Symptoms, signs, and ill-defined conditions: a leading cause of death among minorities

The impact of the COVID-19 pandemic on non-COVID-associated mortality: A descriptive longitudinal study of UK data

Background

It has been previously reported in the literature that the COVID-19 pandemic resulted in overall excess deaths and an increase in non-COVID deaths during the pandemic period.Specifically, our research elucidates the impact of the COVID-19 pandemic on non-COVID associated mortality.

Study aim

To compare mortality rates in non-COVID conditions before and after the onset of the COVID-19 pandemic in England and Wales.

Study design

Annual mortality data for the years 2011-2019 (pre-pandemic) and 2020 (pandemic) in England and Wales were retrieved from the Office for National Statistics (ONS). These data were filtered by ICD-10 codes for nine conditions with high associated mortality. We calculated mortality numbers - overall and age stratified (20-64 and 65+ years) and rates per 100 000, using annual mid-year population estimates.

Methods

Interrupted time series analyses were conducted using segmented quasi-Poisson regression to identify whether there was a statistically significant change (p < 0.05) in condition-specific death rates following the pandemic onset.

Results

Eight of the nine conditions investigated in this study had significant changes in mortality rate during the pandemic period (2020). All-age mortality rate was significantly increased in: 'Symptoms Signs and Ill-defined conditions', 'Cirrhosis and Other Diseases of the Liver', and 'Malignant Neoplasm of the Breast', whereas 'Chronic Lower Respiratory Disorders' saw a significant decrease. Age-stratified analyses also revealed significant increases in the 20-64 age-group in: 'Cerebrovascular Disorders', 'Dementia and Alzheimer's Disease', and 'Ischaemic Heart Diseases'.

Conclusion

Trends in non-COVID condition-specific mortality rates from 2011 to 2020 revealed that some non-COVID conditions were disproportionately affected during the pandemic. This may be due to the direct impact COVID-19 had on these conditions or the effect the public health response had on non-COVID risk factor development and condition-related management. Further work is required to understand the reasons behind these disproportionate changes.

Out-of-Hospital COVID-19 Deaths: Consequences for Quality of Medical Care and Accuracy of Cause of Death Coding

Objectives. To examine age and temporal trends in the proportion of COVID-19 deaths occurring out of hospital or in the emergency department and the proportion of all noninjury deaths assigned ill-defined causes in 2020. Methods. We analyzed newly released (March 2021) provisional COVID-19 death tabulations for the entire United States. Results. Children (younger than 18 years) were most likely (30.5%) and elders aged 64 to 74 years were least likely (10.4%) to die out of hospital or in the emergency department. In parallel, among all noninjury deaths, younger people had the highest proportions coded to symptoms, signs, and ill-defined conditions, and percentage symptoms, signs, and ill-defined conditions increased from 2019 to 2020 in all age-race/ethnicity groups. The majority of young COVID-19 decedents were racial/ethnic minorities. Conclusions. The high proportions of all noninjury deaths among children, adolescents, and young adults that were coded to ill-defined causes in 2020 suggest that some COVID-19 deaths were missed because of systemic failures in timely access to medical care for vulnerable young people. Public Health Implications. Increasing both availability of and access to the best hospital care for young people severely ill with COVID-19 will save lives and improve case fatality rates.

Evaluation of coding ill-defined and unknown causes of death in the Republic of Serbia

One of the most frequently used indicators for the quality of mortality statistics is the use of R-codes as the cause of death (COD) in death certificates. The aim of this study was to analyse the coding of ill-defined and unknown causes of death in the Republic of Serbia (RS). The data for this descriptive study, covering a ten-year period (2006-2015), were obtained from the National Mortality Register. Since population and economic features differ widely between regions in RS, we compared the Belgrade region (BR) with other regions (Or). We estimated the frequency of certain types of death investigation methods regarding R00-99-coded deaths. The frequency of R-codes, by subcategories, and code-specific mortality rates were calculated by region for each year. The use of R-codes was significantly lower in BR than in Or (OR 0.85; 95% CI, 0.84-0.66; p < 0.001). The most frequent method of determining COD was external examination of the body, both in BR and Or (60.7% and 85.5%, respectively). The rate of forensic autopsies in BR was 38.1% while in Or it was only 3.6%. Clinical autopsies were performed in 1% of deaths in BR, compared to 0.5% in Or. Our results suggest that in BR the use of R-codes compared to other CODs has decreased over the past years while there has been an increasing trend in autopsy proportions; in Or the frequency of R-codes, as well as of autopsy proportions, has remained unchanged.

Unpacking Hispanic Ethnicity-Cancer Mortality Differentials Among Hispanic Subgroups in the United States, 2004-2014

Introduction: National data on the epidemiology of cancer are commonly reported by broad racial/ethnic categories, such as "Hispanic." However, few studies have disaggregated Hispanic groups and explored mortality differentials in this heterogeneous population. This paper aims to further examine cancer mortality differentials among Hispanic subgroups in the U.S. Materials and Methods: The study examined cancer deaths in the United States from 2004 to 2014 among decedents classified as Mexican, Puerto Rican, Cuban, Dominican, Central/South American and non-Hispanic white on the death certificate among those who were 20 years or older at the time of death. Data were obtained from the National Vital Statistics System. Sex-specific age-adjusted mortality rates were computed for a 10-year period and each individual year, for all cancers combined. Differences by age group, cancer sites, and age distribution were also assessed. Results: A total of 296,486 Hispanic cancer deaths were identified. Mortality rates of the Hispanic subgroups compare favorably with those of non-Hispanic whites. The mortality rates for Mexicans are very similar to those of all Hispanics combined, whereas the rates for Cuban and Puerto Ricans are higher. Dominicans and Central/South Americans had the overall lowest mortality rates. Statistically significant decreases in cancer mortality rates were noted in some sub-groups, but rates increased among Dominican women. Age-adjusted mortality rates by cancer site varied among Hispanics subgroups and gender. Among Cubans, only 5% of cancer deaths occurred before the age of 50 compared to 16% of cancer deaths among Central/South American. Conclusion: While it is common to present data on the burden of cancer among Hispanics as an aggregate group, this study illustrates that the burden of cancer varies by Hispanic subgroups. The disaggregation of Hispanics by ancestry/country of origin allows for a clearer understanding of the health status of this growing population and is needed if health disparities are to be adequately identified, understood and addressed.

Fine particulate matter components and emergency department visits among a privately insured population in Greater Houston

Although adverse health effects of PM2.5 (particulate matter with aerodynamic diameter less than 2.5μm) mass have been extensively studied, it remains unclear regarding which PM2.5 components are most harmful. No studies have reported the associations between PM2.5 components and adverse health effects among a privately insured population. In our study, we estimated the short-term associations between exposure to PM2.5 components and emergency department (ED) visits for all-cause and cause-specific diseases in Greater Houston, Texas, during 2008-2013 using ED visit data extracted from a private insurance company (Blue Cross Blue Shield Texas [BCBSTX]). A total of 526,453 ED visits were included in our assessment, with an average of 236 (±63) visits per day. We selected 20 PM2.5 components from the U.S. Environmental Protection Agency's Chemical Speciation Network site located in Houston, and then applied Poisson regression models to assess the previously mentioned associations. Interquartile range increases in bromine (0.003μg/m(3)), potassium (0.048μg/m(3)), sodium ion (0.306μg/m(3)), and sulfate (1.648μg/m(3)) were statistically significantly associated with the increased risks in total ED of 0.71% (95% confidence interval (CI): 0.06, 1.37%), 0.71% (95% CI: 0.21, 1.22%), 1.28% (95% CI: 0.34, 2.24%), and 1.22% (95% CI: 0.23, 2.23%), respectively. Seasonal analysis suggested strongest associations occurred during the warm season. Our findings suggest that a privately insured population, presumably healthier than the general population, may be still at risk of adverse health effects due to exposure to ambient PM2.5 components.

Socioeconomic differences in the use of ill-defined causes of death in 16 European countries

BACKGROUND

Cause-of-death data linked to information on socioeconomic position form one of the most important sources of information about health inequalities in many countries. The proportion of deaths from ill-defined conditions is one of the indicators of the quality of cause-of-death data. We investigated educational differences in the use of ill-defined causes of death in official mortality statistics.

METHODS

Using age-standardized mortality rates from 16 European countries, we calculated the proportion of all deaths in each educational group that were classified as due to "Symptoms, signs and ill-defined conditions". We tested if this proportion differed across educational groups using Chi-square tests.

RESULTS

The proportion of ill-defined causes of death was lower than 6.5% among men and 4.5% among women in all European countries, without any clear geographical pattern. This proportion statistically significantly differed by educational groups in several countries with in most cases a higher proportion among less than secondary educated people compared with tertiary educated people.

CONCLUSIONS

We found evidence for educational differences in the distribution of ill-defined causes of death. However, the differences between educational groups were small suggesting that socioeconomic inequalities in cause-specific mortality in Europe are not likely to be biased.

Colorectal cancer incidence and mortality disparities in new Mexico

Background. Previous analyses indicated that New Mexican Hispanics and American Indians (AI) did not experience the declining colorectal cancer (CRC) incidence and mortality rates observed among non-Hispanic whites (NHW). We evaluated more recent data to determine whether racial/ethnic differences persisted. Methods. We used New Mexico Surveillance Epidemiology and End Results data from 1995 to 2009 to calculate age-specific incidence rates and age-adjusted incidence rates overall and by tumor stage. We calculated mortality rates using National Center for Health Statistics' data. We used joinpoint regression to determine annual percentage change (APC) in age-adjusted incidence rates. Analyses were stratified by race/ethnicity and gender. Results. Incidence rates continued declining in NHW (APC -1.45% men, -1.06% women), while nonsignificantly increasing for AI (1.67% men, 1.26% women) and Hispanic women (0.24%). The APC initially increased in Hispanic men through 2001 (3.33%, P = 0.06), before declining (-3.10%, P = 0.003). Incidence rates declined in NHW and Hispanics aged 75 and older. Incidence rates for distant-stage cancer remained stable for all groups. Mortality rates declined significantly in NHW and Hispanics. Conclusions. Racial/ethnic disparities in CRC persist in New Mexico. Incidence differences could be related to risk factors or access to screening; mortality differences could be due to patterns of care for screening or treatment.

Coronary death and myocardial infarction among Hispanics in the Northern Manhattan Study: exploring the Hispanic paradox

PURPOSE

Prior studies have reported that Hispanics have lower cardiovascular disease (CVD) mortality despite a higher burden of risk factors. We examined whether Hispanic ethnicity was associated with a lower risk of nonfatal myocardial infarction (MI) coronary death (CD) and vascular death.

METHODS

A total of 2671 participants in the Northern Manhattan Study without clinical CVD were prospectively evaluated. Cox models were used to calculate hazard ratios (HR) and 95% confidence intervals (CI) for the association of race-ethnicity with nonfatal MI, CD, and vascular death after adjusting for demographic and CVD risk factors.

RESULTS

Mean age was 68.8 (10.4) years; 52.8% were Hispanic (88% Caribbean-Hispanic). Hispanics were more likely to have hypertension (73.1% vs. 62.2%, p < .001) and diabetes (22.0% vs. 13.3%, p < .001), and less likely to perform any physical activity (50.1% vs. 69.2%, p < .001) compared to non-Hispanic whites (NHW). During a mean 10 years of follow-up there were 154 nonfatal MIs, 186 CD, and 386 vascular deaths. In fully adjusted models, Hispanics had a lower risk of CD (adjusted HR = 0.36, 95% CI: 0.21-0.60), and vascular death (adjusted HR = 0.62, 95% CI: 0.43-0.89), but not nonfatal MI (adjusted HR = 0.95, 95% CI: 0.56-1.60) when compared to NHW.

CONCLUSIONS

We found a "Hispanic paradox" for coronary and vascular deaths, but not nonfatal MI.

U.S. mortality from liver cirrhosis and alcoholic liver disease in 1999-2004: regional and state variation in relation to per capita alcohol consumption

Apparent per-capita alcohol consumption in 2001 in four U.S. regions (West, Northeast, South, and Midwest), and in 50 states was examined in relation to mortality rates (1999-2004) from liver cirrhosis and for the subcategory alcoholic liver disease. Alcohol consumption and mortality rates were highest in the west. The alcoholic liver disease mortality rate by state was strongly correlated with alcohol consumption, but several outlier or mismatch states were identified. Per-capita alcohol consumption should be useful for US public health policy, as suggested for Europe and Canada, but outlier states require further study.

Impact of the Family Health Program on the quality of vital information and reduction of child unattended deaths in Brazil: an ecological longitudinal study

BACKGROUND

Vital information, despite of being an important public health instrument for planning and evaluation, in most of the developing countries have still low quality and coverage. Brazil has recently implemented the Family Health Program (PSF), one of the largest comprehensive primary health care programs in the world, which demonstrated effectiveness on the reduction of infant mortality. In the present study we evaluate the impact of the PSF on mortality rates related to the quality of vital information: the under-five mortality rate due to ill-defined causes and unattended death.

METHODS

Data on mortality rates and PSF coverage was obtained for the total 5,507 Brazilian municipalities from 2000 to 2006. A multivariate regression analysis of panel data was carried out with a negative binomial response by using fixed effects models that control for relevant covariates.

RESULTS

A statistically significant negative association was observed between PSF coverage levels, classified in none (0%, the reference category), low (<30.0%), intermediate (>or= 30.0% and <70.0%) and high (>or= 70.0%), and all analysed mortalities rates, with a reduction of 17% (Rate Ratio [RR]: 0.83; 95% confidence interval [CI]: 0.79 - 0.88), 35% (RR: 0.65; 95% CI: 0.61-0.68) and 50% (RR: 0.50; 95% CI: 0.47-0.53) on under-five mortality due to ill-defined causes, respectively. In the mortality rate for unattended death the reduction was even greater, reaching 60% (RR: 0.40; 95% CI: 0.37-0.44) in the municipalities with the highest PSF coverage. The PSF effect on unattended deaths was slightly stronger in municipalities with a higher human development index.

CONCLUSIONS

The PSF, a primary health care program developed mostly in rural and deprived areas, had an important role on reducing the unattended deaths and improving the quality of vital information in Brazil.

Mapping and measuring disparities in welfare for cats across neighborhoods in a large US city

OBJECTIVE

To determine whether disparities in health and welfare among cats are present within neighborhoods and across census tracts in a large US city, and to compare results with area-level human data.

SAMPLE POPULATION

17,587 cat intake records from 2 animal sheltering organizations serving Boston, and summary data from city animal control authorities for a 5-year period (2004 through 2008).

PROCEDURES

Geocoded addresses (n = 15,285) were spatially joined to neighborhood and census tract polygons. Cat intakes and deaths were calculated per capita and compared with human demographic and death data. Poisson mixed-effects models were used to smooth mortality rates and calculate relative risks.

RESULTS

Data from geocoded records indicated that annual rates of cat intakes and deaths ranged widely (0.85 to 10.3 cats/1,000 persons and 0.27 to 3.9 cats/1,000 persons, respectively) within 16 neighborhoods of Boston. The disparity across 156 census tracts that comprised these neighborhoods was even greater (0.10 to 22.1 cats/1,000 persons and 0.15 to 6.47 cats/1,000 persons for intakes and deaths, respectively). Cat deaths were significantly correlated with human premature deaths at the neighborhood level (R2 = 0.77). Overall, annual per capita city-wide shelter-associated mortality rate for cats (estimated at approx 2.6 cats/1,000 persons) was similar to rates in other progressive communities.

CONCLUSIONS AND CLINICAL RELEVANCE

By use of geospatial techniques, 14- to 40-fold gradients in cat deaths were detected across Boston neighborhoods and census tracts. Cat deaths were associated with human premature deaths and socioeconomic indicators reflecting deprivation. Targeted interventions may be effective in resolving these disparities.

Looking under the Hispanic umbrella: cancer mortality among Cubans, Mexicans, Puerto Ricans and other Hispanics in Florida

Cancer is the second leading cause of death among Hispanics. Most of the cancer statistics available both at the state and national levels report cancer statistics for all Hispanics as an aggregate group. The goal of this paper is to provide a population-based overview of cancer mortality among Hispanics (Cubans, Mexicans, Puerto Ricans and other Hispanics) in Florida from 1990 to 2000 and to explore the demographic diversity of this growing ethnic group. The study population consisted of Hispanics and White non-Hispanics who died from cancer. Cancer mortality rates and proportion of cancer deaths by type and age at death for the selected racial/ethnic groups were calculated. Our findings indicate that the cancer death rates of the Hispanic subgroups compared favorably with those of White non-Hispanics and that cancer rates often presented for all Hispanics mask important differences between the different ethnic subgroups that fall under the Hispanic umbrella.

Racial misclassification and disparities in cardiovascular disease among American Indians and Alaska Natives

BACKGROUND

National vital event data suggest that cardiovascular disease (CVD) mortality rates are lower for American Indians and Alaska Natives (AIAN) than for the general US population, but these data are disproportionately flawed for AIAN because of racial misclassification.

METHODS AND RESULTS

Vital event data adjusted for racial misclassification and published by the Indian Health Service were used to compare trends in CVD mortality from 1989 to 1991 to 1996 to 1998 between AIAN, US all-races, and US white populations. Without misclassification accounted for, AIAN initially had the lowest mortality rates from major CVD, but by the end of the study, their rates were the highest. Adjustment for misclassification revealed an early and rapidly growing disparity between CVD mortality rates among AIAN compared with rates in the US all-races and white populations. By 1996 to 1998, the age- and misclassification-adjusted number of CVD deaths per 100,000 among AIAN was 195.9 compared with age-adjusted rates of 166.1 and 159.1 for US all races and whites, respectively. The annual percent change in CVD mortality for AIAN was 0.5 compared with -1.8 in the other groups. Regardless of racial misclassification, the most striking and widening disparities were found for middle-aged AIAN, but CVD mortality among AIAN > or =65 years of age was lower than in the other populations.

CONCLUSIONS

A previously underrecognized disparity in CVD mortality exists for AIAN, particularly among middle-aged adults. Moreover, these disparities are increasing. Efforts to reduce CVD mortality in AIAN must begin before the onset of middle age.

Regional patterns and trends in cancer mortality among American Indians and Alaska Natives, 1990-2001

BACKGROUND

National estimates of cancer mortality indicate relatively low rates for American Indians (AIs) and Alaska Natives (ANs). However, these rates are derived from state vital records in which racial misclassification is known to exist.

METHODS

In this cross-sectional study of cancer mortality among AIs and ANs living in counties on or near reservations, the authors used death records and census population estimates to calculate annualized, age-adjusted mortality rates for key cancer types for the period 1996-2001 for 5 geographic regions: East (E), Northern Plains (NP), Southwest (SW), Pacific Coast (PC), and Alaska (AK). Mortality rate ratios (MRRs) and 95% confidence intervals (95% CIs) also were calculated to compare rates with those in the general United States population (USG) for the same period. To examine temporal trends, MRRs for 1996-2001 were compared with MMRs for 1990-1995.

RESULTS

The overall cancer mortality rate was lower in AIs and ANs (165.6 per 100,000 population; 95% CI, 161.7-169.5) than in the USG (200.9 per 100,000 population; 95% CI, 200.7-201.2). In the regional analysis, however, cancer mortality was higher in AK (MRR=1.26; 95% CI, 1.17-1.36) and in the NP (MMR=1.37; 95% CI, 1.31-1.44) than in the USG. In both regions, the excess mortality was attributed to cancer of the lung, colorectum, liver, stomach, and kidney. In the SW, the mortality rate for cancer of the liver and stomach was higher than the rate in the USG, in contrast with that region's nearly 4-fold lower mortality rate for lung cancer (MRR=0.23; 95% CI, 0.19-0.27). Rates of cervical cancer mortality were higher among AIs and ANs (MRR=1.35; 95% CI, 1.13-1.62), notably in the NP and SW. Rates of breast cancer mortality generally were lower (MRR=0.60; 95% CI, 0.55-0.66), notably in the PC, SW, and E. Cancer mortality increased by 5% in AIs and ANs (MRR for 1996-2001 compared with 1990-1995: 1.05; 95% CI, 1.01-1.08), whereas it decreased by 6% in the USG (MMR=0.94; 95% CI, 0.94-0.94).

CONCLUSIONS

Regional data should guide local cancer prevention and control activities in AIs and ANs. The disparity in temporal trends in cancer mortality between AIs and ANs and the USG gives urgency to improving cancer control in this population.

All-cause and cardiovascular mortality among diabetic participants in the San Antonio Heart Study: evidence against the "Hispanic Paradox"

OBJECTIVE

The observation that Hispanics have lower all-cause and cardiovascular mortality, despite increased diabetes and obesity, lower socioeconomic status (SES), and barriers to health care, has been termed the "Hispanic Paradox." We examined the relationship between ethnicity and all-cause and cardiovascular mortality in Mexican Americans (MAs) and non-Hispanic whites (NHWs) with diabetes.

RESEARCH DESIGN AND METHODS

In the San Antonio Heart Study, a prospective cohort, we compared the mortality in 554 U.S.-born MAs, 95 Mexico-born MAs, and 178 NHW participants with diabetes aged 25-72 years. Over an average of 10.4 years, 188 deaths occurred: 115 from cardiovascular disease (CVD) [death certificate ICD-9 codes 401-414 or 420-447 (excluding 427.5)]. Because of potential differences between migrants and nonmigrants, hazard ratios (HRs) were calculated comparing U.S.-born MAs and Mexico-born MAs with NHWs.

RESULTS

The age- and sex-adjusted HR for all-cause mortality comparing U.S.-born MAs with NHWs was 1.66 (95% CI 1.15-2.40), while comparing Mexico-born MAs with NHWs was 1.14 (95% CI 0.63-2.06). Cardiovascular mortality HRs were 1.66 (95% CI 1.04-2.65) and 0.89 (95% CI 0.40-2.01), respectively. After adjusting for possible confounders, such as fasting glucose and diabetes duration, the hazard of all-cause and cardiovascular mortality (although not statistically significant) appeared higher in U.S.-born MAs than in the other two groups.

CONCLUSIONS

We found it important to differentiate MAs by birthplace. Among diabetic participants, contrary to the prediction of the "Hispanic Paradox," compared with NHWs, U.S.-born MAs were at greater risk of all-cause and cardiovascular mortality, while Mexico-born MAs appeared to be at similar risk.

Geographical variation in mortality from systemic lupus erythematosus in the United States

The aim was to identify demographic and environmental factors that affect the incidence and course of systemic lupus erythematosus (SLE) by studying geographical variation in mortality from the disease. Counts of SLE deaths during a 10-y period were determined for each of the 3111 counties in the United States. The counts were subjected to statistical techniques for detecting spatial clusters with significantly higher or lower mortality than expected. Census data were used to compare attributes of the resulting clusters. Four clusters with significantly elevated SLE mortality were identified. They were centered in Alabama, Arkansas, Louisiana and New Mexico and had 41-65% more SLE deaths than expected. Four other clusters with significantly low mortality were centered in Minnesota, Vermont, Virginia and Washington and had 32-44% fewer deaths than expected. Comparison of SLE mortality rates between the New Mexico and Vermont clusters yielded relative risks of 3.2, 3.4 and 5.9 for white, black and other race women, respectively, and of 2.1, 5.2 and 'undefined' for white, black and other race men. Census data showed that the clusters with elevated mortality had higher poverty rates and/or greater concentrations of ethnic Hispanics than those with lower mortality. SLE mortality rates show great regional variation within the United States. The variation appears to reflect, in part, geographical patterns in socioeconomic status and in the distribution of persons of Hispanic origin.

Community-wide coronary heart disease mortality in Mexican Americans equals or exceeds that in non-Hispanic whites: the Corpus Christi Heart Project

PURPOSE

Previous comparisons of coronary heart disease mortality between Mexican Americans and non-Hispanic whites have given paradoxic results: despite their adverse cardiovascular risk profiles, especially a greater prevalence of diabetes, Mexican Americans are reported to have lower rates of mortality from coronary heart disease.

SUBJECTS AND METHODS

We performed a community-based surveillance among all residents of Nueces County, Texas, aged 25 to 74 years, from 1990 to 1994. All death certificates were obtained and coded, and deaths potentially related to coronary heart disease were selected and validated by standardized methods blinded to ethnicity. Validated in-hospital and out-of-hospital coronary heart disease mortality was compared between 785 Mexican Americans and 862 non-Hispanic white women and men.

RESULTS

Validated coronary heart disease mortality in Mexican Americans exceeded that for non-Hispanic whites in the same community. Among women, definite coronary heart disease mortality was 40% greater among Mexican Americans (rate ratio [RR] 1.43, 95% confidence interval [CI]: 1.12 to 1.82), as was all coronary heart disease mortality (RR, 1.32, 95% CI: 1.08 to 1.63). Among men, Mexican Americans had greater rates of all (RR, 1.11; 95% CI: 0.96 to 1.28) and definite coronary heart disease mortality (RR, 1.16; 95% CI: 0.91 to 1.47), but the associations were not statistically significant.

CONCLUSIONS

When community-wide mortality rates from coronary heart disease are properly validated, Mexican Americans have rates equal to or higher than those of non-Hispanic whites. Community-based surveillance with validation of coronary heart disease as the cause of death is necessary to avoid the errors that occur with the use of death certificates alone.

Mortality in Hartford, Connecticut: a comparison with the South Bronx, New York

Very high mortality rates have been reported in large inner-city areas such as the South Bronx and Harlem in New York City, but also may occur in smaller US urban areas. Using published death rates for the South Bronx as the standard, the standardized mortality ratio was slightly lower than 1.00 for Hartford, Connecticut (population 139,739 in 1990), but more than 1.00 for three impoverished Hartford census tracts that contained public housing projects. Compared with the South Bronx, death rates in Hartford were lower for human immunodeficiency virus (HIV), injury-homicide, and alcohol-drugs, but higher for hypertension-stroke (in all three tracts) and cancer (in two of the three tracts). Variations in patterns of causes of death among impoverished US urban areas have implications for planning epidemiologic studies and targeting interventions.

Socioeconomic differentials in mortality risk among men screened for the Multiple Risk Factor Intervention Trial: I. White men

OBJECTIVES

This study examined socioeconomic differentials in risk of death from a number of specific causes in a large cohort of White men in the United States.

METHODS

For 300 685 White men screened for the Multiple Risk Factor Intervention Trial between 1973 and 1975, data were collected on median income of White households in the zip code of residence, age, cigarette smoking, blood pressure, serum cholesterol, previous myocardial infarction, and drug treatment for diabetes. The 31 737 deaths that occurred over the 16-year follow-up period were grouped into specific causes and related to median White family income.

RESULTS

There was an inverse association between age- adjusted all-cause mortality and median family income. There was no attenuation of this association over the follow-up period, and the association was similar for the 22 clinical centers carrying out the screening. The gradient was seen for many-but not all-of the specific causes of death. Other risk factors accounted for some of the association between income and coronary heart disease and smoking-related cancers.

CONCLUSIONS

Socioeconomic position, as measured by median family income of area of residence, is an important determinant of mortality risk in White men.

Decreasing rates of cervical cancer among American Indians and Hispanics in New Mexico (United States)

Minority women in New Mexico (United States)--including American Indian and Hispanic women--have shown disproportionately high incidence rates of invasive cervical cancer during the 1960s and 1970s. Several public health programs in New Mexico were directed toward early detection of cervical cellular abnormalities, particularly targeting the state's minority women. To evaluate the effectiveness of these programs, we examined the New Mexico Surveillance, Epidemiology, and End Results (SEER) data collected from 1969-92, and calculated average annual, age-specific, and age-adjusted incidence rates by ethnic group (American Indian, Hispanic, and non-Hispanic White) for five-year time intervals. We also calculated age-adjusted mortality rates for cervical cancer in the same ethnic groups using state vital records. Age-adjusted incidence rates for invasive cervical cancer show substantial temporal decreases, especially for minority women in the state. The age-adjusted incidence rate decreased by 66 percent, from 30.3 to 10.3 per 100,000 for American Indian women, and by 61 percent, from 26.1 to 10.2 per 100,000 for Hispanic women. A stage shift to earlier stages of cervical neoplasia occurred over the study period, with a substantially higher proportion of in situ compared with invasive cancers diagnosed in the most recent cf the most remote time period. The ratio of incidence rates of in situ to invasive cancers changed dramatically for both American Indian and Hispanic women. Cervical cancer mortality rates decreased steadily among Hispanic women from 1958 to 1992; the decrease among American Indian women was less stable and fluctuated due to small numbers. Ongoing targeted screening programs should help to reduce cervical cancer incidence and mortality further in New Mexico.

Trends in alcohol-related mortality among New Mexico's American Indians, Hispanics, and non-Hispanic whites

Reduction of alcohol-related mortality is a national goal for health promotion and disease prevention. We conducted this analysis to determine whether trends in New Mexico's Hispanics, non-Hispanic Whites, and American Indians were consistent with national trends in alcohol-related mortality, and whether differences in drinking patterns could account for racial and ethnic differences in rates. Age-adjusted, race-specific, and ethnic-specific alcohol-related mortality rates and 95% confidence intervals were calculated for 5-year periods for 1958-1991 using New Mexico vital statistics data. We estimated the prevalence of acute and chronic at-risk drinking behaviors and abstinence from data collected by the Behavioral Risk Factor Surveillance System (BRFSS) for the period 1986-1992. We found that alcohol-related mortality rates varied substantially by race, ethnicity, sex, age, and calendar period. American Indians had the highest rates for both sexes. Rates increased sharply from the period 1958-1962 until the late 1970s and the early 1980s, and then began to decrease rapidly. However, during the most recent decade, the rates have followed contrasting trends in the three ethnic and racial groups. Although rates have continued to decline among non-Hispanic Whites, rates for Hispanics and American Indians have not declined, and still remain substantially higher than rates during the 1958-1962 period. Differences in at-risk drinking behaviors reported to the BRFSS do not explain the contrast in race-specific and ethnic-specific mortality rates. Although progress has been made in reducing national per capita alcohol consumption and alcohol-related mortality, certain high-risk racial and ethnic groups may not be sharing in the progress.

Mortality differences between elderly Mexican Americans and non-Hispanic whites in San Antonio, Texas

OBJECTIVE

To identify differences in causes of death between elderly Mexican Americans (MA) and non-Hispanic whites (NHW).

DESIGN

Retrospective death certificate review.

SUBJECTS

Elderly Mexican Americans and non-Hispanic Whites age 65 and over who died in Bexar County, Texas during 1989.

MEASURES

Data obtained from chart review included age, sex, race/ethnicity, and cause of death. Age-adjusted and cause-specific mortality rates, odds ratios (OR), and 95% confidence intervals (CI) were calculated.

RESULTS

Mexican Americans were at greater risk of dying in nine of the thirty causes of death examined. The mortality rates of MA subjects were higher than those of NHW from death caused by diabetes (OR = 3.19, CI = 2.27-4.49), renal failure (OR = 2.06, CI = 1.44-2.94), congestive heart failure (OR = 1.50, CI = 1.44-2.94), and multiple systemic diseases (OR = 2.59, CI = 1.89-3.57). Among the male subjects, MA had a greater risk than NHW of dying from myocardial infarction (OR = 1.83, CI = 1.15-2.90), coronary disease (OR = 1.37, CI = 1.07-1.75) and septicemia/pyuria (OR = 2.12, CI = 1.09-4.10). Among female subjects, MA had a greater likelihood of dying from cirrhosis (OR = 3.03, CI = 1.00-9.29). For only one of the causes of death was the risk lower among MA than NHW: MA female subjects had a lesser chance of dying from the chronic obstructive pulmonary disease (COPD) than NHW females (OR = 0.36, CI = 0.18-0.72).

CONCLUSION

Mexican American elders have a greater risk of dying from non-insulin dependent diabetes mellitus and renal failure than their NHW counterparts. Elderly MA men have a greater risk of dying from cardiovascular disease than their NHW counterparts. Mexican American women may have a greater risk of dying from cirrhosis, but a lower risk of dying from complications of COPD. Finally, death from ill defined causes, such as multiple systemic diseases, may be a major under-acknowledged cause of death among older MA.

Contrasting trends of prostate cancer incidence and mortality in New Mexico's Hispanics, non-Hispanic whites, American Indians, and blacks

BACKGROUND

Prostate cancer has increased in epidemic proportions during the 1980s. Although marked differences in ethnic and racial temporal trends for prostate cancer have been observed both in the United States and internationally, the trends in Hispanics and American Indians have not been described extensively.

METHODS

To characterize the occurrence of prostate cancer among non-Hispanic whites, Hispanics, American Indians, and blacks in New Mexico, the authors examined cancer incidence data collected by the New Mexico Tumor Registry for the period 1969-1991 and mortality data collected by the New Mexico Bureau of Vital Statistics for the period 1958-1991.

RESULTS

From 1969 to 1991, age-adjusted incidence rates increased from 74.4 to 139.1 per 100,000 (87%) among non-Hispanic whites and from 54.0 to 94.7 (75%) among Hispanics. American Indians had the lowest incidence rates of all groups. Over the same period, incidence rates for local-stage cancers increased by 93% and 81% among non-Hispanic whites and Hispanics, respectively, but were stable for American Indians and blacks, whereas rates for regional-stage cancers increased sharply. Incidence rates of distant-stage disease decreased among non-Hispanic whites from 1969 through 1991. In contrast, incidence rates of distant-stage disease among Hispanics increased through 1982. From 1983 to date, age-adjusted mortality rates of prostate cancer decreased among all groups except Hispanics.

CONCLUSION

The patterns of incidence and mortality are consistent with a stage migration. The recent decrease in age-adjusted prostate cancer mortality rates for non-Hispanic whites is consistent with that expected following the decrease in distant-stage disease incidence. Differential access to medical care and prostate cancer screening may account for these trends.

Racial differences in ill defined cancer mortality in the United States and in the District of Columbia

STUDY OBJECTIVE

The aim was to examine the epidemiology of unknown primary cancer mortality in the USA during 1979 to 1988 by age, sex, race, year, and geographical area.

DESIGN

National (US) and state data were abstracted for deaths due to ill defined cancer (ICD-9 195.0 to 199.1) and all cancers combined (ICD-9 140.0-209.9). Age adjusted mortality rates were calculated using the 1980 USA population as the standard, and standardised rate ratios were derived. National total cancer incidence data were obtained from the surveillance, epidemiology and end results (SEER) program, and age and sex specific relative (black/white) cancer incidence rates were derived and compared to relative (black/white) mortality rates for ill defined cancer. State and regional median family income levels were obtained from the 1980 census and compared to corresponding mortality rates.

SETTING

This study used data for the US population, the 50 states, and the District of Columbia.

MEASUREMENTS AND MAIN RESULTS

During 1984-1988, ill defined cancers accounted for an average of 34,921 deaths each year in the USA (13.7 per 100,000 population). The mortality rate due to ill defined cancers is greater among blacks (19.3 per 100,000) than whites (13.2 per 100,000) (RR = 1.5) and has not declined since 1979. There is considerable geographical variation in the ill defined cancer mortality rate. Thus among blacks the highest rates were clustered in the central states (23 per 100,000) and the lowest rates were seen in the mountain and western states (17 per 100,000). The District of Columbia had the highest overall rate (21.7 per 100,000) when compared to all other states. The black/white relative mortality rate due to ill defined cancer was consistently greater than the black/white relative incidence of all cancers.

CONCLUSIONS

Ill defined cancer mortality is the fourth leading site of cancer mortality in the USA, and accounts for 7.4% of cancer deaths annually. The large proportion of ill defined cancer deaths may have biased the accuracy of national and local cancer incidence and mortality statistics. The higher mortality of ill defined cancer among blacks is not explained by the higher overall cancer incidence among blacks and suggests the influence of socioeconomic or cultural barriers that may result in underutilisation of health services or substandard health care. Ill defined cancer mortality may be a sentinel indicator of deficiencies in the health care delivery system as well as a measure of progress against cancer.

Surveillance of sentinel occupational mortality in the District of Columbia: 1980 to 1987

Epidemiological surveillance of sentinel occupationally related deaths commonly relies on computerized analyses of mortality data obtained from vital statistics records. A computer search of death records in the District of Columbia for the period 1980 to 1987 identified 15 cases that noted asbestosis, silicosis, coal worker's pneumoconiosis, or primary cancer of the pleura/mesothelioma as the underlying cause of death. A manual review of the death certificates for the same period identified three times as many cases (n = 48) with any mention of these conditions. Problems with performing surveillance of these events using death certificates include the lack of sufficient information to identify mesotheliomas and the failure to code and computerize all contributing causes of death.