Key Points
Question What causes of death are associated with the widening disparities in mortality among US youth of different races and ethnicities in recent years?
Findings In this cross-sectional study of mortality in youth aged 1 to 19 years in the US, injuries, especially firearm injuries, were associated with worsening disparities between Black and American Indian or Alaska Native and White youth. Between 2016 and 2020, the homicide rate in Black youth was 12.81 per 100 000 youth (rate ratio with White youth, 10.20), and the suicide rate for American Indian or Alaska Native youth was 11.37 per 100 000 youth (rate ratio with White youth, 2.60).
Meaning In this study, racial and ethnic disparities were observed for almost all leading causes of injury and disease and were associated with recent increases in US mortality rates.
Abstract
Importance Mortality rates in US youth have increased in recent years. An understanding of the role of racial and ethnic disparities in these increases is lacking.
Objective To compare all-cause and cause-specific mortality trends and rates among youth with Hispanic ethnicity and non-Hispanic American Indian or Alaska Native, Asian or Pacific Islander, Black, and White race.
Design, Setting, and Participants This cross-sectional study conducted temporal analysis (1999-2020) and comparison of aggregate mortality rates (2016-2020) for youth aged 1 to 19 years using US Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research database. Data were analyzed from June 30, 2023, to January 17, 2024.
Main Outcomes and Measures Pooled, all-cause, and cause-specific mortality rates per 100 000 youth (hereinafter, per 100 000) for leading underlying causes of death were compared. Injuries were classified by mechanism and intent.
Results Between 1999 and 2020, there were 491 680 deaths among US youth, including 8894 (1.8%) American Indian or Alaska Native, 14 507 (3.0%) Asian or Pacific Islander, 110 154 (22.4%) Black, 89 251 (18.2%) Hispanic, and 267 452 (54.4%) White youth. Between 2016 and 2020, pooled all-cause mortality rates were 48.79 per 100 000 (95% CI, 46.58-51.00) in American Indian or Alaska Native youth, 15.25 per 100 000 (95% CI, 14.75-15.76) in Asian or Pacific Islander youth, 42.33 per 100 000 (95% CI, 41.81-42.86) in Black youth, 21.48 per 100 000 (95% CI, 21.19-21.77) in Hispanic youth, and 24.07 per 100 000 (95% CI, 23.86-24.28) in White youth. All-cause mortality ratios compared with White youth were 2.03 (95% CI, 1.93-2.12) among American Indian or Alaska Native youth, 0.63 (95% CI, 0.61-0.66) among Asian or Pacific Islander youth, 1.76 (95% CI, 1.73-1.79) among Black youth, and 0.89 (95% CI, 0.88-0.91) among Hispanic youth. From 2016 to 2020, the homicide rate in Black youth was 12.81 (95% CI, 12.52-13.10) per 100 000, which was 10.20 (95% CI, 9.75-10.66) times that of White youth. The suicide rate for American Indian or Alaska Native youth was 11.37 (95% CI, 10.30-12.43) per 100 000, which was 2.60 (95% CI, 2.35-2.86) times that of White youth. The firearm mortality rate for Black youth was 12.88 (95% CI, 12.59-13.17) per 100 000, which was 4.14 (95% CI, 4.00-4.28) times that of White youth. American Indian or Alaska Native youth had a firearm mortality rate of 6.67 (95% CI, 5.85-7.49) per 100 000, which was 2.14 (95% CI, 1.88- 2.43) times that of White youth. Black youth had an asthma mortality rate of 1.10 (95% CI, 1.01-1.18) per 100 000, which was 7.80 (95% CI, 6.78-8.99) times that of White youth.
Conclusions and Relevance In this study, racial and ethnic disparities were observed for almost all leading causes of injury and disease that were associated with recent increases in youth mortality rates. Addressing the increasing disparities affecting American Indian or Alaska Native and Black youth will require efforts to prevent homicide and suicide, especially those events involving firearms.
Between 2019 and 2021, all-cause pediatric mortality rates in the US increased by 18.3%, the largest such increase in at least half a century.1 The increase was based on homicides, suicides, motor vehicle crashes (MVCs), and drug overdoses, while COVID-19 played a minor role.1 Previously, all-cause mortality had been decreasing among youth of all races and ethnicities due to advances in health care, expanded insurance coverage, and progress in injury prevention,2-4but that trend reached a nadir in 2014.
Disparities in death rates among American Indian or Alaska Native, Black, and White youth have been increasing in the last several years. Between 2014 and 2020, all-cause mortality rates increased 36.7% in Black youth and 22.3% in American Indian or Alaska Native youth while increasing 4.7% in White youth.5However, a knowledge gap exists regarding causes of death and the widening inequalities among racial and ethnic groups.
Although previous studies have examined disparities in pediatric all-cause mortality within a region6 or by cause of death,7-9 few have disaggregated national data by race and ethnicity across leading causes of death.10,11Disaggregating analyses of recent data is important to clarify which causes of death are associated with the widening disparities and current increases in all-cause mortality, identify the populations at greatest risk, and evaluate public health progress aimed at reducing disparities in specific causes of death.
This cross-sectional study conducted a temporal analysis between 1999 and 2020 and a comparison of aggregate mortality rates per 100 000 youth (hereinafter, per 100 000) or leading causes of death per 100 000 from 2016 to 2020 and for COVID-19 from 2020 to 2021. Data were obtained from the Underlying Cause of Death database of the US Centers for Disease Control and Prevention (CDC) Wide-Ranging Online Data for Epidemiologic Research (WONDER).5 Mortality information was derived from death certificates that contain a single underlying cause of death determined by a physician. CDC WONDER provided pooled all-cause and cause-specific mortality rates using modified census counts in 2000 and 2010 and intercensal or postcensal estimates for other years.5 Data were analyzed from June 30, 2023, to January 17, 2024. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline. This study was determined to not meet the Office of Extramural Research definition of human participant research because personally identifiable data were not used and was thus exempt from review per the Common Rule (45 CFR §46).
Race and ethnicity of the decedent were provided by an informant (eg, family member) or the funeral director. Prior to 2003, only 1 of 4 racial categories could be selected in accordance with Office of Management and Budget standards. Beginning in 2003, some states permitted the selection of 1 or more of 5 racial categories. To provide uniformity across this transition, the National Center for Health Statistics developed a race-bridging method to compare single-race data and multiple-race data.12 This approach allows for a comparison of race-specific trends over time. Bridged-race data (available for 1999-2020) were used for the temporal analyses and the aggregate rate comparisons except for pooled COVID-19 mortality rates in 2020 and 2021 (for which only single-race data were available). Data were aggregated from 2016 to 2020 to capture the most recent 5 years available from bridged-race data. Because CDC WONDER censored small numbers of patients to prevent identification, mortality data were not available for some strata.
This study included youth aged 1 to 19 years from all 50 US states and Washington, DC, with race and ethnicity classified with the Census bridged-race format as Hispanic ethnicity or as non-Hispanic American Indian or Alaska Native, Asian or Pacific Islander, Black, or White race. White youth were the referent group to highlight the disparities in marginalized racial and ethnic groups. Infants younger than 1 year were excluded because the causes of death in this group are primarily perinatal conditions that are uncommon in older age groups.
Crude age-specific mortality rates were estimated for the 10 leading causes of death among youth aged 1 to 19 years, as defined by CDC WONDER from 1999 to 2020. Since injuries are the leading cause of death among US youth, injury deaths were disaggregated by mechanism (according to methods by Cunningham et al10) and intent. Asthma was selected from the broader category of chronic lower respiratory diseases for detailed analysis due to its importance in the pediatric population. The category of septicemia was widened to other infections to capture a wider array of viral, fungal, and bacterial infections. Deaths from heart and cerebrovascular diseases were grouped together as circulatory diseases (eTable 1 in Supplement 1). COVID-19 was added to the list of outcomes using mortality data from 2020 to 2021. As with other causes, only deaths in which COVID-19 was considered the underlying cause were counted. CDC WONDER computes 95% CIs using the SE (for 100 or more deaths) or a Poisson variable (for 99 or fewer deaths).5 Exact Poisson CIs were calculated for rate ratios using a medical calculator (MedCalc version 22.017; MDCalc).
The Joinpoint Regression Program version 5.0.2 was used to specify the years (joinpoints) when the slopes of mortality rates changed, the rate of increase (measured by the annual percentage change), and statistical significance (2-sided test, α = .05 threshold). The increases reported herein represent those that occurred between joinpoints with slopes significantly greater than 0 (P < .05).
Between 1999 and 2020, there were 491 680 deaths among youth aged 1 to 19 years, including 320 309 deaths (65.1%) in males and 171 371 deaths (34.9%) in females. Most deaths involved teenagers: 262 098 (53.3%) occurred in youth aged 15 to 19 years, 74 816 (15.2%) occurred in youth aged 10 to 14 years, 57 950 (11.8%) occurred in children aged 5 to 9 years, and 96 816 (19.7%) occurred in children aged 1 to 4 years. There were deaths of 8894 (1.8%) American Indian or Alaska Native, 14 507 (3.0%) Asian or Pacific Islander, 110 154 (22.4%) Black, 89 251 (18.2%) Hispanic, and 267 452 (54.4%) White youth.
Throughout this period, the highest all-cause mortality rates occurred among American Indian or Alaska Native and Black youth (Figure 1). Joinpoint analyses revealed statistically significant increases in all-cause mortality among all racial and ethnic groups except Asian or Pacific Islander and White youth (eTable 2 in Supplement 1). These increases began in 2013 for American Indian or Alaska Native and Hispanic youth and 2014 for Black youth.
Injuries, specifically from firearms and MVCs, were the leading source of widening disparities over time (Figure 2; eFigure 1 in Supplement 1). For each cause and race group, we used the nadir as calculated by the joinpoint analyses (eTable 2 in Supplement 1) from 1999 to 2020 as the baseline for calculating rate increases. After decreasing between 1999 and 2013, firearm mortality increased between 2013 and 2020 by 124.0% (baseline of 4.04 per 100 000) in American Indian or Alaska Native youth and 108.4% (baseline of 8.35 per 100 000) in Black youth. Firearm mortality in Hispanic youth increased between 2014 and 2020 by 82.3% (baseline of 2.20 per 100 000).
MVC fatality rates decreased for much of the period between 1999 and 2020, particularly among American Indian or Alaska Native youth. However, between 2010 and 2020, MVC fatality rates among Black youth increased by 34.2% (baseline 4.94 per 100 000) (Figure 2).
Between 2018 and 2020, drug-related mortality increased 227.8% (baseline 0.66 per 100 000) in Black youth, 215.1% (baseline 0.74 per 100 000) in Hispanic youth, and 65.0% (baseline of 1.40 per 100 000) in White youth. Although drug-related deaths have historically been highest among White youth, rates among Black and Hispanic youth reached statistical parity in 2020.
Between 2014 and 2020, homicides in Black youth increased by 76.0% (baseline of 9.56 per 100 000), and homicides in White youth increased by 47.0% (baseline of 1.00 per 100 000) (eFigure 2 in Supplement 1). Among American Indian or Alaska Native youth, homicide rates increased by 48.2% (baseline 3.59 per 100 000) between 2016 and 2020. Homicide rates among Hispanic youth increased by 50.0% (baseline 2.30 per 100 000) between 2018 and 2020.
Suicide rates among American Indian or Alaska Native youth increased throughout the entire period (1999-2020) and began increasing among Black youth in 2014, Hispanic youth in 2012, and White youth in 2008. Increases in suicide rates between these joinpoints and 2020 were 93.8% among American Indian or Alaska Native youth, 81.8% among Black youth, 67.9% among Hispanic youth, and 48.7% among White youth (eFigure 2 and eTable 2 in Supplement 1). These disproportionate increases among Black and Hispanic youth narrowed the gap between these groups and the historically higher suicide rates in White youth (eFigure 2 in Supplement 1).
Between 2016 and 2020, pooled all-cause mortality rates were 48.79 per 100 000 (95% CI, 46.58-51.00) in American Indian or Alaska Native youth, 15.25 per 100 000 (95% CI, 14.75-15.76) in Asian or Pacific Islander youth, 42.33 per 100 000 (95% CI, 41.81-42.86) in Black youth, 21.48 per 100 000 (95% CI, 21.19-21.77) in Hispanic youth, and 24.07 per 100 000 (95% CI, 23.86-24.28) in White youth (Table). All-cause mortality ratios compared with White youth were 2.03 (95% CI, 1.93-2.12) among American Indian or Alaska Native youth, 0.63 (95% CI, 0.61-0.66) among Asian or Pacific Islander youth, 1.76 (95% CI, 1.73-1.79) among Black youth, and 0.89 (95% CI, 0.88-0.91) among Hispanic youth (eTable 3 in Supplement 1).
Injuries accounted for most deaths in every group except Asian or Pacific Islander youth. The injury mortality rate for American Indian or Alaska Native youth was 34.67 per 100 000 (95% CI, 32.81-36.53), which was 2.30 (95% CI, 2.17-2.43) times that of White youth. The injury mortality rate for Black youth was 27.07 per 100 000 (95% CI, 26.66- 27.49), which was 1.79 (95% CI, 1.76-1.83) times that of White youth (Table; eTable 3 in Supplement 1).
By mechanism, the leading cause of death for Black youth was firearm injuries, whereas the leading cause of death for American Indian or Alaska Native, Hispanic, and White youth was MVCs (Table). Asian or Pacific Islander youth were most likely to die from MVC, suffocation (including hanging), and firearm injuries.
Mortality for American Indian or Alaska Native youth was higher compared with White youth for all mechanisms of injury (Table; eTable 3 in Supplement 1; Figure 3). The disparities were highest in suffocation deaths (a category that includes hanging), firearm injury, and MVCs. American Indian or Alaska Native youth had a suffocation mortality rate of 7.79 (95% CI, 6.90- 8.67) per 100 000, 3.71 (95% CI, 3.28- 4.17) times that of White youth. American Indian or Alaska Native youth had a firearm mortality rate of 6.67 (95% CI, 5.85- 7.49) per 100 000, which was 2.14 (95% CI, 1.88- 2.43) times that of White youth.
Mortality for Black youth was higher compared with White youth for all mechanisms of injury except for drug-related deaths and suffocation, for which it was lower. The most pronounced disparity involved firearm deaths. The firearm mortality rate for Black youth was 12.88 (95% CI, 12.59-13.17) per 100 000, which was 4.14 (95% CI, 4.00-4.28) times that of White youth.
By intent, the most likely causes of death for American Indian or Alaska Native youth were suicide and unintentional MVCs. The most common cause of death for Asian or Pacific Islander youth was suicide. Black youth were most likely to die from homicide. Hispanic and White youth were most likely to die from unintentional MVCs. Homicides accounted for most firearm deaths in Black (86.5%) and Hispanic youth (67.3%), whereas suicides accounted for most firearm deaths in American Indian or Alaska Native (52.1%), Asian or Pacific Islander (54.2%), and White (67.7%) youth.
For American Indian or Alaska Native youth, the largest disparities were seen in homicide and suicide. The homicide rate for American Indian or Alaska Native youth was 4.49 (95% CI, 3.82- 5.16) per 100 000, which was 3.57 (95% CI, 3.05-4.17) times that of White youth. The suicide rate for American Indian or Alaska Native youth was 11.37 (95% CI, 10.30-12.43) per 100 000, which was 2.60 (95% CI, 2.35-2.86) times that of White youth.
For Black youth, the greatest disparity was seen in homicide. The homicide rate for Black youth was 12.81 (95% CI, 12.52-13.10), which was 10.20 (95% CI 9.75-10.66) times that of White youth (eTable 3 in Supplement 1; Figure 3). Mortality differed greatly by sex; homicide mortality in Black males was 21.09 per 100 000 and 4.27 per 100 000 in Black females.
Deaths in the selected disease categories represented 52.5% of all disease deaths from 2016 to 2020. Black youth were significantly more likely to die from all categories of disease compared with White youth (Figure 4; Table; eTable 3 in Supplement 1). Among diseases, the largest rate ratios between Black and White individuals occurred with asthma, COVID-19, and circulatory diseases. Black youth had an asthma mortality rate of 1.10 (95% CI, 1.01-1.18) per 100 000, which was 7.80 (95% CI, 6.78-8.99) times that of White youth. Dilated cardiomyopathy and myocarditis were factors in disparities in circulatory disease deaths in Black youth.
Death rates were significantly higher among American Indian or Alaska Native youth compared with White youth for many diseases (eTable 3 in Supplement 1). Notably, the risk of death from pneumonia and influenza was 1.04 (95% CI, 0.74-1.41) per 100 000, which was 3.11 (95% CI, 2.20-4.28) times that of White youth. Data were inadequate to explore causes of circulatory disease deaths in American Indian or Alaska Native youth.
Hispanic youth had higher death rates from COVID-19, other infection, and cancer—and lower death rates from circulatory diseases—compared with White youth. Asian or Pacific Islander youth had lower death rates for congenital anomalies and asthma but higher death rates from other infections compared with White youth.
Large increases in all-cause pediatric mortality have occurred in recent years, a departure from decades of progress due to improvements in motor vehicle safety, vaccinations, and other medical advances.1 This study found that even larger increases occurred among specific race and ethnicity populations. American Indian or Alaska Native and Black youth died at significantly higher rates than White youth—and the gap is widening.
This study found disparities based on race, a social construct influenced by politics, geography, and culture.13 The large rate ratios reflect the legacy of systemic racism and its association with income, educational level, and neighborhood conditions that are factors in injuries and disease. Systemic racism “structures opportunity and assigns value based on phenotype, or the way people look.”14 Addressing these systemic factors is essential to mitigate the disproportionate risks of injury and disease.
This study found that injury was the leading cause of pediatric mortality in most race and ethnicity groups and that firearms played a dominant role, particularly among Black youth. Black youth experienced a 39.2% increase in firearm deaths between 2019 and 2020 and, according to single-race data,5 an additional 23.0% increase in 2021. The increase in firearm deaths may be due to greater gun purchasing,15 pandemic-related social disruption,16 changes in policing,17and heightened lethality of shootings.18
Suicide increased over the past 2 decades, representing the most serious consequence of the current mental health crisis.19 The factors associated with increases in suicide are complex but include cyber-bullying and easier access to firearms20 and opioids.21 Suicide rates are increasing most rapidly among Black and Hispanic youth. Potential explanations for these disparities include poverty, earlier puberty,22 adverse childhood experiences23 and inadequate access to mental health services.24
American Indian or Alaska Native and Black youth experienced a greater risk of MVC death as occupants and pedestrians than White youth. Reduced use of occupant restraints (eg, car seats, boosters, seat belts)25,26 and greater reliance on older vehicles have been reported in these populations.27 Alcohol-impaired fatalities are more common among American Indian or Alaska Native motorists than those in other groups.28 Environmental factors in disparities in pedestrian mortality include greater proximity to high-speed roads and lack of sidewalks and crossings.29
This study found notable racial and ethnic disparities in disease mortality. Disparities between Black and White youth were particularly large for asthma. Black youth are more likely to develop asthma30 in part due to exposure to tobacco smoke31 and other air pollutants.32 Incidence alone, however, does not completely explain the difference in mortality. Although Black youth are approximately 1.5 times as likely to develop asthma,30 this study found that Black youth were almost 8 times as likely to die from the disease compared with White youth. Many asthma deaths are associated with inadequate use of controller medications.33 Potential factors include worse health care access and differences in which controller medications are prescribed and taken.34,35Exposure to smoke and particulate matter can also trigger exacerbations.36
Mortality from circulatory diseases was more common in American Indian or Alaska Native and Black youth than among White youth. In Black youth, these disparities were associated with myocarditis and dilated cardiomyopathy. The incidence of dilated cardiomyopathy in Black youth is approximately twice that in White youth.37 Researchers have identified dozens of genes associated with dilated cardiomyopathy.38 It is unclear what role these genes play in disparities in incidence. Survival is also worse in Black patients, for whom lower transplant referral rates and higher rates of graft failure have been reported compared with White youth.38
Mortality is only one marker of health. This study does not address nonfatal injuries39 or the long-lasting effects on the family and community with the loss of a child.
This study had several limitations. First, data for all races and ethnicities could not be examined across all causes of death due to strata with small numbers being censored. Second, the temporal analysis did not extend beyond 2020 (except for COVID-19 for reasons previously described); it is challenging to compare bridged-race data with preliminary single-race data from 2021 because estimates can vary by 10% or more within different racial and ethnic groups. The disparities reported here may have shifted during the COVID-19 pandemic. Third, the broad Office of Management and Budget race and ethnicity categories used by CDC WONDER could obscure disparities across subgroups. Fourth, death certificates may misclassify causes of death. Fifth, the study did not explore other factors such as educational level, income, and geography that may interact with race and may have a role in disparities. Future research may further disaggregate data to explore the intersection between race, poverty, sex, place, and other characteristics that influence mortality.
This study found racial and ethnic disparities for almost all leading causes of injury and disease that were factors in increases in youth mortality. Addressing the increasing disparities in mortality affecting American Indian or Alaska Native and Black youth will require efforts to prevent homicide and suicide, especially those events involving firearms.
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Article Information
Accepted for Publication: February 29, 2024.
Published Online: May 4, 2024. doi:10.1001/jama.2024.3908
Corresponding Author: Elizabeth R. Wolf, MD, MPH, Virginia Commonwealth University School of Medicine, 1000 E Broad St, Richmond, VA 23219 (elizabeth.wolf@vcuhealth.org).
Author Contributions: Drs Wolf and Woolf had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Wolf, Rivara, Woolf.
Acquisition, analysis, or interpretation of data: Wolf, Orr, Sen, Chapman, Woolf.
Drafting of the manuscript: Wolf, Rivara.
Critical review of the manuscript for important intellectual content: Rivara, Orr, Sen, Chapman, Woolf.
Statistical analysis: Wolf, Sen, Chapman, Woolf.
Administrative, technical, or material support: Orr.
Supervision: Wolf.
Conflict of Interest Disclosures: Dr Orr reported grants from National Institutes of Health 1K23DK132513-01A1 and an award from American Board of Pediatrics Foundation to explore the clinical supply of the pediatric subspecialty workforce outside the submitted work. No other disclosures were reported.
Meeting Presentation: This paper was presented at the Pediatric Academic Societies Meeting May 4, 2024; Toronto, Ontario, Canada.
Disclaimer: Dr Rivara is the Editor of JAMA Network Open but was not involved in any of the decisions regarding review of the manuscript or its acceptance.
Data Sharing Statement: See Supplement 2.
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