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The National Health and Nutrition Examination Survey (NHANES) collects information on human papillomavirus (HPV) vaccination history as well as sexual activity. We evaluated data from NHANES to assess report of HPV vaccination with ≥1 dose and 3 doses among females and males aged 11 to 26 years during 2007-2014. We also examined age at first vaccine dose and age at first sexual activity among females aged 14 to 26 years. Vaccination significantly increased in females aged 13 to 26 years, but not among 11- to 12-year-old girls, and remained low for both females and males. In NHANES 2011-2014, among females with known age at first vaccine dose, 43.1% reported having had sex before or in the same year they received their first HPV vaccine, and this varied by race/ethnicity. Clinicians should provide strong recommendations consistent with guidelines, including routine vaccination of girls and boys at age 11 or 12 years. [ABSTRACT FROM AUTHOR]

Background: More than 25 million adults in the United States have chronic pain. Chronic pain has been associated with suicidality, but previous studies primarily examined nonfatal suicidal behaviors rather than suicide deaths associated with chronic pain or the characteristics of such deaths.Objective: To estimate the prevalence of chronic pain among suicide decedents in a large multistate sample and to characterize suicide decedents with and without chronic pain.Design: Retrospective analysis of National Violent Death Reporting System (NVDRS) data. The NVDRS links death certificate, coroner or medical examiner, and law enforcement data collected by investigators, who often interview informants who knew the decedent to gather information on precipitating circumstances surrounding the suicide. Information is abstracted by using standard coding guidance developed by the Centers for Disease Control and Prevention.Setting: 18 states participating in the NVDRS.Participants: Suicide decedents with and without chronic pain who died during 1 January 2003 to 31 December 2014.Measurements: Demographic characteristics, mechanism of death, toxicology results, precipitating circumstances (mental health, substance use, interpersonal problems, life stressors), and suicide planning and intent.Results: Of 123 181 suicide decedents included in the study, 10 789 (8.8%) had evidence of chronic pain, and the percentage increased from 7.4% in 2003 to 10.2% in 2014. More than half (53.6%) of suicide decedents with chronic pain died of firearm-related injuries and 16.2% by opioid overdose.Limitation: The results probably underrepresent the true percentage of suicide decedents who had chronic pain, given the nature of the data and how they were captured.Conclusion: Chronic pain may be an important contributor to suicide. Access to quality, comprehensive pain care and adherence to clinical guidelines may help improve pain management and patient safety.Primary Funding Source: None. [ABSTRACT FROM AUTHOR]

Problem/condition: In 2019, approximately 67,000 persons died of violence-related injuries in the United States. This report summarizes data from CDC's National Violent Death Reporting System (NVDRS) on violent deaths that occurred in 42 states, the District of Columbia, and Puerto Rico in 2019. Results are reported by sex, age group, race and ethnicity, method of injury, type of location where the injury occurred, circumstances of injury, and other selected characteristics., Period Covered: 2019., Description of System: NVDRS collects data regarding violent deaths obtained from death certificates, coroner and medical examiner records, and law enforcement reports. This report includes data collected for violent deaths that occurred in 2019. Data were collected from 39 states with statewide data (Alabama, Alaska, Arizona, Colorado, Connecticut, Delaware, Georgia, Hawaii, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Rhode Island, South Carolina, Utah, Vermont, Virginia, Washington, West Virginia, Wisconsin, and Wyoming), three states with data from counties representing a subset of their population (30 California counties, representing 57% of its population, and 47 Illinois counties and 40 Pennsylvania counties, representing at least 80% of their populations), the District of Columbia, and Puerto Rico. NVDRS collates information for each violent death and links deaths that are related (e.g., multiple homicides, homicide followed by suicide, or multiple suicides) into a single incident., Results: For 2019, NVDRS collected information on 50,374 fatal incidents involving 51,627 deaths that occurred in 42 states (39 states collecting statewide data, 30 California counties, 47 Illinois counties, and 40 Pennsylvania counties), and the District of Columbia. In addition, information was collected for 831 fatal incidents involving 897 deaths in Puerto Rico. Data for Puerto Rico were analyzed separately. Of the 51,627 deaths, the majority (64.1%) were suicides, followed by homicides (25.1%), deaths of undetermined intent (8.7%), legal intervention deaths (1.4%) (i.e., deaths caused by law enforcement and other persons with legal authority to use deadly force acting in the line of duty, excluding legal executions), and unintentional firearm deaths (<1.0%). The term "legal intervention" is a classification incorporated into the International Classification of Diseases, Tenth Revision, and does not denote the lawfulness or legality of the circumstances surrounding a death caused by law enforcement. Demographic patterns and circumstances varied by manner of death. The suicide rate was higher for males than for females. Across all age groups, the suicide rate was highest among adults aged 45-54 years. In addition, non-Hispanic American Indian or Alaska Native (AI/AN) and non-Hispanic White (White) persons had the highest suicide rates among all racial and ethnic groups. Among males, the most common method of injury for suicide was a firearm, whereas poisoning was the most common method of injury among females. Among all suicide victims, suicide was most often preceded by a mental health, intimate partner, or physical health problem or by a recent or impending crisis during the previous or upcoming 2 weeks. The homicide rate was higher for males than for females. Among all homicide victims, the homicide rate was highest among persons aged 20-24 years compared with other age groups. Non-Hispanic Black (Black) males experienced the highest homicide rate of any racial or ethnic group. Among all homicide victims, the most common method of injury was a firearm. When the relationship between a homicide victim and a suspect was known, the suspect was most frequently an acquaintance or friend for male victims and a current or former intimate partner for female victims. Homicide most often was precipitated by an argument or conflict, occurred in conjunction with another crime, or, for female victims, was related to intimate partner violence. Nearly all victims of legal intervention deaths were male, and the legal intervention death rate was highest among men aged 25-29 years. The legal intervention death rate was highest among AI/AN males, followed by Black males. A firearm was used in the majority of legal intervention deaths. When a specific type of crime was known to have precipitated a legal intervention death, the type of crime was most frequently assault or homicide. The three most frequent circumstances reported for legal intervention deaths were as follows: the victim's death was precipitated by another crime, the victim used a weapon in the incident, and the victim had a mental health or substance use problem (other than alcohol use). Unintentional firearm deaths were most frequently experienced by males, White persons, and persons aged 15-24 years. These deaths most frequently occurred while the shooter was playing with a firearm and were precipitated by a person unintentionally pulling the trigger or mistakenly thinking the firearm was unloaded. The rate of deaths of undetermined intent was highest among males, particularly among Black and AI/AN males, and among adults aged 30-44 years. Poisoning was the most common method of injury in deaths of undetermined intent, and opioids were detected in nearly 80% of decedents tested for those substances., Interpretation: This report provides a detailed summary of data from NVDRS on violent deaths that occurred in 2019. The suicide rate was highest among AI/AN and White males, whereas the homicide rate was highest among Black males. Mental health problems, intimate partner problems, interpersonal conflicts, and acute life stressors were primary circumstances for multiple types of violent death., Public Health Action: Violence is preventable, and data can guide public health action. NVDRS data are used to monitor the occurrence of violence-related fatal injuries and assist public health authorities in developing, implementing, and evaluating programs, policies, and practices to reduce and prevent violent deaths. For example, the New Hampshire Violent Death Reporting System (VDRS), Indiana VDRS, and Colorado VDRS have used their VDRS data to guide suicide prevention efforts and generate reports highlighting where additional focus is needed. In New Hampshire, VDRS data have been used to monitor the increase in suicide rates during 2014-2018 and guide statewide collaborative prevention efforts. Indiana VDRS used local data to demonstrate differences in suicide and other related mental health problems among Black persons and highlight a need for improved suicide awareness and culturally competent mental health care. The Colorado VDRS conducted geospatial and demographic analysis, considering local VDRS data with existing suicide prevention efforts and resources, to identify regions with high suicide rates regions and populations at high risk for suicide. Similarly, states participating in NVDRS have used their VDRS data to examine related to homicide in their state. In North Carolina for example, where homicide rates among AI/AN and Black persons were approximately 2.5 times higher than the statewide homicide rate, the North Carolina VDRS program aims to partner with historically Black colleges and universities in the state to train researchers to use VDRS data to address health equity issues in and around their immediate community., Competing Interests: All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.

Problem/condition: Homicide is a leading cause of death for American Indians/Alaska Natives (AI/ANs). Intimate partner violence (IPV) contributes to many homicides, particularly among AI/AN females. This report summarizes data from CDC's National Violent Death Reporting System (NVDRS) on AI/AN homicides. Results include victim and suspect sex, age group, and race/ethnicity; method of injury; type of location where the homicide occurred; precipitating circumstances (i.e., events that contributed to the homicide); and other selected characteristics., Period Covered: 2003-2018., Description of System: NVDRS collects data regarding violent deaths obtained from death certificates, coroner/medical examiner reports, and law enforcement reports and links related deaths (e.g., multiple homicides and homicide followed by suicide) into a single incident. This report includes data on AI/AN homicides that were collected from 34 states (Alabama, Alaska, Arizona, California, Colorado, Georgia, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Missouri, Nebraska, Nevada, New Jersey, New Mexico, New York, North Carolina, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, Utah, Virginia, Washington, and Wisconsin) and the District of Columbia., Results: NVDRS collected data on 2,226 homicides of AI/ANs in 34 states and the District of Columbia during 2003-2018. The age-adjusted AI/AN homicide rate was 8.0 per 100,000 population. The homicide rate was three times higher in AI/AN males than females (12.0 versus 3.9), and the median age of AI/AN victims was 32 years (interquartile range: 23-44 years). Approximately half of AI/AN homicide victims lived or were killed in metropolitan areas (48.2% and 52.7%, respectively). A firearm was used in nearly half (48.4%) of homicides and in a higher percentage of homicides of AI/AN males than females (51.5% versus 39.1%). More AI/AN females than males were killed in a house or apartment (61.8% versus 53.7%) or in their own home (47.7% versus 29.0%). Suspects were identified in 82.8% of AI/AN homicides. Most suspects were male (80.1%), and nearly one third (32.1%) of suspects were AI/ANs. For AI/AN male victims, the suspect was most often an acquaintance or friend (26.3%), a person known to the victim but the exact nature of the relationship was unclear (12.3%), or a relative (excluding intimate partners) (10.5%). For AI/AN female victims, the suspect was most often a current or former intimate partner (38.4%), an acquaintance or friend (11.5%), or a person known to the victim but the exact nature of the relationship was unclear (7.9%). A crime precipitated 24.6% of AI/AN homicides (i.e., the homicide occurred as the result of another serious crime). More AI/AN males were victims of homicides due to an argument or conflict than females (54.7% versus 37.3%), whereas more AI/AN females were victims of homicides due to IPV than males (45.0% versus 12.1%). For homicides related to IPV, 87.2% of AI/AN female victims were killed by a current or former intimate partner, whereas approximately half (51.5%) of AI/AN male victims were corollary victims (i.e., victims killed during an IPV-related incident who were not the intimate partners themselves)., Interpretation: This report provides a detailed summary of NVDRS data on AI/AN homicides during 2003-2018. Interpersonal conflict was a predominant circumstance, with nearly half of all AI/AN homicides precipitated by an argument and for female victims, 45.0% precipitated by IPV., Public Health Action: NVDRS provides critical and ongoing data on AI/AN homicides that can be used to identify effective and early intervention strategies for preventing these deaths. When possible, violence prevention efforts should include community-developed, culturally relevant, and evidence-based strategies. These efforts should incorporate traditional native knowledge and solutions, implement and possibly adapt evidence-based IPV and other violence prevention strategies, and consider the influence of historical and larger societal factors that increase the likelihood of violence in AI/AN communities., Competing Interests: All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflicts of interest were reported.

The coronavirus disease 2019 (COVID-19) pandemic has been associated with mental health challenges related to the morbidity and mortality caused by the disease and to mitigation activities, including the impact of physical distancing and stay-at-home orders.* Symptoms of anxiety disorder and depressive disorder increased considerably in the United States during April-June of 2020, compared with the same period in 2019 (1,2). To assess mental health, substance use, and suicidal ideation during the pandemic, representative panel surveys were conducted among adults aged ≥18 years across the United States during June 24-30, 2020. Overall, 40.9% of respondents reported at least one adverse mental or behavioral health condition, including symptoms of anxiety disorder or depressive disorder (30.9%), symptoms of a trauma- and stressor-related disorder (TSRD) related to the pandemic † (26.3%), and having started or increased substance use to cope with stress or emotions related to COVID-19 (13.3%). The percentage of respondents who reported having seriously considered suicide in the 30 days before completing the survey (10.7%) was significantly higher among respondents aged 18-24 years (25.5%), minority racial/ethnic groups (Hispanic respondents [18.6%], non-Hispanic black [black] respondents [15.1%]), self-reported unpaid caregivers for adults § (30.7%), and essential workers ¶ (21.7%). Community-level intervention and prevention efforts, including health communication strategies, designed to reach these groups could help address various mental health conditions associated with the COVID-19 pandemic., Competing Interests: All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. Charles A. Czeisler reports an endowed professorship provided to Harvard Medical School by Cephalon, Inc. for educational and research support to Harvard Medical School and Brigham and Women’s Hospital from Philips Respironics, Inc, which supported in part the contract with Qualtrics LLC to administer the survey. Elise R. Facer-Childs reports a grant from the Science and Industry Endowment Fund Ross Metcalf STEM+ Business Fellowship, administered by the Commonwealth Scientific and Industrial Research Organisation. Mark É. Czeisler reports a grant from the Australian-American Fulbright Commission for a research project that was cancelled because of COVID-19. Mark E. Howard reports a grant from the Institute for Breathing and Sleep, Austin Health (Australia). Shantha M.W. Rajaratnam reports a grant from the Turner Institute for Brain and Mental Health, Monash University (Australia). Charles A. Czeisler, Elise R. Facer-Childs, Laura K. Barger, Joshua F. Wiley, Matthew D. Weaver, Mark É. Czeisler, Mark E. Howard, Rebecca Robbins, and Shantha M.W. Rajaratnam report contributions by Archangels for the screener used to determine unpaid caregiver status in the survey; and a grant from Whoop, Inc, for administration of the survey in June. No other potential conflicts of interest were disclosed.

Suicide disproportionately affects American Indians/Alaska Natives (AI/AN). The suicide rate among AI/AN has been increasing since 2003 (1), and in 2015, AI/AN suicide rates in the 18 states participating in the National Violent Death Reporting System (NVDRS) were 21.5 per 100,000, more than 3.5 times higher than those among racial/ethnic groups with the lowest rates.* To study completed suicides across all ages of AI/AN, NVDRS data collected from 2003 to 2014 were analyzed by comparing differences in suicide characteristics and circumstances between AI/AN and white decedents. Group differences were assessed using chi-squared tests and logistic regression. Across multiple demographics, incident characteristics, and circumstances, AI/AN decedents were significantly different from white decedents. More than one third (35.7%) of AI/AN decedents were aged 10-24 years (versus 11.1% of whites). Compared with whites, AI/AN decedents had 6.6 times the odds of living in a nonmetropolitan area, 2.1 times the odds of a positive alcohol toxicology result, and 2.4 times the odds of a suicide of a friend or family member affecting their death. Suicide prevention efforts should incorporate evidence-based, culturally relevant strategies at individual, interpersonal, and community levels (2) and need to account for the heterogeneity among AI/AN communities (3,4)., Competing Interests: No conflicts of interest were reported

Homicide is one of the leading causes of death for women aged ≤44 years.* In 2015, homicide caused the death of 3,519 girls and women in the United States. Rates of female homicide vary by race/ethnicity (1), and nearly half of victims are killed by a current or former male intimate partner (2). To inform homicide and intimate partner violence (IPV) prevention efforts, CDC analyzed homicide data from the National Violent Death Reporting System (NVDRS) among 10,018 women aged ≥18 years in 18 states during 2003-2014. The frequency of homicide by race/ethnicity and precipitating circumstances of homicides associated with and without IPV were examined. Non-Hispanic black and American Indian/Alaska Native women experienced the highest rates of homicide (4.4 and 4.3 per 100,000 population, respectively). Over half of all homicides (55.3%) were IPV-related; 11.2% of victims of IPV-related homicide experienced some form of violence in the month preceding their deaths, and argument and jealousy were common precipitating circumstances. Targeted IPV prevention programs for populations at disproportionate risk and enhanced access to intervention services for persons experiencing IPV are needed to reduce homicides among women.

During its February 2015 meeting, the Advisory Committee on Immunization Practices (ACIP) recommended 9-valent human papillomavirus (HPV) vaccine (9vHPV) (Gardasil 9, Merck and Co., Inc.) as one of three HPV vaccines that can be used for routine vaccination. HPV vaccine is recommended for routine vaccination at age 11 or 12 years. ACIP also recommends vaccination for females aged 13 through 26 years and males aged 13 through 21 years not vaccinated previously. Vaccination is also recommended through age 26 years for men who have sex with men and for immunocompromised persons (including those with HIV infection) if not vaccinated previously. 9vHPV is a noninfectious, virus-like particle (VLP) vaccine. Similar to quadrivalent HPV vaccine (4vHPV), 9vHPV contains HPV 6, 11, 16, and 18 VLPs. In addition, 9vHPV contains HPV 31, 33, 45, 52, and 58 VLPs. 9vHPV was approved by the Food and Drug Administration (FDA) on December 10, 2014, for use in females aged 9 through 26 years and males aged 9 through 15 years. For these recommendations, ACIP reviewed additional data on 9vHPV in males aged 16 through 26 years. 9vHPV and 4vHPV are licensed for use in females and males. Bivalent HPV vaccine (2vHPV), which contains HPV 16, 18 VLPs, is licensed for use in females. This report summarizes evidence considered by ACIP in recommending 9vHPV as one of three HPV vaccines that can be used for vaccination and provides recommendations for vaccine use.