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From the Centers for Disease Control and Prevention
August 2, 2006

Homicides Among Children and Young Adults—Puerto Rico, 1999-2003

JAMA. 2006;296(5):510-511. doi:10.1001/jama.296.5.510

MMWR. 2006;55:361-364

1 figure, 1 table omitted

Interpersonal violence causes substantial morbidity and mortality worldwide and poses a considerable economic burden, equivalent to 4%-5% of the gross national product in certain countries.1 The Commonwealth of Puerto Rico is a U.S. territory with a 2004 population of approximately 3.9 million.2 In Puerto Rico, homicides were the 12th leading cause of death overall in 2003, ranking fifth among males and 15th among females.3 This report summarizes an analysis of death certificate data on violent deaths of children and young adults in Puerto Rico during 1999-2003, which determined that 93% of homicide victims aged <30 years were young males, the most common method of homicide was assault by firearm discharge, and the rate of homicide among males aged 25-29 years increased during the period. To address this problem, the Puerto Rican government has initiated a comprehensive strategy that includes enhancing an integrated surveillance system for fatal and nonfatal assault, supporting research on interpersonal violence, and establishing local prevention programs (e.g., violence prevention curricula in selected schools).

The University of Puerto Rico Center for Hispanic Youth Violence Prevention obtained annual data from the Puerto Rico Health Department, Division of Statistics3 on homicides among persons aged <30 years in Puerto Rico during 1999-2003 and examined the data by age group, sex, and method (e.g., assault by firearm discharge or assault by sharp object) for each year.4 Homicide was defined as death resulting from an injury purposefully inflicted by another person (including legal intervention) for which the underlying cause listed on the death certificate corresponded to codes X85–Y09, Y35, and Y89.0* of the International Statistical Classification of Diseases and Related Health Problems, 10th Revision.5 Death rates were determined on the basis of the decedent's county of residence. Categorization of rural versus urban was based on application of codes developed by the U.S. Department of Agriculture to the 2000 U.S. Census population assessment. Intercensal population estimates for 1999-2003 obtained from the Census Office of the Puerto Rico Planning Board were used to calculate rates.6 Rates based on fewer than 20 deaths or with a coefficient of variation of >30% are considered unstable and should be interpreted with caution.

During 1999-2003, of 3,613 total homicides in Puerto Rico, 2,303 (64%) occurred among persons aged <30 years. Of these homicides, 2,148 (93%) were among males. The homicide rate for males was 14 times the rate for females (47.7 per 100,000 population versus 3.5, respectively). For both males and females, the homicide rate was highest among persons aged 20-24 years (126.8 and 7.6, respectively).

Among both male and female homicide victims aged <30 years, firearms were the most common method (90.1% of males, 65.4% of females), followed by assault with a sharp object (4.6% of males, 21.2% of females), and all other methods (5.3% of males, 13.5% of females). Among persons aged 15-29 years, homicides were most common during July and August; 91.2% of homicides occurred in urban areas, although only 60.3% of homicide victims were urban residents.

Homicide rates varied by age group. Although homicide rates among persons aged 15-19 years declined slightly (from 36.3 per 100,000 in 1999 to 31.2 per 100,000 in 2003), rates among persons aged 25-29 years increased 47.6% (from 45.0 to 66.4), especially among males (from 82.9 to 129.8, an increase of 56.7%).

Reported by:

B Mirabal, MD, I Rodríguez, MS, CN Vélez, PhD, Univ of Puerto Rico Center for Hispanic Youth Violence Prevention, San Juan, Puerto Rico. A Crosby, MD, J Hoffman, PhD, Div of Violence Prevention, National Center for Injury Prevention and Control, CDC.

CDC Editorial Note:

Homicide rates among persons aged 15-29 years in the United States declined from 1993 to 2003 (from 21.6 per 100,000 to 13.4 per 100,000) but remain the second leading cause of death in this age group.1 In Puerto Rico, however, homicides are the leading cause of death for the same age group, and the rate increased during 1999-2003 (from 49.8 in 1999 to 54.1 in 2003).3 During 1999-2003, persons aged <30 years accounted for 43% of the population of Puerto Rico but approximately 64% of all homicide victims. Homicides occurred predominantly among males and in urban areas, and by firearms. The persistence of high homicide rates among young persons in Puerto Rico indicates a critical need for addressing potential contributors to interpersonal violence.

The findings in this report are subject to at least three limitations. First, the data were obtained from death certificates, which lack information about the circumstances, perpetrator, and victim/perpetrator relationship. This limits the ability to describe certain types of homicides (e.g., child maltreatment versus peer assault) and their unique risk factors; age and sex distributions of homicides are likely to differ by type of homicide. Second, death certificates provide little or no information about socioeconomic status, an important risk factor for interpersonal violence.1 Finally, death certificates might misclassify some homicides as other causes of death.7

Recent studies indicate that approximately 90% of the estimated 520,000 homicides worldwide in 2000 occurred in low- to middle-income countries, including in Central and South America and the Caribbean.1 In these regions, high levels of poverty and income inequality between communities are major contributors to social and family violence.7 A recent study of homicides in Puerto Rico during 1990-1999 concluded that the risk of dying from homicide in Puerto Rico was among the highest in the world (23.2 per 100,000, compared with a worldwide average of 10.7 per 100,000)1,8; homicide rates in Puerto Rico correlated directly with high population density.8

Research on risk and protective factors has identified several potential contributors to youth interpersonal violence in Puerto Rico, including neighborhood environment, rapid urbanization, political violence, organized criminal activity, illegal drug use, and drug trafficking.7 Studies of violence in Central and South America also have demonstrated the influence of individual factors (e.g., age, sex, or exposure to aggression) and household factors (e.g., history of family violence or household beliefs that support violent solutions to conflict) on interpersonal violence.7 An understanding of these factors should aid in the development of violence prevention programs for Puerto Rican communities.

Multiple efforts have been initiated in Puerto Rico to address the problem of interpersonal violence. Since 2000, the Center for Hispanic Youth Violence Prevention has participated in the development, implementation, and evaluation of strategies to address violence among Hispanic youth from a public health perspective. Activities include conducting research on risk and protective factors, training health and education professionals in youth violence prevention competencies (e.g., recognizing at-risk youth), and adapting an evidence-based violence prevention curriculum for cultural appropriateness and evaluating its implementation with students in a high-risk community in San Juan.9

The Puerto Rican government also has implemented several strategies to address the problem of violence, including distributing the World Report on Violence and Health1 to community leaders and government health organizations, instituting increased police surveillance in high-crime neighborhoods, installing video equipment to monitor streets and alert law enforcement to criminal activity, and allocating resources to enhance forensic investigations. In addition, the governor-appointed Commission for Violence Prevention and the Puerto Rico Health Department are designing and implementing a pilot surveillance project that merges public health and criminal justice data on violent deaths, especially those among adolescents and young adults; the findings will be used to guide future public health initiatives to reduce and prevent violent deaths in Puerto Rico. These monitoring and data analysis activities will need to be integrated with comprehensive prevention strategies that include ongoing assessment of community needs, multisectoral collaboration, youth participation, and early intervention in the lives of at-risk youth to address risk and protective factors regarding interpersonal violence.

*X85: assault (homicide) by drugs, medicaments, and biological substances; X86: assault (homicide) by corrosive substance; X87: assault (homicide) by pesticides; X88: assault (homicide) by gases and vapors; X89: assault (homicide) by other specified chemicals and noxious substances; X90: assault (homicide) by unspecified chemical or noxious substance; X91: assault (homicide) by hanging, strangulation, and suffocation; X92: assault (homicide) by drowning and submersion; X93: assault (homicide) by handgun discharge; X94: assault (homicide) by rifle, shotgun, and larger firearm discharge; X95: assault (homicide) by other and unspecified firearm discharge; X96: assault (homicide) by explosive material; X97: assault (homicide) by smoke, fire, and flames; X98: assault (homicide) by steam, hot vapors, and hot objects; X99: assault (homicide) by sharp object; Y00: assault (homicide) by blunt object; Y01: assault (homicide) by pushing from high place; Y02: assault (homicide) by pushing or placing victim before moving object; Y03: assault (homicide) by crashing of motor vehicle; Y04: assault (homicide) by bodily force; Y05: sexual assault (homicide) by bodily force; Y06: neglect and abandonment; Y07: other maltreatment syndromes; Y08: assault (homicide) by other specified means; Y09: assault (homicide) by unspecified means; Y35: legal intervention; Y89.0: sequelae of legal intervention.

Krug ED, Dahlberg LL, Mercy JA, Zwi AB, Lozano RWorld report on violence and health. Geneva, Switzerland: World Health Organization; 2002
US Census Bureau.  2004 population estimates, Census 2000. Available at http://www.census.gov
Puerto Rico Health Department.  Violent death rates by years, 1962-2003. San Juan, PR: Auxiliary Secretariat for Planning and Development, Division of Statistical Analysis; 2005
Puerto Rico Health Department.  Deaths by homicides, procedures, age group, and gender. San Juan, PR: Auxiliary Secretariat for Planning and Development, Division of Statistical Analysis; 2005
World Health Organization.  International statistical classification of diseases and related health problems, 10th revision. 2nd ed. Geneva, Switzerland: World Health Organization; 2004
Puerto Rico Health Department.  Population by age and sex groups. San Juan, PR: Auxiliary Secretariat for Planning and Development, Division of Statistical Analysis; 2005
Buvinic M, Morrison A, Shifter M. Violence in Latin America and the Caribbean: a framework for action. Washington, DC: InterAmerican Development Bank; 1999
Rodríguez J, Irizarry A. El homicidio en Puerto Rico: características y nexos con la violencia. [Homicides in Puerto Rico: characteristics and nexuses with violence] San Juan, PR: Universidad Carlos Albizu; 2003
Thornton TN, Craft CA, Dahlberg LL, Lynch BS, Baer K. Best practices of youth violence prevention: a sourcebook for community action. Atlanta, GA: US Department of Health and Human Services, CDC, National Center for Injury Prevention and Control; 2000