Analyzing Child Firearm Assault Injuries by Race and Ethnicity During the COVID-19 Pandemic in 4 Major US Cities

Introduction

Firearm violence in the United States has increased since the start of the COVID-19 pandemic, with particularly large increases in child injuries reported.1,2 Racial and ethnic disparities in all-age firearm injuries and deaths also appear to have grown.3 However, little research has examined how pandemic-related increases in firearm assaults may have disproportionally affected Black, Hispanic, and Asian children.

Methods

In this cross-sectional study, we used data on firearm assaults (hereafter, shootings) with child (age <18 years) injuries from 2015 to 2021 in New York City, New York; Los Angeles, California; Chicago, Illinois; and Philadelphia, Pennsylvania. These represent the 3 most populous US cities, plus the city with more than 1 million population with the highest firearm homicide rate (Philadelphia). The Boston University institutional review board waived review and the requirement for informed consent because data were publicly available. We followed STROBE guidelines for cross-sectional research. Our data included both fatal and nonfatal shootings for each city except Chicago, where only fatal shootings were available for those younger than 18 years. Race and ethnicity was classified by police. We included Asian, Black, and White race and Hispanic and non-Hispanic ethnicity; other races appeared too infrequently for stable rate estimates. Using yearly population counts from the US Census, we calculated injury rates by racial and ethnic group and rates relative to the lowest-incidence group (ie, disparities). Rates for non-Hispanic Asian and non-Hispanic Black children were likely underestimates due to census data limitations (eMethods in Supplement 1). We treated March 15, 2020, as the pandemic start date.4

Next, we aggregated all racial and ethnic groups to estimate population-wide change associated with the pandemic. We used quasi-Poisson time series regression to model counts of child shootings for each week of the study period (ie, 365 weeks). The model included a linear term for year, a cubic B-spline with 7 equally spaced knots for week of year, a binary pandemic indicator, and a population offset. We ran the model separately for each city and ran a pooled model that included city fixed effects. We used a sandwich estimator to compute heteroskedasticity-robust SEs and estimated the number of pandemic-attributable injuries.

We used bootstrapping to generate confidence intervals for rates, disparities, and attributable counts. Analyses were conducted in R version 4.2.1 (R Project for Statistical Computing). We prespecified the level of significance as 2-sided 95% CIs.

Results

Child shootings during the study period totaled 2672 (Table 1). The lowest rates (0.54 [95% CI, 0.40-0.68] per 100 000 person-years) were among non-Hispanic White children, whose rates did not increase during the pandemic. The highest rates were among non-Hispanic Black children (21.04 [95% CI, 20.11-21.99] per 100 000 person-years), whose rates increased. The Black-White disparity grew from a relative risk of 27.45 (95% CI, 21.03-36.22) before the pandemic to 100.66 (95% CI, 59.06-232.66) during the pandemic. Point estimates for Hispanic-White disparities tripled, and those for Asian-White disparities nearly tripled.

The pandemic was associated with nearly a 2-fold increase in child firearm assault rates (incidence rate ratio [IRR], 1.93; 95% CI, 1.65-2.29; P < .001) (Table 2). The estimated increase was largest in New York (IRR, 2.99; 95% CI, 2.09-4.28; P < .001). We estimated a pandemic-attributable increase of 503.5 child injuries across all cities (95% CI, 402.5-589.4 child injuries) from March 15, 2020, through December 31, 2021.

Discussion

In this study, child firearm assaults increased substantially during the COVID-19 pandemic in 4 major US cities. Racial and ethnic disparities increased, as Hispanic, Asian, and especially Black children experienced disproportionate shares of the increased violence.

One limitation of this study is that our design did not assess causes of these changes. However, our results are broadly consistent with research identifying sharper pandemic-associated violence increases in neighborhoods with less racial and economic privilege.5 Possible explanations include COVID-19’s exacerbation of inequities in access to health, employment, and educational resources.

The concentration of firearm victimization among Black, Hispanic, and Asian children must be addressed at the individual, community, and societal levels. It is critical to focus community safety and mental health interventions in the most affected communities and to target structural racism as a fundamental driver of the US firearm violence epidemic.

Accepted for Publication: January 30, 2023.

Published: March 8, 2023. doi:10.1001/jamanetworkopen.2023.3125

Corresponding Author: Jonathan Jay, DrPH, JD, Department of Community Health Sciences, Boston University School of Public Health, 801 Massachusetts Ave, Crosstown Center Room 444, Boston, MA 02118 (jonjay@bu.edu).

Author Contributions: Dr Jay had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Jay, Xie, Shareef.

Acquisition, analysis, or interpretation of data: Jay, Martin, Patel, Xie, Simes.

Drafting of the manuscript: All authors.

Statistical analysis: Jay, Patel, Simes.

Obtained funding: Jay.

Administrative, technical, or material support: Martin, Shareef.

Supervision: Jay.

Conflict of Interest Disclosures: None reported.

Funding/Support: Dr Jay was supported by grant K01 MD016956 from the National Institute on Minority Health and Health Disparities.

Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Data Sharing Statement: See Supplement 2.

Additional Contributions: The authors thank Jason Goldstick, PhD, and peer reviewers for thoughtful comments. Suzanne McLone, MPH, provided research assistance; she was compensated for her time.