Abstract
This cohort study uses administrative health data to evaluate trends in pediatric firearm injuries before and during the COVID-19 pandemic.
Firearm injuries are the leading cause of injury-related death for US children,1 and increased societal violence during the COVID-19 pandemic, including mass shooting events, has sparked renewed public attention toward this public health crisis. Some early pandemic studies revealed a spike in firearm injuries,2,3 whereas others found unchanged rates.4,5 We evaluated contemporary trends in pediatric firearm injuries before and during the pandemic to determine whether sociodemographic risk factors were similar.
Methods
This retrospective cohort study used data from the Pediatric Health Information System (PHIS), an administrative database that includes 49 tertiary care pediatric hospitals across the US. This study was approved by the University of Utah Institutional Review Board, which waived the informed consent requirement because deidentified were used. We followed the STROBE reporting guideline.
We included all children younger than 18 years diagnosed with firearm injury based on International Classification of Diseases, Tenth Revision codes (W32-34, X72-X74, X93-X95, and Y22-Y24). To account for seasonal variability in trauma volume, patients who presented during the first 21 months of the pandemic (April 2020-December 2021) were compared with patients treated during corresponding months of the preceding years (April 2018-December 2019). The primary outcome was monthly firearm injury rates. Demographic characteristics, intent categories, and mortality rates were compared using χ2 and Wilcoxon rank sum tests. Multivariable Poisson regression was used to assess the association between monthly firearm injuries and COVID-19 while controlling for age, sex, patient- or guardian-reported race and ethnicity based on US Census groups, insurance, zip code–based median household income, rurality, and region. Statistical analyses were performed using R, version 4.2.1 (R Foundation for Statistical Computing), and the threshold for statistical significance was a 2-sided P < .05.
Results
The analysis included 4574 children (mean [SD] age, 12.5 [4.7] years; 3595 boys [78.5%] 979 girls [21.4%]; 612 Hispanic or Latinx [13.4%], 2981 non-Hispanic Black [65.2%], and 758 non-Hispanic White [16.6%] individuals). There were 1815 firearm injuries before vs 2759 during the pandemic, a 52% increase. The monthly median (IQR) number of firearm injuries was significantly higher during (128 [118-142]) than before (86 [76-92]; P < .001) the pandemic (Table and Figure). Compared with the proportion of children with firearm injuries before the pandemic, a greater proportion of non-Hispanic Black children (62% vs 67%; P < .001), those aged 0 to 5 years (12% vs 15%; P = .03), and those with public insurance (76% vs 80%, P < .001) had firearm injuries during the pandemic. There were no significant differences between cohorts by sex, household income, rurality, region, mortality, or intent. The COVID-19 pandemic was independently associated with increased monthly firearm injuries after controlling for all covariates (incident rate ratio, 1.35; 95% CI, 1.27-1.43; P < .001).
Table. Characteristics of Children With Firearm Injuries Before vs After the COVID-19 Pandemic.
| Characteristic | Children, No. (%) | P valuea | |
|---|---|---|---|
| Prepandemic (n = 1815) | Pandemic (n = 2759) | ||
| Monthly firearm injuries, median (IQR) | 86 (76-92) | 128 (118-142) | <.001 |
| Firearm injury intent | |||
| Unintentional | 1072 (59.1) | 1718 (62.3) | .10 |
| Assault | 639 (35.2) | 873 (31.6) | |
| Self-harm | 51 (2.8) | 85 (3.1) | |
| Undetermined intent | 53 (2.9) | 83 (3.0) | |
| Sex | |||
| Female | 388 (21.4) | 591 (21.4) | .99 |
| Male | 1427 (78.6) | 2168 (78.6) | |
| Age group, y | |||
| 0-5 | 225 (12.4) | 417 (15.1) | .03 |
| 6-11 | 268 (4.8) | 379 (13.7) | |
| 12-17 | 1322 (72.8) | 1963 (71.1) | |
| Race and ethnicity | |||
| Hispanic or Latinx | 240 (13.2) | 372 (13.5) | <.001 |
| Non-Hispanic Black | 1126 (62.0) | 1855 (67.2) | |
| Non-Hispanic White | 351 (19.3) | 407 (14.8) | |
| Otherb | 98 (5.4) | 125 (4.5) | |
| Household income quartile by zip codec | |||
| Fourth | 476 (26.2) | 659 (23.9) | .20 |
| Third | 438 (24.1) | 736 (26.7) | |
| Second | 442 (24.4) | 672 (24.4) | |
| First | 459 (25.3) | 692 (25.1) | |
| Primary insurance payer | |||
| Private | 310 (17.1) | 358 (13.0) | <.001 |
| Public | 1372 (75.6) | 2198 (79.7) | |
| Self-pay or otherd | 133 (7.3) | 203 (7.4) | |
| Residential location | |||
| Rural | 179 (9.9) | 257 (9.3) | .50 |
| Urban | 1636 (90.1) | 2502 (90.7) | |
| Geographic region | |||
| Northeast | 102 (5.6) | 144 (5.2) | .05 |
| Midwest | 538 (29.6) | 730 (26.5) | |
| South | 1047 (57.7) | 1704 (61.8) | |
| West | 128 (7.1) | 181 (6.6) | |
| Mortality | 94 (5.2) | 159 (5.8) | .40 |
Pearson χ2 test or Wilcoxon rank sum test.
Other race and ethnicity included Asian, American Indian or Alaska Native, and Native Hawaiian, or Other Pacific Islander.
Household income quartiles were defined as follows: fourth (>$41 657), third ($33 312-$41 657), second ($26 974-$33 311), and first (<26 974).
Other insurance payers included third parties not categorized as commercial or government payers.
Figure. Monthly Pediatric Firearm Injuries Before and During the COVID-19 Pandemic.
The prepandemic period was April 2018 to December 2019, and the pandemic period was April 2020 to December 2021.
Discussion
Rates of children with firearm injuries presenting to US children’s hospitals significantly increased during the COVID-19 pandemic and remained elevated throughout 2021. Non-Hispanic Black children and those with public insurance had greater proportions of firearm-injured children during vs before the pandemic. This unequal burden of injury mirrors the disproportionate implications of COVID-19 for minoritized communities; pandemic conditions exacerbated many structural inequities that contribute to health disparities, and our findings may reflect the disparities that some minoritized children experienced during the study period.
Study limitations are inherent to administrative data, including the potential for injury misclassification, wherein coding biases are nondifferential between periods. Furthermore, PHIS data are not nationally representative, limiting generalizability to non–children’s hospitals. Although there was a significant decline in overall emergency department visits to PHIS hospitals during the pandemic,6 trauma patient volumes may have been altered by triage and transfer patterns at adult and community institutions. These variables are not captured in the current data and warrant investigation.
This study reveals a surge in pediatric firearm injuries presenting to US children’s hospitals during the COVID-19 pandemic. These data can inform health policy and support advocacy efforts to prevent firearm injuries and prepare health systems to provide robust, trauma-informed care.
References
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