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After decades of decline, the United States saw a nearly 20% increase in all-cause mortality in children and adolescents ages 1-19 (hereafter, “youth”) from 2019-2021.1 This rise can be attributed to an accelerating upward trend in firearm-related deaths, disproportionately concentrated in Black youth, that began in 2013 and was exacerbated in the COVID-19 pandemic years (Supplementary Appendix, available with the full text of this letter at NEJM.org).2,3 Whether this increase is concentrated in urban areas, consistent with historic trends, is unknown.4,5 We used 1999-2022 data from CDC Wonder Underlying Cause of Death database, classifying firearm-related deaths using International Classification of Disease codes. We calculated crude mortality rates per 100,000 youth and estimated the proportion of deaths related to firearms, stratified by race/ethnicity and urban/rural categories. Additional methods, including Tables S1 & S2 & Figs S1a-e, are provided in the Supplementary Appendix.

International Classification of Disease codes. We calculated crude mortality rates per 100,000 youth and estimated the proportion of deaths related to firearms, stratified by race/ethnicity and urban/rural categories. Additional methods, including Tables S1 & S2 & Figs S1a-e, are provided in the Supplementary Appendix. Youth firearm-related mortality rates have increased since 1999, most notably among Black rural youth, who make up 9% of the Black youth population (Fig. 1). In 2013, the firearm-related mortality rates for Black and White rural youth were comparable, with firearms accounting for 12% (53 out of 437) and 11% (282 out of 2618) of their respective death totals. By 2022, a third of all deaths in Black rural youth (204 out of 594) were firearm-related (Fig. S2). That year, the firearm-related mortality rate per 100,000 for Black rural youth was 20.0 (95% CI, 17.5-23.0), four times that of White rural youth (5.0; 95% CI: 4.5-5.5). Despite Black youth making up only 10% of the rural population aged 1-19, they accounted for 30% (204 out of 690) of all rural youth firearm fatalities. In sharp contrast with patterns before 2018, these Black rural firearm deaths equaled or surpassed the rate for Black urban youth (18.6; 95% CI, 17.8-19.4). Of the 2,279 firearm-related deaths in Black youth in 2022, 204 (9%) occurred in those residing in rural settings. These deaths were overwhelmingly (86%) homicides (Fig. S3), concentrated in the South (Figs. S4 & S5), and more common in older adolescents (Fig. S6).

rate for Black urban youth (18.6; 95% CI, 17.8-19.4). Of the 2,279 firearm-related deaths in Black youth in 2022, 204 (9%) occurred in those residing in rural settings. These deaths were overwhelmingly (86%) homicides (Fig. S3), concentrated in the South (Figs. S4 & S5), and more common in older adolescents (Fig. S6). This study reveals a critical, overlooked aspect of rising youth mortality: a fourfold increase in firearm-related deaths among Black rural youth, primarily due to homicides. Solutions will require research to understand the unique circumstances driving this epidemic of firearm-related mortality among Black rural youth.