Introduction: Previous work using data from the 1980s showed higher rates of pedestrian mortality in the southern United States.
Methods: This study was a descriptive analysis of state-specific mortality information from the National Center for Health Statistics for 1999-2002 and the National Highway Traffic Safety Administration for 2003.
Results: Highest rates were in the southern rim ("Sunbelt") states for the U.S. population and for the non-Hispanic white population. Rural rates in the highest quartile were 2.1 (95% CI 1.8 to 2.6) times those in the lowest quartile. Urban rates in the highest quartile were 2.2 (95% CI 1.9 to 2.5) times those in the lowest quartile. Posted speed limits at crash sites were 2.6 (95% CI 2.0 to 3.4) times more likely to be > or = 35 mph (48.3 km/h) in the highest quartile than in the lowest quartile. Pedestrians killed in the highest quartile were 1.9 (95% CI 1.2 to 3.1) times more likely to have blood alcohol concentrations > or = 0.25 g/dL than pedestrians in the lowest quartile.
Conclusions: The highest pedestrian fatality rates concentrate in Sunbelt states experiencing rapid population growth in the past 50 years. This pattern may result from at least three features of these states: (a) a high percentage of urban vehicle miles traveled; (b) urban sprawl; and (c) a high prevalence of alcohol use - especially heavy use - among Sunbelt pedestrians.