Age-standardized Rates Research Articles

Burden of Ischemic Heart Diseases among US States from 1990-2019.

Ischemic Heart Disease (IHD) is a leading cause of global mortality, including in the United States. Understanding the burden of IHD in the United States is crucial for informed decision-making and targeted interventions aimed at reducing morbidity and mortality associated with this leading cause of death. This study aimed to understand the burden of IHD, identify gender disparities and risk factors, explore the relationship between socioeconomic growth and IHD, and analyze risk factor distribution across the states of the United States. This study utilized data from the Global Burden of Diseases Study 2019, which provided comprehensive information on IHD from 1990 to 2019. Data related to IHD from these years were extracted using a query tool from the Institute for Health Metrics and Evaluation (IHME) website. The study assessed the relationship between IHD and socioeconomic development using the Socio-demographic Index (SDI) and measured the overall impact of IHD using Disability-adjusted Life Years (DALYs), considering premature death and disability. Additionally, the study analyzed the burden of IHD attributed to six main risk factors. Data analysis involved comparing prevalence, mortality, SDI, DALYs, attributable burden, and risk estimation among the states. Between 1990 and 2019, there was an improvement in socioeconomic development in all states. Age-standardized rates of disease burden for IHD decreased by 50% [ASDR 3278.3 to 1629.4 (95% UI: 1539.9-1712.3) per 100,000] with the most significant decline observed in Minnesota. Males had higher burden rates than females in all states, and the southeast region had the highest mortality rates. The prevalence of IHD showed a declining trend, with approximately 8.9 million cases (95% UI: 8.0 million to 9.8 million) in 2019, representing a 37.1% decrease in the Age-standardized Prevalence Rate (ASPR) from 1990. Metabolic risks were the leading contributors to the disease burden, accounting for 50% of cases, with Mississippi having the highest attributable risk. Arkansas had the highest attributable risk for high cholesterol and smoking. Conversely, Minnesota had the lowest burden of IHD among all the states. This study highlights variations in the burden of IHD across US states and emphasizes the need for tailored prevention programs to address specific risk factors and gender differences. Understanding the trend in IHD may inform policymakers and healthcare professionals in effectively allocating resources to reduce the burden of IHD and improve national health outcomes.

Transition towards cancer mortality predominance over cardiovascular disease mortality in Brazil, 2000–2019: a population-based study

Cardiovascular disease (CVD) and cancer are the first and second leading causes of death in Brazil and worldwide. However, an ongoing epidemiological transition in which cancer surpasses CVD has been observed in many high and middle-income countries. In this study, we provided a nationwide analysis of the transition towards cancer mortality predominance over CVD mortality in Brazil. We leveraged data from 5570 municipalities using the Mortality Information System and classified the causes of death using ICD-10 codes. Age-standardized CVD and cancer mortality rates were calculated annually between 2000 and 2019. Mortality rate ratios (MRRs=CVD rates divided by cancer rates) described the predominance of cancer or CVD mortality across municipalities and states. Choropleth maps displayed state-specific MRRs and the transition in the predominant cause of death over time. From 2000 to 2019, CVD mortality rates declined in 25 out of 27 states, whereas cancer mortality increased in 15 states, indicating a shift towards cancer predominance. While in 2000 cancer mortality was lower than CVD in all states and only exceeded the latter in 7% of the municipalities, by 2019 the gap narrowed considerably, with 13% of municipalities displaying higher cancer mortality rates vs CVD mortality rates. Additionally, higher household income correlated with higher mortality from cancer vs CVD. An ongoing epidemiological transition in which cancer mortality surpasses CVD mortality is occurring in Brazil, particularly in municipalities with higher household incomes. Our findings may provide important information for policymakers and public health practitioners in Brazil. National Council for Scientific and Technological Development (CNPq).

Intersectionality of sex and race in COVID-19 mortality and vaccination inequities in Massachusetts

BackgroundInequities in COVID-19 incidence, morbidity, and mortality between racial and ethnic groups in the United States (U.S.) have been documented since the start of the pandemic in early 2020. Similarly, disparities by sex for COVID-19 morbidity and mortality have emerged, with men dying at a higher rate than women. Little research has been done to understand how the intersection of sex and race impacts COVID-19 inequities in Massachusetts (MA). This cross-sectional study examined how COVID-19 mortality rates (February 2020- May 2023) and vaccination rates (December 2020-February 2023) varied by sex across racial groups in MA.MethodsUsing Massachusetts Department of Public Health data of all COVID-19 mortality cases and primary series vaccinations in MA from 2020 to 2023, we calculated both age-specific and age-adjusted COVID-19 mortality rates in order to account for differences in age distributions across sex-race groups.ResultsOverall, men across all age-race groups consistently had a higher mortality rate compared to their female counterparts. The age-standardized mortality rate difference between White men and White women is the smallest, with the rate for White men being 1.3 times higher than White women. The age-standardized mortality rate between Hispanic men and Hispanic women varies the largest, with the rate for Hispanic men being 1.7 times higher than Hispanic women. Notably, Black women and White women have similar vaccination rates, yet the age-standardized mortality rate for Black women is 1.4 times the rate of White women.ConclusionsOur findings show that there are disparities at the intersection of sex and race for COVID-19 mortality and vaccination in MA. This highlights the importance for targeted COVID-19 interventions at the intersection of sex and race and the need for detailed COVID-19 reporting by sex within race groups.

The burden of cirrhosis and other chronic liver disease in the middle east and North Africa (MENA) region over three decades

BackgroundCirrhosis comprises a significant health challenge in the Middle East and North African (MENA) region impacting healthcare systems and communities. This study sought to investigate trends in the burden of cirrhosis and other chronic liver disease, different etiologies, deaths, and the disability burden utilizing data from the Global Burden of Disease (GBD) database.MethodsAnalyzing epidemiological trends from 1990 to 2021 across 21 MENA countries, this research utilized data on age-standardized incidence rates (ASIR), age-standardized death rates, and age-standardized disability-adjusted life years (DALYs) to evaluate the burden of cirrhosis and other chronic liver disease. The study also examined national variations and sociodemographic relationships.ResultsThe study identified a 114.9% increase in cirrhosis and other chronic liver disease incidence within the MENA region between 1990 and 2021, with 7,344,030 incident cases reported in 2021. The ASIR showed a steeper rise in females (9.6%) compared to males (7.0%). Etiology-specific analysis revealed an increase in the ASIR for MASLD related cirrhosis and other chronic liver disease by 22.2%, while those due to alcohol as well as hepatitis B and C decreased by 28.1%, 59.3%, and 30%, respectively. Despite the rising incidence, overall age-standardized death rates across all etiologies decreased by 54.3%, with DALYs showing a 51.4% decrease during the same period. Country-specific trends varied significantly, with Oman recording the highest annual ASIR increase (0.64%), and Qatar observing the most substantial annual reduction in age-standardized death rates (-2.88%).ConclusionThe study highlights evolving trends in cirrhosis and other chronic liver disease within the MENA region, emphasizing the necessity for comprehensive, etiology, and gender-specific interventions. Despite an increasing incidence, the observed improvements in mortality rates and age-standardized disability burden indicate progress in public health efforts to mitigate cirrhosis’s impact. These findings point to the complex nature of cirrhosis outcomes and the urgent need for tailored strategies to manage its increasing burden effectively.

The burden of sepsis in Italy: an analysis of treatable mortality trends

Abstract Background The burden of sepsis, a life-threatening condition triggered by the body’s extreme response to infection, remains a critical global healthcare concern. Sepsis-related deaths often result from delayed recognition, insufficient treatment, or gaps in healthcare delivery. The study aims to analyze treatable mortality for sepsis in Italy and its regions. Methods A retrospective study was conducted on data of treatable mortality for sepsis in Italy and its regions. According to joint OECD/Eurostat list, we included sepsis deaths with the ICD-10 codes A40 (excl. A40.3 [sepsis due to Streptococcus pneumoniae]) and A41 (excl. A41.3 [sepsis due to Hemophilus influenzae]) from 2006 to 2019. Through data on the resident population two-year age-standardized rates by region were calculated. Results From 2006/7 to 2018/9 an overall increase was observed in Italy, from 1.6 to 2.2 age-standardized mortality rates with a maximum peak in 2014/5 (+46.7%). This trend was confirmed for Lombardy (+47.8%), Veneto (+48.8%), Emilia-Romagna (+49.3%), Tuscany (52.0%), Marche (+58.4%%), Abruzzo (39.4%), Molise (26.7%), Apulia (+57.0%), Sicily (+57.2%), and Sardinia (+46.8%). Aosta Valley (+72,5%) had a maximum peak in 2010/1, while Piedmont (+42.5%), Autonomous Province (A.P.) of Bolzano (+27.8%), A.P. of Trento (+45.0%), Friuli-Venezia Giulia (+23.3%) in 2012/3, Calabria (+46.4%) in 2016/7 and lastly Campania (+52.9%) and Basilicata (+73.0%) in 2018/9. Liguria (+49.8%), Latium (47.2%) and Umbria (49.3%) showed two maximum values, one in the 2012/3 and the other in the 2014/5. Conclusions We observed an overall increase in age-standardized mortality rates throughout Italy, with a peak in 2014/5. This trend was resumed in ten regions, while three regions showed multiple peaks, indicating fluctuations in mortality rates. These findings underline the importance of targeted health interventions and policy initiatives to address region-specific health challenges. Key messages • Regional disparities in mortality rates highlight the necessity for customized health interventions and policy measures between Italian regions. • Recognizing fluctuating mortality trends in specific regions is crucial to effectively address various health challenges.

Gender disparities and infective endocarditis burden in the United States and European Union: a comparative analysis

Abstract Background Despite improvement in diagnostics and treatment options, infective endocarditis (IE) remains a significant burden for healthcare systems. While high-income countries have improved diagnosis of IE, the progress in interventional cardiology with a rise in cardiac devices associated infections, and people migrations offset some of these gains. Purpose To the best of our knowledge, there is a lack of comparative data between high-income countries, including the United States (US) and European Union (EU). Methods We collected the age-standardized rates of incidence (ASIR), deaths (ASDR), and disability-adjusted life years (ASDALYs) in the US and EU from 1993 to 2019 with the Global Health Data Exchange query tool. The Bayesian geospatial regression analysis and estimated annual percentage change (EAPC) to quantify the trends in age-standardized rates (ASR) were used. The data were stratified based on the gender, year, and location. Results Males in the US had an overall ASIR of 17.2/100k with an increasing trend between 1993 and 2019, and an annual average rate of change of 0.8 % (EAPC of 0.8%). A similar trend and higher rates were noted in males in the EU, with ASIR of 20.9/100k and EAPC of 2.0%. For the same period, females in the US had lower ASIR than females in the EU (11.9/100k vs. 13.6/100k) , and lower annual percent change (1% vs. 1.3%). In the US, ASDR was higher in males than females (1.6/100k vs. 1.28/100k), but females had higher annual percentage change (EAPC of 2.7% in males and 3.3% in females). Compared to US, males and females in the EU had lower ASDR in 2019 (1.2/100k in males, and 1.0/100k in females) with lower annual percentage changes of 2.5% and 1.7%, respectively. The ASDALY was significantly higher in the US, for both males (34.6/100k) and females (25.5/100k), with a greater increase in an annual average rate of change of 2.7% in females than in males (2.2%). EU males had ASDALY of 24.9/100k with an EAPC of 1.8%, while females had 16.7/100K with an annual average increase of 1.2%. Figure 1, Table 1 Conclusion ASIR of IE appears to be higher in the EU for both males and females. Conversely, ASDR and ASDALY manifest higher rates in the US across both genders, with females notably demonstrating a higher annual percentage increase for these metrics. Further studies are needed to assess the nature of these differences and to inform health policies.The age-standardized rates in US and EUThe differences in the EAPC

Disparities by region, age, and sex in cardiovascular disease burden attributable to high fasting plasma glucose in China, 2010-2018: a nationwide, population-based study

Abstract Background Elaborating and understanding disparities in the burden of cardiovascular disease (CVD) attributable to high fasting plasma glucose (FPG) is important to improve diabetes prevention and promote cardiovascular health. In this study, we aimed to estimate the burden of CVD and its subtypes attributable to high FPG between 2010 and 2018 in China, by age, sex, region and socio-demographic index (SDI). Methods We pooled data on 791 373 people aged 25 years and older from three population-based surveys, and the temporal-spatial Bayesian hierarchical model was used to estimate age- specific, sex- specific, province- specific, and year-specific average FPG levels from 2010 to 2018. We estimated population attributable fraction for CVD by age and sex for 31 provinces. Data on CVD deaths at the provincial level were obtained from surveillance systems, which were used to compute death numbers and years of life lost (YLLs) due to CVD that could be attributed to high FPG using the counterfactual scenario of theoretical minimum risk level. We also decomposed changes in attributable burdens into four explanatory components, including population growth, population aging, risk exposure to FPG, and in risk-deleted mortality rates for CVD. Results In 2018, an estimated total of 512·29 thousand (95% uncertainty interval [UI] 488·60 to 538·65) adults aged 25 or older were attributable to high FPG in China, with 281·54 thousand (95%UI 267·89 to 295·05) of these deaths occurring in men and 229·75 thousand (95%UI 210·98 to 251·89) in women. The age composition of CVD mortality caused by high FPG suggested a trend toward older ages from 2010 to 2018 (Figure 1). High FPG accounted for 1 093·45 crude YLLs per 100 000 people (95%UI 1 059·13 to 1 131·73) due to FPG-related CVD in 2018, with substantial variation across provinces. The age-standardised CVD mortality rate attributable to high FPG increased by 3·99%, from 41·93 per 100 000 people (95%UI 40·07 to 43·88) in 2010 to 43·60 per 100 000 (95%UI 41·77 to 45·62) in 2018. In 2018, the higher age-standardised CVD mortality rate attributable to high FPG was observed in the high-middle SDI region and the middle SDI region. By province, the age-standardised mortality rate due to FPG-related CVD in both sexes combined varied from 21·31 per 100 000 people in Tibet to 77·66 per 100 000 people in Heilongjiang in 2018. Nationally, compared to 2010, exposure to high FPG and population aging in 2018 were the primary drivers of increased FPG-related deaths due to CVD (Figure 2). Conclusions The CVD burden attributable to high FPG was still large in China, and varied markedly across regions and provinces. Exposure to high FPG and population ageing were associated with substantial changes in the number of FPG-related CVD deaths between 2010 and 2018. Findings of this study emphasize the importance of developing population-specific tailored measures in China and other regions with similar condition.Figure 1Figure 2

Estimating risk using the novel Particulate Matters years index (ePM-years index). A report from the nationwide EP-PARTICLES study

Abstract Background Air pollution is the largest environmental risk factor, especially for cardiovascular disease (CVD). In this study, we present an original concept of estimating the risk associated with exposure to air pollution: the Particulate Matters years index (ePM-years index). Objective To assess the predictive performance of the ePM-years index. Methods The ePM-years index is an indicator of hypothetical exposure to air pollution. It is estimated by multiplying the number of years spent in a given environment by the difference between the average annual PM2.5 concentration and the allowed level of pollution given by World Health Organization (WHO) guidelines (Figure 1). We collected data from 2011 to 2020 on mortality and hospitalizations from National Health Fund and the Central Statistical Office in Poland, respectively. For further analysis, we used an age-standardized rate (SR), established on the European Standard Population structure. The source of air pollution data was GEM-AQ air quality modeling system. All data were connected with TERYT codes, all analyses were conducted at the county level (LAU-1) and then aggregated to the voivodeship level (NUTS-2). Poisson regression models were used to estimate associations between CVD mortality, ePM-years, and population level social and health status. We also estimated the attributable fraction of CVD mortality due to air pollution using AirQ+ methodology from the WHO. Results We recorded 4,010,531 deaths including 1,669,464 (41.6%) deaths due to CVD with a median age of 78.16 (SD=12.54), and 53.4% of females (N=914,932). Current smokers amounted to 29.9% (23.4%-33.2%). The main causes of death were coronary artery disease [405,268 (24.3%)] and heart failure [376,592 (22.6%)]. The mean Gross Domestic Product (GDP) per capita was 9644 EUR (7517-12,048), and the mean yearly PM2.5 concentration was 23.3 (SD=6.3) μg/m3, corresponding with the mean ePM-index 35.8 (21.5-66.6) in analysed time. The SR for CVD mortality was 500.3 (min. 461.9 – max. 604.5), the SR hospitalization rates were as follows: hypertension 312 (299-342), diabetes 90 (78.9-95.9), and HF 557.9 (310-728.4). There was an association of the ePM-years index with CVD mortality (shown as increase per 10 ePM-years): In Model 1 adjusted for GDP, risk ratio (RR) 1.023 (95% confidence interval (CI): 1.002-1.044); in Model 2 adjusted for comorbidities, RR=1.025 (95%CI: 1.004-1.046); in Model 3 adjusted for GDP, comorbidities and weather conditions RR=1.027 (95%CI: 1.005-1.049). We estimated that 16.2% (N=324,460) [95%CI: 12.54% -17.9%] of CVD deaths were attributable to PM2.5 exposure, using the WHO's air quality guideline as the reference. Conclusions The ePM-years index may be used as a tool for risk stratification for patients and incorporated into CVD outcomes prediction models. The index can help with planning of appropriate primary and secondary prevention schemes related to long-term pollution exposure.

Quantifying Cardiovascular Disease Burden and Quality of Care Index across Four Visegrád Countries

Abstract Background Cardiovascular diseases (CVDs) have surged to become the leading cause of premature death in Europe. Yet, analyses examining the Quality of Care Index (QCI) and CVD burden within the 4-Visegrád (4V) nations remain notably sparse. This study aims to address this gap by comprehensively assessing both the QCI and CVDs burden across these countries. Methods The burden of CVDs was assessed using data extracted from the GBD-study 2019. We employed min-max normalization to standardize each health indicator, including Mortality-to-Incidence Rate, Prevalence-to-Incidence Rate, Disability-Adjusted Life Years-to-Prevalence rate, and Years of Life Lost-to-Years Lived with Disability. Subsequently, we utilized a weighted sum approach to aggregate the normalized values of the health indicators. The QCI was then derived as the sum of the products of normalized values and their corresponding weights. Results In 2019, age-standardized rates (per 100,000) significantly decreased compared to those in 1990. Ischemic heart disease remained the primary cause of death in all 4V countries, followed by stroke. Czechia exhibited the most substantial reduction in 2019 compared to the rates in 1990, with incidence and mortality rates decreasing by -252.55 and -308.95, respectively. Poland demonstrated the highest reduction, compared to the Central European average rates, in both incidence (-113.73; 95% CI: -125.08_-103.79) and death rates (-74.79; 95% CI: -73.53_-75.31) in 1990, and in 2019 (-175.22; 95% CI: -169.52_-178.29 and -41.55; 95% CI: -40.12_-40.64, respectively). Poland scored highest in QCI among the 4V countries, with Czechia scoring the lowest. Conclusions The findings underscore the imperative for continued efforts to boost cardiovascular healthcare and outcomes in the region. While the reduced ratio signals improvement, there remain avenues for refining disease management, prevention strategies, and access to care to further enhance patient outcomes. Key messages • Our study on 4V nations’ QCI and CVD burden underscores urgent need for sustained efforts in cardiovascular healthcare, with notable rate reductions since 1990. • Challenges persist in managing heart disease and stroke in the 4-Visegrád (4V) countries.

Overdiagnosis of lung cancer in Chinese populations

Abstract Background Low-dose computed tomography (LDCT) has been widely-used in employee health examinations in China since 2011. This study was designed based on the Cancer Surveillance data to quantify the overdiagnosis of lung cancer due to the introduction of LDCT in Chinese populations. Methods This registry-based cohort study included 46,978 incident cases and 34,475 deaths of lung cancer from Pudong New Area of Shanghai, China, during 2002-2020. We calculated the age-standardized rates (ASR) and average annual changes (AAC) of mortality and overall, stage-specific and histological type-specific incidence by sex to evaluate the potential overdiagnosis of lung cancer. We further estimated the numbers and proportions of lung cancer cases attributable to overdiagnosis by sex and period based on the comparison between the shape of the age-specific curves with that prior to the introduction of LDCT in the populations. Results The ASR of incidence of lung cancer increased rapidly since 2011 in both men (AAC: 1.90%; 95%CI: 0.87, 2.92) and women (AAC: 4.40%; 95%CI: 3.19, 5.62), whereas the ASR of mortality declined persistently, with AAC of -0.12% (-0.64, 0.39) in men and -0.19% (-0.47, 0.09) in women. The upward trends in incidence were mainly observed in women, for early-stage cancer and for lung adenocarcinoma. Overall, the overdiagnosis rate of lung cancer grew from 22% in 2011-2015 to 50% in 2016-2020 in women. Further analysis demonstrated elevated numbers (proportions) of lung adenocarcinoma cases attributable to overdiagnosis, which increased from 182 (8%) in 2011-2015 to 827(22%) in 2016-2020 in men, and from 1,842 (85%) to 4,171 (89%) in women. Conclusions This registry-based cohort study observed considerable and increasing overdiagnosis of lung adenocarcinoma in Chinese men and women. Guideline is urgently needed to maximize the benefits of LDCT screening and reduce the potential overdiagnosis of lung cancer in the populations. Key messages • The secular trends in incidence and mortality of lung cancer in Chinese populations demonstrated the overdiagnosis since 2011, when the LDCT was used as a part of staff health examination in China. • Overdiagnosis of lung cancer in Chinese populations increased incrementally over time and was mainly observed among women.

Inequalities in prevalence rate of edentulism in the European Union between 1990 and 2019

Abstract Background Edentulism, characterized by tooth loss, serves as a global indicator of oral health burden, particularly affecting older and economically disadvantaged populations. We aimed to assess health inequalities in age-standardized prevalence rate (ASPR) of edentulism across 28 EU member states and EU as a whole between 1990 and 2019. Methods We retrieved ASPR, annual rate of change (ARC) and 95% uncertainty interval from the Global Burden of Disease (GBD) 2019 study. We calculated the ASPR ratio between 1990 and 2019 and country-paired ASPR for 2019. To estimate the inequalities between countries between 1990 and 2019, we used the Gini Coefficient (GC) and Slope Index of Inequality (SII). Results The EU ASPR for edentulism was 5912 (95% UI: 4751-7473) in 1990 while in 2019 it was 5048 (95% UI: 3970-6485). Sweden had the lowest ASPR in 1990, while Spain held this position in 2019. The highest rates in 1990 were observed in Poland and the Netherlands, with the Netherlands maintaining the highest ASPR in 2019. Spain exhibited the lowest ARC at -0.325 (95% UI: -0.477--0.193), while Sweden was the sole country with a positive value, at 0.034 (95% UI: -0.009-0.075). The ASPR ratio across all EU member states exhibited a range of values for males, from 1.00-2.16, and for females, from 1.00 to 1.87. The ASPR ratios ranged between 1.81 and 2.16 from 1990 to 2000. The GC was 0.097 (95% UI: 0.076-0.117) in 1990 and subsequently decreased-0.084 (95% UI: 0.063-0.105) by 2019. The SII exhibited a range from 0.062 (95% UI: 0.051-0.072) in 1990-0.046 (95% UI: 0.038-0.054) in 2019. Conclusions Inequalities in edentulism in the EU were similarly low when comparing 1990 and 2019. However, there was an alarming increase in inequalities between 2005 and 2010. This underscores the need for targeted interventions and policy measures-address oral health inequalities, considering socio-economic factors, healthcare policies, sex disparities, and public awareness initiatives. Key messages • Edentulism is a significant public health concern within the EU for approximately 30 years. • It has demonstrated comparable disparities in prevalence at both the beginning and end of the period, with a noticeable intensification in the interim.

All-cause Years of life lost due to death at municipality level in Norway. Association to educational attainment and median income

Abstract Background Norway, with 5.5 million people spread across 356 municipalities, has pursued an active policy to reduce social and geographical health inequalities. Despite, studies find significant health disparities linked to socioeconomic factors at the individual-level, although evidence at larger geographical-levels has been mixed. We used a key burden of disease (BoD) metric, Years of Life Lost (YLL), to examine spatial health inequities among Norwegian municipalities and their association with socioeconomic factors. Methods We analysed data from all residents in Norwegian municipalities with over 1000 inhabitants as of January 1, 2019. Data was sourced from the National Population Register and Statistics Norway. All-cause YLL were calculated based on age-specific aspirational life expectancy obtained from GBD 2019. Deprivation was measured using educational attainment and median income, categorized into quartiles. Geographical maps illustrating municipality-level all-cause age-standardised YLL rates for males and females were generated. Negative binomial regression models assessed associations between socioeconomic factors and YLL rates, adjusting for age, sex, and an index of centralisation. Results High-deprivation municipalities exhibited a 9% higher YLL rate in terms of education (Incidence Rate Ratio [IRR] = 1.09, 95% Confidence Interval [CI] = 1.01-1.17) and a 10% higher YLL rate in terms of income (IRR = 1.10, 95% CI = 1.02-1.08) compared to the least deprived, translating to absolute differences of 1391 and 1466 YLL per 100,000 population, respectively. Additionally, we discuss the potential expansion of this study to incorporate cause-specific outcomes and other BoD metrics based on previous county-level analyses. Conclusions Our study demonstrates the feasibility of using BoD methods to assess geographical deprivation and premature mortality at the municipality level, providing valuable insights for public health policy targeted at small administrative areas.

Did the COVID-19 Pandemic Affect Suicide Rates Differently in Urban and Rural South Korea?

Abstract Background The influence of the COVID-19 pandemic on suicide rates remains a subject of debate. Despite increases in suicidal ideation and attempts reported during the pandemic, several recent meta-analyses have not demonstrated corresponding rises in suicide rates. Given the potential for substantial regional and demographic variability in the psychological consequences of COVID-19-related restrictions, this study explores differential suicide rates in urban versus rural contexts within South Korea subsequent to the pandemic outbreak. Methods This investigation employed age-standardized suicide rates from two periods, 2015-2019 and 2020-2022, across 234 administrative divisions (152 urban, 82 rural). A difference-in-differences approach was utilized to evaluate the pandemic’s impact on suicide rates, segmented by urban and rural classifications. A linear regression model was developed to examine the interaction between location (urban/rural) and time period, controlled for annual variations, perceived stress, and health status within each locale. Results Analysis revealed higher suicide rates in rural areas compared to urban counterparts (β = 1.247, p = 0.003), although no significant changes were observed during the pandemic period itself (β=-0.425, p = 0.682). Furthermore, the interaction between urban/rural status and the pandemic period did not reach statistical significance (p = 0.367). Conclusions The findings indicate no significant contribution of the COVID-19 pandemic to increased suicide rates, irrespective of the urban or rural setting. Further research is warranted to dissect the impact of more direct socioeconomic factors on this dynamic. Key messages • There in no evidence of increased suicide rates during the COVID-19 pandemic in South Korea. • The impact of the COVID-19 pandemic on suicide rates did not significantly different between urban and rural areas.

Excess all-cause mortality in 21 countries during 2022: COVID-19 impact by C-MOR project

Abstract National published COVID-19 mortality estimates do not fully encompass the extent of the pandemic’s impact on mortality. To address this challenge, calculating excess all-cause mortality at the national level is important. Our focus was on understanding total weekly excess mortality for 2022, by analysing mortality data across 2020-2022, from 21 countries participating in the international consortium (C-MOR), which provided data for examination. Excess mortality was calculated by comparing the weekly 2022 age-standardized mortality rates per 100,000 population against a baseline mortality, estimated using historical data from 2015-2019. Excess cumulative mortality for 2022 was found in all 21 countries. The excess mortality for the total population varied between 8.6 and 116.2, with the minimum excess belonging to Peru and the maximum to Georgia. Australia, Austria, Cyprus, Denmark, Estonia, Georgia, Greece, Israel, and Norway showed a higher excess in 2022 than in 2020, while Australia, Austria, Cyprus, Denmark, Israel, Italy, Norway, Spain, and Sweden also showed a higher excess in 2022 than in 2021. Mauritius showed a significant excess mortality for the first time in 2022. For all countries, but Australia, the % of COVID-19 deaths out of all deaths decreased in 2022 compared to 2021. Contrary to the ‘harvesting effect’, which would expect a decline in mortality rates post-pandemic, our results underscore a sustained excess mortality throughout 2022. The 2022 excess deaths are mainly non-COVID-related, stemming from broader pandemic impacts on healthcare systems and other factors. Conversely, in Australia, international boarders reopened in 2022, resulting in the first community-wide transmission and a substantial rise in excess deaths. Our study reveals nuanced excess mortality dynamics post-vaccination, providing crucial insights for policymakers and stressing the necessity of continued vigilance and adaptive strategies against COVID-19’s diverse impacts. Key messages • All countries investigated experienced continued all-cause excess mortality during 2022, compared to pre-pandemic years. For most, excess mortality in 2022 was higher than in 2021 and 2020. • For all countries, except Australia, the contribution of COVID-19 deaths to the mortality estimates in 2022 is decreased, highlighting the impact of indirect pandemic related effects on mortality.

Mortality in migrants with dementia living in the Lazio region, Italy

Abstract Background Dementia is a major cause of disability and death among older people. Older migrants living in Italy are increasing and the prevalence of dementia is expected to rise in this population. Nevertheless, there is lack of real-world information concerning their health outcomes. The aim of this work was to analyse mortality in migrants with dementia living in Lazio, Italy (IMMIDEM project, GR-2021-12372081) Methods In a retrospective cohort study, people with dementia aged ≥50 living in Lazio on 31st December 2018 were selected using Health Information Systems (HIS) and followed-up for 5 years. The migrant status was defined according to the Country of birth as native Italians, people from High Migratory Pressure Countries (HMPC) or Highly Developed Countries (HDC). Age-standardized mortality rate (SMR) was estimated overall and by migrant status. Time to event analysis was performed using Kaplan-Meier curves, log-rank tests, and multivariate Cox regression. Results On 31st December 2018, 38,835 individuals with dementia were living in Lazio, 2.1% from HMPC and 0.9% from HDC. Natives and HDC were older than HPMC, while migrants showed a higher proportion of female. The SMR was lower in migrants from HPMC (42.2%; CI95% 37.0%-48.1%) and from HDC (33.2%; CI95% 25.4%-43.4%) than among natives (52.4%; CI95% 50.7%-54.1%). The age-adjusted mortality hazard ratio (HR) was lower in migrants (HDCs HR = 0.76, CI95%:0.66-0.89; HMPC HR = 0.88, CI95%:0.80-0.97) than natives. Conclusions The study showed a lower mortality rate among migrants with dementia compared to native Italians. Under-diagnosis, the “salmon bias”, and the “‘healthy migrant effect” could explain this apparent paradox, consistently with available literature. In addition, following-up migrants in the HIS may be difficult and underestimation may occur. Enhancing the comprehension of this phenomenon could allow the formulation of more effective, diversity-sensitive policies and practices for the management of dementia. Key messages • The mortality rate among migrants with dementia was found lower than that among native Italians. • Understanding the morbidity and mortality patterns in migrants with dementia is important to develop practice to adequately respond to their health needs and diversity-sensitive polices.

The projected global burden of modifiable risk factors on cardiovascular disease from 2025 to 2100

Abstract Background Cardiovascular diseases (CVDs) are the primary cause of global mortality and morbidity. Controlling modifiable risk factors driving the CVD epidemic is a vital focus of primary prevention efforts worldwide. Understanding the epidemiological trends in these risk factors is therefore essential in designing effective countermeasures against CVDs for the years to come. Purpose This study aims to forecast the disability-adjusted life years (DALYs) associated with CVDs attributable to high systolic blood pressure (SBP), high body-mass index (BMI), high fasting plasma glucose (FPG), high low-density lipoprotein (LDL) and tobacco use from 2025 to 2100, stratified by GBD super-regions, sex, sociodemographic index (SDI), and age-groups. Methods Historical data on DALYs from 1990 to 2019 from the Global Burden of Disease (GBD) study was used to project DALYs associated with modifiable risk factors of CVDs from 2025 to 2100. Trends across GBD super-regions, sex, SDI, and age-groups were also examined. Results Between 2025 and 2100, age-standardised DALY rates (ASDR) per 100,000 population are forecasted to fall across all modifiable risk factors, with the greatest decline seen in tobacco use (-76.0%) and high LDL (-66.9%). Globally, high SBP and high BMI expect the greatest ASDR in 2100 (both 891 per 100,000 population), while tobacco use expects the least (213 per 100,000 population). High BMI is expected to rise 623.0% in South Asia and 221.5% in South-east Asia, East Asia and Oceania from 2025 to 2100, while high FPG is expected to rise 114.2% in North Africa and the Middle-east and 110.6% in South Asia. Females are expected to have lower overall and greater reductions in ASDR across all modifiable risk factors when compared to males from 2025 to 2100. Notably, males expect a 11.0% rise in high BMI worldwide across this period. The age-prevalence of modifiable risk factors is expected to be bimodal in 2100, highest in those aged 50-59 as well as 75-84 years old, possibly suggesting improvements in global screening efforts or the earlier development of metabolic dysfunction. All modifiable risk factors are predicted to fall in high and high-middle SDI regions from 2025 to 2100. In contrast, low, low-middle, and middle SDI regions expect a rise in high FPG and high BMI across this same time frame. The burden of modifiable CVD risk factors is expected to be highest in low-middle SDI regions in 2100, as compared to high-middle SDI regions in 2025. Conclusion While the global decline in ASDR of modifiable risk factors suggests overall improvements in the primary prevention of CVDs, regional spikes in high BMI and FPG calls for the implementation of timely, targeted interventions accounting for local trends in CVD. Moreover, the disproportionate metabolic burden expected in lower SDI regions in the coming decades requires concerted, international support to alleviate the global burden of CVDs.

Regional inequalities in years of life lost within the European Economic Area: Using the Gini coefficient and slope index of inequality to assess spatial disparities

Abstract Background Health inequalities have been linked to reduced life expectations. This study aimed to investigate regional variations in all-cause years of life lost (YLLs) in European Economic Area (EEA) countries prior to the COVID-19 pandemic. Methods Demographic data were extracted from Eurostat for 1390 small regions 32 EEA countries. Age-standardised sex specific YLL rates per 100,000 population in 2019 were estimated for EEA regions (Eurostat NUTS level 3) using methodologies derived from the Global Burden of Disease study. Relative spatial disparities were evaluated using the Gini coefficient (GC) and absolute spatial disparities assessed using the slope index of inequality (SII). Results Between EEA countries, relative geographical inequality in age-standardized YLL rates was higher than within them, slightly more so for males (GC = 16.96% [95% CI = 16.26-17.65]) than females (14.22% [13.62-14.82]). Among females, the UK (11.21% [95% CI 10.11-12.30]), Greece, and Croatia had the highest relative spatial inequality, while Ireland (3.37% [2.26-4.48]), Slovakia, and the Netherlands had the lowest. For males, Belgium (10.76% [9.34-12.17]), the UK, and Croatia exhibited the highest relative spatial inequality, while Ireland (1.99% [1.18-2.81]), Lithuania, and Slovakia had the lowest. Germany had the largest absolute geographical inequality in YLLs among females (SII=16.86% [16.28 to 17.44]), followed by Estonia and the UK. Among males, Estonia had the largest absolute spatial inequality (36.60% [-10.88 to 84.07]), followed by Latvia and Hungary. Ireland had the lowest absolute spatial inequality for both females and males. Conclusions Relative and absolute disparities in premature mortality rates are evident across regions of the EEA, both within countries and across the entire region. These findings offer insights for national and local stakeholders, aiding them in customising public health interventions to target spatial health disparities.

Mortality related to different circulatory diseases: a multiple causes of death analysis, 2008-2022

Abstract Background Mortality from circulatory diseases significantly increased in 2020 compared to pre-pandemic years in many countries. However, data were mostly limited to the underlying cause of death and to the first phases of the pandemic. Analyses of any mention of a disease in death certificates (multiple causes of death approach, MCOD) are more robust to changes in coding rules/practices and to the role of COVID-19 as a competing cause of death. Methods Mortality records were extracted from 2008 to 2022 among residents of the Veneto Region (Northeastern Italy, 4.9 million population). Based on MCOD, age-standardized mortality rates (2013 European standard) were computed for ischemic heart diseases (IHD), cerebrovascular diseases (CVD), atrial fibrillation (AF), and hypertensive diseases (HD). The annual percent change (APC) was estimated through the pre-pandemic period (2008-2019), and change in rates during pandemic years were computed compared to 2019. Results Before the pandemic, rates were steeply declining for IHD (APC -5.1%; 95%CI -5.5, -4.6) and CVD (-4.0%; -4.4, -3.5); mortality related to HD reduced at a slower pace (-1.9%; -2.3, -1.4), whereas AF-related mortality was increasing (+1.0%; 0.1, 1.8). During the first year of the pandemic, the growth in mortality compared to 2019 was +26% for HD, +18% for AF, +13% for CVD and +12% for IHD. In 2021-2022, rates for CVD and IHD returned to pre-pandemic levels; rates for HD reduced with respect to 2020 but remained above the baseline; AF-related mortality was still increasing. Conclusions The pandemic differentially impacted mortality associated to different circulatory diseases, depending on pre-existing long-term trends (increasing for AF) and on susceptibility to severe COVID-19 disease (higher for HD). Continuous surveillance based on MCOD is warranted to properly assess changes in mortality associated to specific circulatory diseases after the end of the pandemic. Key messages • Multiple causes of death analyses are warranted to assess how the pandemic affected pre-existing long term trends in cause-specific mortality. • Mortality related to different circulatory diseases increased in 2020, but pre-pandemic trends, the extent of the increase in 2020, and further changes observed in 2021-2022 largely diverged.

Impact of Noncommunicable Diseases on Years of Life Lost in FB&H During the COVID-19 Pandemic

Abstract This study aims to comprehensively investigate the impact of noncommunicable diseases (NCDs) on years of life lost (YLL) within the Federation of Bosnia and Herzegovina (FB&H) across distinct phases: pre-pandemic, pandemic, and post-pandemic periods. Given that NCDs currently represent more than half of the global disease burden, our focus lies in assessing YLL specifically for cerebral infarction (I63-I64) and diabetes mellitus (E10-E14). Conducting a retrospective data analysis, we utilized mortality data sourced from the Institute for Statistics of FB&H to quantify YLL. This assessment involved multiplying age-specific mortality figures by the remaining life expectancy at the corresponding age, utilizing the GBD 2019 life expectancy table. Examining the period between 2019 and 2022, our analysis aimed to elucidate the pandemic’s potential influence on NCD burden, through the examination of age-standardized YLL rates based on the world standard population. In 2019, YLL attributable to I63-I64 for both sexes totaled 41,244 in 2019, escalating to 44,790 in 2020, and subsequently decreasing to 39,439 and 32,055 in the pandemic years of 2021 and 2022, respectively. For diabetes mellitus (E10-E14), YLL in 2019 amounted to 23,675, with figures for 2020, 2021, and 2022 standing retrospectively at 24,329, 24,114, 19,125. The increase in 2020 may be attributed, in part, to initial healthcare hesitancy during the pandemic’s onset, leading to delayed treatment and heightened mortality rates. Furthermore, patients who died in 2020 from C-19 without being tested may have skewed mortality registration by inflating rates attributed to pre-existing conditions. The declining rates thereafter could be due to a harvesting pandemic effect, in that people who were previously ill died prematurely from C-19. These insights show the pandemic’s profound impact on NCD-related mortality, underscoring the urgent need for targeted interventions and healthcare strategies. Key messages • A substantial reduction in years of life lost (YLL) related to certain noncommunicable diseases was observed during the pandemic. • The pandemic significantly influenced mortality among individuals with noncommunicable diseases, driven partly by healthcare hesitancy and potential misregistration of causes of death.

The normalised mortality, a new measure to ensure valid conclusions from cardiovascular mortality

Abstract Background The quality and efficacy of health systems is assessed by comparing age-standardised mortality (ASM) from cardiovascular diseases (CVD), as they are regarded avoidable by health care. Differences in CVD mortality in West-Europe are surprising and hard to explain: in 2018, ASM for CVD in Germany was much higher (women: 102, men: 155/100,000) than in the Netherlands (65 and 97). Yet, these differences do not root in health system quality, but in different shares of CVD deaths among all deaths (DE: 39%, NL: 25%), which strongly effect CVD mortality. We developed a mortality measure less sensible to differences in shares of CVD deaths to increase plausibility of comparisons and validity of conclusions. Methods WHO data on sex-specific all and CVD deaths, ASM for CVD and all-causes for 2000-2018 for Western-European countries was used to calculate the share of CVD deaths among all deaths. ASM for CVD was divided by the share of CVD deaths resulting in a mortality measure normalized for 1% of CVD deaths. ASM and normalized mortality for CVD were used in comparative analyses. Strength of linear association between total and (normalized) ASM for CVD was estimated (adj. R²). Results Normalised CVD mortality ranked from 2.0 (CHE in women) to 4.9 (SVN in men) in 2018. While ASM for CVD was lowest in Danish women and Dutch men, Switzerland leads both rankings using the normalised CVD mortality. While ASM for CVD was much higher in Germany than in the Netherlands, the countries had the same normalized CVD mortality (2.6). ASM for CVD was moderately associated with all-cause mortality only in men (adj. R² 0.33; in women: -0.06). Using the normalized CVD mortality yielded an adj R² of 0.66 in women and 0.94 in men. The normalised CVD mortality ensures reliable comparisons of CVD mortality eliminating the effect of different shares of CVD deaths. It yields plausible results and enables valid conclusions about health system quality and better decisions for public health. Key messages • Age-standardised CVD mortality rates are effected by different shares of CVD deaths in countries and hinder valid conclusions on health systems efficacy and quality of health systems. • The normalised mortality rate eliminates the effect of different shares of CVD deaths in countries and allows to validly compare CVD mortality.