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. 2018 Aug 28;320(8):792-814.
doi: 10.1001/jama.2018.10060.

Global Mortality From Firearms, 1990-2016

Global Burden of Disease 2016 Injury CollaboratorsMohsen Naghavi  1 Laurie B Marczak  1 Michael Kutz  1 Katya Anne Shackelford  1 Megha Arora  1 Molly Miller-Petrie  1 Miloud Taki Eddine Aichour  2 Nadia Akseer  3 Rajaa M Al-Raddadi  4 Khurshid Alam  5 Suliman A Alghnam  6 Carl Abelardo T Antonio  7 Olatunde Aremu  8 Amit Arora  9   10 Mohsen Asadi-Lari  11   12 Reza Assadi  13 Tesfay Mehari Atey  14 Leticia Avila-Burgos  15 Ashish Awasthi  16   17 Beatriz Paulina Ayala Quintanilla  18   19 Suzanne Lyn Barker-Collo  20 Till Winfried Bärnighausen  21   22 Shahrzad Bazargan-Hejazi  23   24 Masoud Behzadifar  25 Meysam Behzadifar  26 James R Bennett  1 Ashish Bhalla  27 Zulfiqar A Bhutta  3   28 Arebu Issa Bilal  29 Guilherme Borges  30 Rohan Borschmann  31   32 Alexandra Brazinova  33 Julio Cesar Campuzano Rincon  34   35 Félix Carvalho  36 Carlos A Castañeda-Orjuela  37   38 Lalit Dandona  1   17 Rakhi Dandona  1   17 Paul I Dargan  39   40 Diego De Leo  41 Samath Dhamminda Dharmaratne  1   42 Eric L Ding  43 Huyen Phuc Do  44 David Teye Doku  45   46 Kerrie E Doyle  47 Tim Robert Driscoll  48 Dumessa Edessa  49 Ziad El-Khatib  50 Aman Yesuf Endries  51 Alireza Esteghamati  52 Andre Faro  53 Farshad Farzadfar  54 Valery L Feigin  1   55 Florian Fischer  56 Kyle J Foreman  1 Richard Charles Franklin  57 Nancy Fullman  1 Neal D Futran  58 Tsegaye Tewelde Gebrehiwot  59 Reyna Alma Gutiérrez  60 Nima Hafezi-Nejad  61   62 Hassan Haghparast Bidgoli  63 Gessessew Bugssa Hailu  64 Josep Maria Haro  65   66 Hamid Yimam Hassen  67   68 Caitlin Hawley  1 Delia Hendrie  69 Martha Híjar  70   71 Guoqing Hu  72 Olayinka Stephen Ilesanmi  73 Mihajlo Jakovljevic  74 Spencer L James  1 Sudha Jayaraman  75 Jost B Jonas  76   77 Amaha Kahsay  78 Amir Kasaeian  79   80 Peter Njenga Keiyoro  81 Yousef Khader  82 Ibrahim A Khalil  1 Young-Ho Khang  83   84 Jagdish Khubchandani  85 Aliasghar Ahmad Kiadaliri  86 Christian Kieling  87   88 Yun Jin Kim  89 Soewarta Kosen  90 Kristopher J Krohn  1 G Anil Kumar  17 Faris Hasan Lami  91 Van C Lansingh  92   93 Heidi Jane Larson  1   94 Shai Linn  95 Raimundas Lunevicius  96   97 Hassan Magdy Abd El Razek  98 Muhammed Magdy Abd El Razek  99 Reza Malekzadeh  100   101 Deborah Carvalho Malta  102 Amanda J Mason-Jones  103 Richard Matzopoulos  104   105 Peter T N Memiah  106 Walter Mendoza  107 Tuomo J Meretoja  108   109 Haftay Berhane Mezgebe  110 Ted R Miller  69   111 Shafiu Mohammed  21   112 Maziar Moradi-Lakeh  113 Rintaro Mori  114 Devina Nand  115   116 Cuong Tat Nguyen  44 Quyen Le Nguyen  44 Dina Nur Anggraini Ningrum  117   118 Felix Akpojene Ogbo  119 Andrew T Olagunju  120   121 George C Patton  122   123 Michael R Phillips  124 Suzanne Polinder  125 Farshad Pourmalek  126 Mostafa Qorbani  127 Afarin Rahimi-Movaghar  128 Vafa Rahimi-Movaghar  129 Mahfuzar Rahman  130 Rajesh Kumar Rai  131   132 Chhabi Lal Ranabhat  133 David Laith Rawaf  134   135 Salman Rawaf  136   137 Ali Rowhani-Rahbar  138 Mahdi Safdarian  139 Saeid Safiri  140 Rajesh Sagar  141 Joseph S Salama  1 Juan Sanabria  142   143 Milena M Santric Milicevic  144 Rodrigo Sarmiento-Suárez  145 Benn Sartorius  146 Maheswar Satpathy  147 David C Schwebel  148 Soraya Seedat  149 Sadaf G Sepanlou  100   101 Masood Ali Shaikh  150 Nigussie Tadesse Sharew  151 Ivy Shiue  152 Jasvinder A Singh  153   154 Mekonnen Sisay  49 Vegard Skirbekk  155 Adauto Martins Soares Filho  156 Dan J Stein  157   158 Mark Andrew Stokes  159 Mu'awiyyah Babale Sufiyan  160 Mamta Swaroop  161 Bryan L Sykes  162 Rafael Tabarés-Seisdedos  163 Fentaw Tadese  164 Bach Xuan Tran  165 Tung Thanh Tran  44 Kingsley Nnanna Ukwaja  166 Tommi Juhani Vasankari  167 Vasily Vlassov  168 Andrea Werdecker  169 Pengpeng Ye  170 Paul Yip  171 Naohiro Yonemoto  172 Mustafa Z Younis  173   174 Zoubida Zaidi  175   176 Maysaa El Sayed Zaki  177 Simon I Hay  1 Stephen S Lim  1 Alan D Lopez  1   178 Ali H Mokdad  1 Theo Vos  1 Christopher J L Murray  1
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Global Mortality From Firearms, 1990-2016

Global Burden of Disease 2016 Injury Collaborators et al. JAMA. .
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Abstract

Importance: Understanding global variation in firearm mortality rates could guide prevention policies and interventions.

Objective: To estimate mortality due to firearm injury deaths from 1990 to 2016 in 195 countries and territories.

Design, setting, and participants: This study used deidentified aggregated data including 13 812 location-years of vital registration data to generate estimates of levels and rates of death by age-sex-year-location. The proportion of suicides in which a firearm was the lethal means was combined with an estimate of per capita gun ownership in a revised proxy measure used to evaluate the relationship between availability or access to firearms and firearm injury deaths.

Exposures: Firearm ownership and access.

Main outcomes and measures: Cause-specific deaths by age, sex, location, and year.

Results: Worldwide, it was estimated that 251 000 (95% uncertainty interval [UI], 195 000-276 000) people died from firearm injuries in 2016, with 6 countries (Brazil, United States, Mexico, Colombia, Venezuela, and Guatemala) accounting for 50.5% (95% UI, 42.2%-54.8%) of those deaths. In 1990, there were an estimated 209 000 (95% UI, 172 000 to 235 000) deaths from firearm injuries. Globally, the majority of firearm injury deaths in 2016 were homicides (64.0% [95% UI, 54.2%-68.0%]; absolute value, 161 000 deaths [95% UI, 107 000-182 000]); additionally, 27% were firearm suicide deaths (67 500 [95% UI, 55 400-84 100]) and 9% were unintentional firearm deaths (23 000 [95% UI, 18 200-24 800]). From 1990 to 2016, there was no significant decrease in the estimated global age-standardized firearm homicide rate (-0.2% [95% UI, -0.8% to 0.2%]). Firearm suicide rates decreased globally at an annualized rate of 1.6% (95% UI, 1.1-2.0), but in 124 of 195 countries and territories included in this study, these levels were either constant or significant increases were estimated. There was an annualized decrease of 0.9% (95% UI, 0.5%-1.3%) in the global rate of age-standardized firearm deaths from 1990 to 2016. Aggregate firearm injury deaths in 2016 were highest among persons aged 20 to 24 years (for men, an estimated 34 700 deaths [95% UI, 24 900-39 700] and for women, an estimated 3580 deaths [95% UI, 2810-4210]). Estimates of the number of firearms by country were associated with higher rates of firearm suicide (P < .001; R2 = 0.21) and homicide (P < .001; R2 = 0.35).

Conclusions and relevance: This study estimated between 195 000 and 276 000 firearm injury deaths globally in 2016, the majority of which were firearm homicides. Despite an overall decrease in rates of firearm injury death since 1990, there was variation among countries and across demographic subgroups.

Conflict of interest statement

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Ms Ayala Quintanilla reports receipt of support to her institution (the Judith Lumley Centre of La Trobe University) from PRONABEC (the national program of scholarship and educational loan) to support current study of her doctoral course. Dr Kieling reports receipt of authorship royalties from Brazilian publishers Artmed and Manole. Dr Larson reports that her research group has a contract with GlaxoSmithKline for a 15-country study on vaccine acceptance during pregnancy and receipt of funds for convening a research symposium from Merck. Mr Matzopoulos reports serving on the board (unpaid) of Gun Free South Africa. Dr Singh reports receipt of consultancy fees from Savient, Takeda, Regeneron, Merz, Iroko, bioiberica, Crealta/Horizon, allergan, fidia, UBM LLC, WebMD, and the American College of Rheumatology; grants to his institution from Takeda and Savient; serving as the principal investigator for a study funded by Horizon Pharmaceuticals through a grant to DINORA; and serving on the steering committee of OMERACT (Outcome Measures in Rheumatology). Dr Stein reports receipt of personal fees from Lundbeck, Biocodex, Servier, and SUN outside the submitted work. No other disclosures were reported.

Figures

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Figure 1.
Figure 1.. Number of Firearm Deaths and Age-Standardized Rate of Deaths in 1990 and 2016 and the Annualized Rate of Change 1990-2016 in Age-Standardized Rate as a Percent for 20 Countries and Territories (Afghanistan to Bermuda) and by Firearm Subcause for Global Data
The GBD 2016 percentage of well-certified deaths across the time series by location was assigned a 0- to 5-star rating: (5 stars [≥85%], 4 stars [65%-<85%], 3 stars [35%-<65%], 2 stars [10%-<35%], 1 star [>0%-<10%], 0 stars [0%]). Descriptive statistics report the linear fit of a time trend to the data for each location. See the age-standardized mortality rates for aggregate firearm deaths by subcause, year, and location in eTables 8-11 in the Supplement.
Figure 2.
Figure 2.. Number of Firearm Deaths and Age-Standardized Rate of Deaths in 1990 and 2016 and the Annualized Rate of Change 1990-2016 in Age-Standardized Rate as a Percent for 25 Countries and Territories (Bhutan to Cyprus)
See caption for Figure 1.
Figure 3.
Figure 3.. Number of Firearm Deaths and Age-Standardized Rate of Deaths in 1990 and 2016 and the Annualized Rate of Change 1990-2016 in Age-Standardized Rate as a Percent for 25 Countries and Territories (Czech Republic to Guam)
See caption for Figure 1.
Figure 4.
Figure 4.. Number of Firearm Deaths and Age-Standardized Rate of Deaths in 1990 and 2016 and the Annualized Rate of Change 1990-2016 in Age-Standardized Rate as a Percent for 25 Countries and Territories (Guatemala to Latvia)
See caption for Figure 1.
Figure 5.
Figure 5.. Number of Firearm Deaths and Age-Standardized Rate of Deaths in 1990 and 2016 and the Annualized Rate of Change 1990-2016 in Age-Standardized Rate as a Percent for 25 Countries and Territories (Lebanon to Nepal)
See caption for Figure 1.
Figure 6.
Figure 6.. Number of Firearm Deaths and Age-Standardized Rate of Deaths in 1990 and 2016 and the Annualized Rate of Change 1990-2016 in Age-Standardized Rate as a Percent for 25 Countries and Territories (Netherlands to Saint Vincent and the Grenadines)
See caption for Figure 1.
Figure 7.
Figure 7.. Number of Firearm Deaths and Age-Standardized Rate of Deaths in 1990 and 2016 and the Annualized Rate of Change 1990-2016 in Age-Standardized Rate as a Percent for 25 Countries and Territories (Samoa to Tajikistan)
See caption for Figure 1.
Figure 8.
Figure 8.. Number of Firearm Deaths and Age-Standardized Rate of Deaths in 1990 and 2016 and the Annualized Rate of Change 1990-2016 in Age-Standardized Rate as a Percent for 25 Countries and Territories (Tanzania to Zimbabwe)
See caption for Figure 1.
Figure 9.
Figure 9.. Age-Standardized Firearm Death Rate for 1990 and Annualized Rate of Change, 1990-2016
Profiles of firearm mortality were defined in relation to the 2016 global median value of the age-standardized rate of firearm homicide (0.99 per 100 000 persons) or firearm suicide (0.72 per 100 000 persons). High firearm homicide and suicide indicate an age-standardized rate (95% uncertainty interval [UI]) greater than the global median; high both, the estimated age-standardized rates for firearm suicide and firearm homicide (and 95% UIs) are greater than the global median; and low both, the estimated age-standardized rates for firearm suicide and firearm homicide (and 95% UIs) are lower than the global median. For 3-letter country codes, see Figures 1 through 8.
Figure 10.
Figure 10.. Global Number and Proportion of Firearm Injury Deaths in 2016 by Age, Sex, and Firearm Subcause
The early neonatal period is defined as 0 to 6 days, late neonatal as 7 to 27 days, and postneonatal as 28 to 364 days.
Figure 11.
Figure 11.. Age-Standardized Rate per 100 000 Persons of Firearm Homicide and Firearm Suicide, 2016
Profiles of firearm mortality were defined in relation to the 2016 global median value of the age-standardized rate of firearm homicide or firearm suicide. High firearm homicide and suicide indicate an age-standardized rate (95% uncertainty interval [UI]) greater than the global median; high both, the estimated age-standardized rates for firearm suicide and firearm homicide (and 95% UIs) are greater than the global median; and low both, the estimated age-standardized rates for firearm suicide and firearm homicide (and 95% UIs) are lower than the global median. For 3-letter country codes, see Figures 1 through 8.
Figure 12.
Figure 12.. Estimated Firearm Ownership and the Age-Standardized Rate per 100 000 Persons of Firearm Injury Deaths, 2016
Estimated firearm ownership is represented by an index that combined 2007 Small Arms Survey estimates (derived from firearm registry data), survey data, and expert estimation (see eTable 4 in the Supplement) with the estimated proportion of firearm suicides by location by rescaling each estimate of firearm ownership for a location from 0 to 100 and then averaging these values. The maximum value of this combined metric is a mean score of 100 (United States), while the minimum value is 0.3 (Japan) (eTable 5 in the Supplement). The sociodemographic index is a composite measure of income per capita, fertility, and education level. For 3-letter country codes, see Figures 1 through 8.

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