LETTERS well as the plethora of factors that might influence out- Figure. Flow Diagram for Case Identification comes in patients with complex conditions like heart fail- ure. However, traditional biological factors fail to explain 501 Shooting events assessed for eligibility substantial variability in health outcomes in patients with 491 Identified by automated news 1,2 service reports cardiovascular disease. Emerging evidence, including our 486 Google.com or Yahoo.com 5 GunPolicy.org study, suggests that considering social factors like health lit- 10 Identified by review of retrieved eracy will enhance the ability to identify patients at high risk news articles for adverse outcomes. 217 Excluded Pamela N. Peterson, MD, MSPH 106 No injury to humans Frederick A. Masoudi, MD, MSPH 58 Near miss 48 Struck animal or object Author Affiliations: Denver Health Medical Center, Denver, Colorado (Dr Peter- 29 Injury but not from stray bullet son) ([email protected]); and University of Colorado Denver, Au- 82 Outside time period rora (Dr Masoudi). Conflict of Interest Disclosures: Both authors have completed and submitted the 284 Events met case criteria and ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Peterson reported included in analysis (317 individuals) receiving the Pharmaceutical Roundtable Award from the American Heart Asso- ciation. Dr Masoudi reported having contracts with the Oklahoma Foundation for Medical Quality and the American College of Cardiology Foundation and serving on an advisory board for Amgen. Proportions were calculated based on all cases identi- 1. Peterson PN, Rumsfeld JS, Liang L, et al; American Heart Association Get With fied. To detect reporting bias, we compared case-fatality the Guidelines-Heart Failure Program. A validated risk score for in-hospital mor- ratios for persons injured by stray bullets in cases arising tality in patients with heart failure from the American Heart Association Get With the Guidelines program. Circ Cardiovasc Qual Outcomes. 2010;3(1):25-32. from violence with those for persons injured by nonstray 2. Lee DS, Austin PC, Rouleau JL, Liu PP, Naimark D, Tu JV. Predicting mortality bullets in those same cases and for firearm-related among patients hospitalized for heart failure: derivation and validation of a clini- 5 cal model. JAMA. 2003;290(19):2581-2587. assaults in the United States in 2007, and we determined whether outcome severity and characteristics of persons injured were associated with the number of articles retrieved, using the Wilcoxon rank sum test with a RESEARCH LETTER 2-tailed PϽ.05 representing statistical significance. Data were analyzed using SAS version 9.1.3 for Windows (SAS Stray Bullet Shootings in the United States Institute, Cary, North Carolina) and VassarStats (Vassar To the Editor: Stray bullet shootings create fear and College, Poughkeepsie, New York). The University of insecurity in affected communities1-3; entire populations California, Davis, institutional review board exempted have been advised to remain indoors at times of high this project from review. risk.4 No nationwide information on these shootings is Results. We reviewed 1996 nonduplicate reports on 501 available. shooting events; 284 (56.7%) events met case criteria Methods. We defined a stray bullet as having escaped (FIGURE). Of these, 168 (59.2%) were incidental to vio- the sociogeographic space or perimeter customarily set lence (TABLE). Seven cases (2.5%) resulted from an unin- by the circumstances surrounding the firing of the gun tended firing of a gun. from which it came, and cases as shooting events that Altogether, 317 persons received stray bullet injuries; involved at least 1 stray bullet injury to a person: a gun- 142 (44.8%) were female, and 176 (55.5%) were outside shot wound or injury by secondary mechanism. Cases the age range 15 to 34 years (Table). Most individuals could arise from violence, shooting sports, celebratory (258, 81.4%) were unaware of the events leading to the gunfire,4 or other activity. We included bystander shoot- gunfire that caused their injuries. Many (129, 40.7%) ings arising from violence if the bystander had no active were at home; most of these persons (88, 68.2%) were role and was not targeted intentionally, shootings in indoors. Sixty-five persons (20.5%) died, 18 (27.7%) of which persons were injured by shooters targeting struc- them at the shooting site and 55 (84.6%) on the day they tures, and shootings from unintended gunfire when the were shot. Fourteen persons received nonfatal injuries by shooter and the person shot were not the same person. secondary mechanisms. The case-fatality ratio for stray We excluded shootings in which persons were targeted at bullet injuries did not differ from that for non–stray bul- random but shot intentionally. let injuries (20.8%; 11/53; difference, 0.3%; 95% confi- Between March 1, 2008, and February 28, 2009, we con- dence interval, −9.7% to 13.6%) or firearm-related assault ducted real-time surveillance using Google and Yahoo! news nationwide (20.6%; 12 632/61 308; difference, 0.1%; 95% alert services, searching on stray bullet, and the news ar- confidence interval, −5.7% to 4.2%). chives of GunPolicy.org. One year later, we searched for fol- Cases involving stray bullet fatalities yielded more re- low-up reports. We did not retrieve articles when payment ports than others (median, 8; interquartile range [IQR], 4-11, or a subscription was required (Ͻ5%) or, in secondary and 2; IQR, 1-4, respectively; PϽ.001). There was no dif- searches, articles that had not been archived (~2%). ference by sex (median, 3; IQR, 2-6, for females and 3; IQR, ©2011 American Medical Association. All rights reserved. JAMA, August 3, 2011—Vol 306, No. 5 491 Downloaded from jama.ama-assn.org by Garen Wintemute on August 2, 2011 LETTERS that reporting was not biased by severity. Missing infor- Table. Circumstances of Stray Bullet Shootings and Demographics of Persons Killed or Injured mation was common. Characteristic No. (%) Garen J. Wintemute, MD, MPH Circumstance Barbara Claire Incidental to violence 168 (59.2) Vanessa McHenry Hunting, other sports 21 (7.4) Mona A. Wright, MPH Celebratory 13 (4.6) Maintenance, handling 8 (2.8) Author Affiliations: Violence Prevention Research Program, University of Califor- Other 9 (3.2) nia, Davis, Sacramento ([email protected]). Author Contributions: Dr Wintemute had full access to all of the data in the study Unknown 65 (22.9) and takes responsibility for the integrity of the data and the accuracy of the data Demographics analysis. Sex Study concept and design: Wintemute, Claire, McHenry, Wright. Male 159 (50.2) Acquisition of data: Wintemute, Claire, McHenry, Wright. Analysis and interpretation of data: Wintemute, Wright. Female 142 (44.8) Drafting of the manuscript: Wintemute, McHenry. Unknown 16 (5.1) Critical revision of the manuscript for important intellectual content: Wintemute, Age, y Claire, Wright. 0-4 27 (8.5) Statistical analysis: Wintemute. 5-14 72 (22.7) Obtained funding: Wintemute. Administrative, technical, or material support: Wintemute, Claire, McHenry, Wright. 15-24 53 (16.7) Study supervision: Wintemute. 25-34 32 (10.1) Conflict of Interest Disclosures: All authors have completed and submitted the 35-44 23 (7.3) ICMJE Form for Disclosure of Potential Conflicts of Interest. All of the authors are performing work under contract on a project funded by the California Depart- 45-54 19 (6.0) ment of Justice called the “Firearms and Domestic Violence Education and Inter- 55-64 18 (5.7) vention Project.” Funds are paid to the Regents of the University of California. No other disclosures were reported. Ն65 17 (5.4) Funding/Support: This work was supported in part by grants from the California Well- Unknown 56 (17.7) ness Foundation, the Joyce Foundation, and the Eli and Edythe L. Broad Foundation. Role of the Sponsor: The funders had no role in the design and conduct of the study; in the collection, analysis, and interpretation of the data; or in the prepa- ration, review, or approval of the manuscript. 1-6, for males; P=.47) or age within or outside the range Additional Contributions: We are grateful to Philip Alpers, School of Public Health, University of Sydney, for his observations on stray bullet shootings. Mr Alpers re- 15 to 34 years (median, 3; IQR, 2-6, and 3; IQR, 2-8, re- ceived no compensation for his contribution. spectively; P=.32). 1. Howard DE, Kaljee L, Rachuba LT, Cross SI. Coping with youth violence: as- Comments. Most stray bullet shootings arise from vio- sessments by minority parents in public housing. Am J Health Behav. 2003; lence, but they frequently affect females, children, and 27(5):483-492. 2. Horowitz K, McKay M, Marshall R. Community violence and urban families: older adults. Those who are shot have little or no warn- experiences, effects, and directions for intervention. Am J Orthopsychiatry. 2005; ing; opportunities for prevention once shooting starts are 75(3):356-368. limited. 3. Wolfer TA. Coping with chronic community violence: the variety and implica- tions of women’s efforts. Violence Vict. 2000;15(3):283-301. Several limitations deserve mention. Any definition of 4. Centers for Disease Control and Prevention (CDC). New Year’s Eve injuries caused “stray bullet” contains an element of subjectivity. Under- by celebratory gunfire: Puerto Rico, 2003. MMWR Morb Mortal Wkly Rep. 2004; 6 53(50):1174-1175. reporting by news media and failure of automated 5. WISQARS (Web-based Injury Statistics Query and Reporting System). Centers retrieval services to capture reports may have led to for Disease Control and Prevention. http://www.cdc.gov/injury/wisqars/index .html. Accessed November 14, 2010. underascertainment and bias in our data. We do not 6. Sorenson SB, Manz JGP, Berk RA. News media coverage and the epidemiol- report rates; the very similar case-fatality ratios suggest ogy of homicide.