general injury prevention program offers a possible model. Convening an external prevention task force with a focus on injury prevention helped North Carolina make the case that injury prevention efforts needed a more organized platform.

Of course, laws are susceptible to various interpretations, and each state needs to evaluate the specifics of its legal framework for public health authorities to assess whether expansion or clarification of those authorities is desirable or achievable. In some states, for example, a health department may succeed in building a comprehensive and effective injury prevention program on the legal foundation of a statute generally authorizing protection of the public’s health. Other states may find it productive to clarify the authority provided in a general statute by promulgating a rule or regulation expressly establishing a comprehensive injury prevention program.

Clearly laws alone will not prevent injuries; they must be effectively acted on. Further study of how laws are translated into effective action would be very useful. Additional work is also needed to define the optimal components of a state statute providing the authority for injury prevention; the Turning Point Model State Public Health Act provides a useful starting point for that work. Further exploration of whether and in what contexts it is preferable for these authorities to be mandated or discretionary would be helpful.

A national effort to support work at the state level, aimed at enacting laws to authorize or clarify the full scope of injury prevention practice in all states, could help make injury prevention a robust part of public health practice and improve the public’s health.