Excess Burden Of Mortality Research Articles

Spatio-temporal patterns of excess mortality from non-COVID causes of death in the United States, march-December 2020.

Objectives To estimate the burden of excess mortality from 17 underlying causes of death between March-December 2020 in the United States, and to compare trends in excess deaths from non-COVID causes vs. from COVID-19. Methods Using time series models, we estimated monthly counts of all-cause and cause-specific excess deaths. We stratified by geographic region and compared temporal trends in excess deaths from non-COVID causes to trends in deaths attributed to COVID-19. Results Of approximately 500,000 excess deaths, 70% were attributed to COVID-19. We observed increases in several underlying causes of death, ranging from a 3% increase in kidney disease deaths to a 24% increase in homicides, as well as decreases in deaths from cancer (-0.3%), influenza and pneumonia (-2%), chronic lower respiratory disease (-3%), and suicide (-7%). Trends in excess deaths from cardiovascular disease, diabetes, and Alzheimer's disease closely mirrored trends in deaths from COVID-19. Trends in excess liver disease, homicide, suicide, and motor vehicle accident deaths were negatively correlated with trends in deaths from COVID-19. There was wide regional variation in excess death rates for some causes of death, including a disproportionate increase in homicide and motor vehicle accident deaths in the Great Lakes, and a sustained reduction in cancer deaths in the Mideast and New England. Conclusions Increases in cardiovascular disease, diabetes, and Alzheimer's disease deaths from March-December 2020 likely reflect healthcare system disruptions or acute complications of COVID-19. Excess deaths from homicide and liver disease are more likely to reflect social and economic effects of the emerging pandemic, or other separate causes.

Excess multi-cause mortality linked to influenza virus infection in China, 2012-2021: a population-based study.

The aim of this study is to estimate the excess mortality burden of influenza virus infection in China from 2012 to 2021, with a concurrent analysis of its associated disease manifestations. Laboratory surveillance data on influenza, relevant population demographics, and mortality records, including cause of death data in China, spanning the years 2012 to 2021, were incorporated into a comprehensive analysis. A negative binomial regression model was utilized to calculate the excess mortality rate associated with influenza, taking into consideration factors such as year, subtype, and cause of death. There was no evidence to indicate a correlation between malignant neoplasms and any subtype of influenza, despite the examination of the effect of influenza on the mortality burden of eight diseases. A total of 327,520 samples testing positive for influenza virus were isolated between 2012 and 2021, with a significant decrease in the positivity rate observed during the periods of 2012-2013 and 2019-2020. China experienced an average annual influenza-associated excess deaths of 201721.78 and an average annual excess mortality rate of 14.53 per 100,000 people during the research period. Among the causes of mortality that were examined, respiratory and circulatory diseases (R&C) accounted for the most significant proportion (58.50%). Fatalities attributed to respiratory and circulatory diseases exhibited discernible temporal patterns, whereas deaths attributable to other causes were dispersed over the course of the year. Theoretically, the contribution of these disease types to excess influenza-related fatalities can serve as a foundation for early warning and targeted influenza surveillance. Additionally, it is possible to assess the costs of prevention and control measures and the public health repercussions of epidemics with greater precision.

Disparities in violent fatal injury among racial and ethnic minorities, 2009-2019: a portfolio analysis of United States-National Institutes of Health.

The excess mortality burden due to violent fatal injuries is an urgent public health issue for adolescents and young adults, especially those from racial and ethnic minority populations. We examined the research portfolio of the United States National Institutes of Health (NIH) related to violent fatal injuries between 2009 and 2019 to focus on adolescents and young adults from NIH-designated populations experiencing health disparities and to identify trends and research gaps. We analyzed funded projects by populations covered, geographic location of the study population, type of research (etiology, intervention, methodology), type of determinants, and publications generated. In 10 years, NIH funded 17 grants that produced 90 publications. Researchers used socioecological frameworks most to study violent crime, except in rural locations. Research gaps include the direct impact of violent crime among those victimized and health care (the least studied determinant) and premature mortality disparities caused by hate crimes.

Melanoma survival by age group: Population-based disparities for adolescent and young adult patients by stage, tumor thickness, and insurance type

Melanoma survival literature predominantly represents patients >65years of age. Study of younger patients may reveal potential age-group-specific differences in survival outcome. Identify factors associated with differences in melanoma survival in 2 age groups, adolescents and young adults (AYAs; ages 15-39) and older adults (ages 40-64). This population-based registry study included all cases (n=81,597) of cutaneous melanoma diagnosed at ages 15 to 64 from 2004 to 2015 in California. Age-group-specific multivariable Cox hazard regressions were used. In the adjusted, age-group-specific models, AYA patients with stage IV melanoma had worse survival (hazard ratio: 20.39, 95% CI: 13.30-31.20) than was observed among older adults (hazard ratio: 10.79, 95% CI: 9.33-12.48). Thicker tumors and public insurance were also associated with worse survival for AYAs than observed in models for older adults. AYAs experienced better survival when detected at earlier stages. Registry data do not routinely collect behavioral information or family history of melanoma. Survival was much worse for AYAs with stage IV melanoma than observed among older adults. To improve AYA survival, early melanoma detection is critical. Greater awareness, suspicion, and screening for AYA melanoma may disrupt delays in diagnosis and reduce the excess burden of mortality from stage IV melanoma in young patients.

Are men’s happiness and life satisfaction linked to why men die earlier than women? A panel study from 1981 to 2020 in 102 countries

The motivation for happiness research rather than GDP is becoming important to the role of many governments across the globe. When people are asked to list the key characteristics of a good life, they are more likely to include happiness, health, living well and longer. This study investigates whether factors that predict men’s happiness and life satisfaction explain why men die earlier than women. The present research analyses data (N=426,452; 51.90% females) collected by the World Value Survey from 1981 to 2020 in 102 countries, and from six continents. A multilevel random-effects regression analysis was conducted in which individuals were nested by countries. We investigated variations across nations, country-level of development, and geographical regions. Men were slightly less happy and less satisfied with their lives compared to women. State of health, household’s financial satisfaction, freedom of choice, family importance, and being married were positively associated with happiness/life satisfaction. In contrast, being men, being in a low-income household, or being unemployed were negatively associated with happiness/life satisfaction. Unemployed men and men who were living in Africa or the Middle East regions were less satisfied with their lives compared to women. The excess mortality burden on men is due to a mix of biological, behavioural, and social factors. Happy people may live longer because of underlying factors such as health status, household financial satisfaction, and social connections. Policies targeting men’s health and social connections are needed.

Total, sex and age-specific excess mortality during 2020 in 20 countries part of the C-MOR consortium

Abstract Nationally published COVID-19 mortality estimates might underestimate the actual mortality burden attributed to COVID-19. Estimations of excess all-cause mortality can provide more accurate estimates of the toll of the pandemic. This study aims to estimate the overall, sex and age-specific excess all-cause mortality in 20 countries, during 2020. Total, sex and age-specific weekly all-cause death counts for 2015-2020 were extracted from national vital statistics databases. Percent excess mortality for 2020 was calculated by comparing average weekly 2020 mortality rates against average weekly mortality rates from the past five years (2015-2019). Comparisons were performed for the total population, per sex, and per age groups (<65 vs. 65+ or < 70 vs.70+) depending on data availability. Percent difference in average weekly mortality between 2020 and 2015-2019 ranged from negative for Australia and Norway, to < 5% for Denmark, Cyprus, Estonia, Israel, and Sweden, 5-10% for Georgia, Mauritius, Ukraine, Austria, France, Scotland and Northern Ireland, to ∼10-21% for England & Wales, Italy, Brazil, USA, Slovenia, and to 89% for Peru. The percent difference in average weekly mortality between 2020 and 2015-2019 for males was higher than for females except for Cyprus, Estonia, Slovenia and the USA. Lastly, in age specific analyses, for the majority of countries the % increase in average weekly mortality between 2020 and 2015-2019, was higher in the oldest age group investigated, however, for Peru and the USA (<65 vs. 65+ years) and for Cyprus and Mauritius (<70 vs. 70+ years), mortality increased similarly in both age groups. This study highlights that the excess mortality burden during the COVID-19 pandemic disproportionally affected specific countries, males, and in most, but not all countries, the oldest age groups. Strengthening of health resilience in the most affected countries, while targeting population groups impacted the most, is of paramount public health importance. Key messages • Excess mortality burden during the COVID-19 pandemic disproportionally affected specific countries, and even within countries specific sex and age groups. • Further investigation into the determinants of excess mortality is needed to suggest steps to strengthen health resilience in the countries and target population groups impacted the most.

Global Excess Mortality during COVID-19 Pandemic: A Systematic Review and Meta-Analysis.

Background: Currently, reported COVID-19 deaths are inadequate to assess the impact of the pandemic on global excess mortality. All-cause excess mortality is a WHO-recommended index for assessing the death burden of COVID-19. However, the global excess mortality assessed by this index remains unclear. We aimed to assess the global excess mortality during the COVID-19 pandemic. Methods: We searched PubMed, EMBASE, and Web of Science for studies published in English between 1 January 2020, and 21 May 2022. Cross-sectional and cohort studies that reported data about excess mortality during the pandemic were included. Two researchers independently searched the published studies, extracted data, and assessed quality. The Mantel–Haenszel random-effects method was adopted to estimate pooled risk difference (RD) and their 95% confidence intervals (CIs). Results: A total of 79 countries from twenty studies were included. During the COVID-19 pandemic, of 2,228,109,318 individuals, 17,974,051 all-cause deaths were reported, and 15,498,145 deaths were expected. The pooled global excess mortality was 104.84 (95% CI 85.56–124.13) per 100,000. South America had the highest pooled excess mortality [134.02 (95% CI: 68.24–199.80) per 100,000], while Oceania had the lowest [−32.15 (95% CI: −60.53–−3.77) per 100,000]. Developing countries had higher excess mortality [135.80 (95% CI: 107.83–163.76) per 100,000] than developed countries [68.08 (95% CI: 42.61–93.55) per 100,000]. Lower middle-income countries [133.45 (95% CI: 75.10–191.81) per 100,000] and upper-middle-income countries [149.88 (110.35–189.38) per 100,000] had higher excess mortality than high-income countries [75.54 (95% CI: 53.44–97.64) per 100,000]. Males had higher excess mortality [130.10 (95% CI: 94.15–166.05) per 100,000] than females [102.16 (95% CI: 85.76–118.56) per 100,000]. The population aged ≥ 60 years had the highest excess mortality [781.74 (95% CI: 626.24–937.24) per 100,000]. Conclusions: The pooled global excess mortality was 104.84 deaths per 100,000, and the number of reported all-cause deaths was higher than expected deaths during the global COVID-19 pandemic. In South America, developing and middle-income countries, male populations, and individuals aged ≥ 60 years had a heavier excess mortality burden.

Field Burning Fallout: Quantifying Emissions from Sugarcane Fires.

Field Burning Fallout: Quantifying Emissions from Sugarcane Fires.

Impact of the COVID-19 crisis on the mortality profiles of the foreign-born in France during the first pandemic wave

BackgroundImmigrants in Western countries have been particularly affected by the COVID-19 crisis. ObjectiveWe analysed excess mortality rates among the foreign-born population and changes in their distinctive mortality profiles (“migrant mortality advantage”) during the first pandemic wave in France. Data and methodsDeaths from all causes in metropolitan France from March 18 to May 19, 2020 were used, with information on sex, age, region of residence and country of birth. Similar data from 2016 through 2019 were used for comparisons. ResultsDuring the pre-pandemic period (2016–2019), immigrant populations (except those from Central and Eastern Europe) had lower standardized mortality rates than the native-born population, with a particularly large advantage for immigrants from sub-Saharan Africa. In the regions most affected by COVID-19 (Grand-Est and Île-de-France), the differences in excess mortality by country of birth were large, especially in the working-age groups (40–69 years), with rates 8 to 9 times higher for immigrants from sub-Saharan Africa, and about 3 to 4 times higher for immigrants from North Africa, from the Americas and from Asia and Oceania relative to the native-born population. The relative overall mortality risk for men born in sub-Saharan Africa compared to native-born men, which was 0.8 before the pandemic, shifted to 1.8 during the first wave (0.9 to 1.5 for women). It also shifted from 0.8 to 1.1 for men from North Africa (0.9 to 1.1 for women), 0.7 to 1.0 for men from the Americas (0.9 to 1.3 for women), and 0.7 to 1.2 for men from Asia and Oceania (0.9 to 1.3 for women). ConclusionOur findings shed light on the disproportionate impact of the first wave of the pandemic on the mortality of populations born outside Europe, with a specific burden of excess mortality within the working-age range, and a complete reversal of their mortality advantage.

Variation in excess all-cause mortality by age, sex, and province during the first wave of the COVID-19 pandemic in Italy

Although previous evidence suggests that the infection fatality rate from COVID-19 varies by age and sex, and that transmission intensity varies geographically within countries, no study has yet explored the age-sex-space distribution of excess mortality associated with the COVID pandemic. By applying the principles of small-area estimation to existing model formulations for excess mortality, this study develops a novel method for assessing excess mortality across small populations and assesses the pattern of COVID excess mortality by province, year, week, age group, and sex in Italy from March through May 2020. We estimate that 53,200 excess deaths occurred across Italy during this time period, compared to just 35,500 deaths where COVID-19 was registered as the underlying cause of death. Out of the total excess mortality burden, 97% of excess deaths occurred among adults over age 60, and 68% of excess deaths were concentrated among adults over age 80. The burden of excess mortality was unevenly distributed across the country, with just three of Italy’s 107 provinces accounting for 32% of all excess mortality. This method for estimating excess mortality can be adapted to other countries where COVID-19 diagnostic capacity is still insufficient, and could be incorporated into public health rapid response systems.

Excess mortality in Russia and its regions compared to high income countries: An analysis of monthly series of 2020

BackgroundRussia has been portrayed in media as having one of the highest death tolls due to the COVID-19 pandemic in the world. However, the precise scale of excess mortality is still unclear. We provide the first estimates of excess mortality in Russia as a whole and its regions in 2020, placing this in an international context. MethodsWe used monthly death rates for Russia and 83 regions plus the equivalent for 36 comparator countries. Expected mortality was derived in two ways using averages in the same months in preceding years and the same averages adjusted for secular trends. Excess death rates were estimated for the whole year and the last 3 quarters. We also estimated the relationships between excess mortality and reported COVID-19 cases and deaths across countries and Russian regions. ResultsEstimating excess deaths rates based on the trend-adjusted average, Russia had the highest excess mortality of any of the 37 countries considered. Using the simple average, Russia had the third highest. Most of the excess deaths were recorded in the 4th quarter of 2020 and the level and trajectory of excess mortality in Russia and most of Eastern European countries differed from that in Western countries. While both the cumulative number of COVID-19 cases and deaths showed positive correlations with excess mortality across countries (r=0.65 and r=0.75, p<0.001), the association across the Russian regions was, surprisingly, negative for cases (r=-0.34, p<0.01) and deaths (r=-0.09, p=0.42). When we replaced reported deaths with final data from death certificates the correlation was positive (r=0.38, p<0.001). ConclusionRussia has one of the largest absolute burden of excess mortality in 2020 but there is a counter-intuitive negative association between excess mortality and cumulative incidence at the regional level. Under-recording of COVID-19 cases seems to be a problem in some regions.

Impact of COVID-19 on motor vehicle injuries and fatalities in older adults in Ontario, Canada

BackgroundOlder adults constitute the group most vulnerable to COVID-19 mortality. As a result, in North America and elsewhere, older adults have been strongly advised to shelter in place. Older adults also represent the fastest growing segment of licensed drivers. ObjectiveWe examined the change in injuries and fatalities sustained by younger and older drivers and pedestrians during the first month of the COVID-19 pandemic. We hypothesized that adults ages 80 years and over would have a proportionally larger reduction than the other drivers and pedestrians. MethodsUsing a cohort design, we compared the proportion of drivers and pedestrians involved in injuries and fatalities attributable to individuals aged 80 years and over, as recorded in the Ministry of Transportation of Ontario (Canada) database, between the 30 days prior to shelter-in-place related to the COVID-19 pandemic and the subsequent 30 days. By way of comparison, we conducted a similar comparison for younger age cohorts (16−24 years, 25−34 years, 35−54 years, 55−64 years, and 65−79 years). ResultsDrivers aged 80 years and over represented 21 per 1000 injuries and fatalities in the 30 days prior to March 17, 2020 (95 % CI: 15−29), and 8 per 1000 injuries and fatalities in the 30 days beginning on that date (95 % CI: 2−20), a 64.7 % reduction (exp (β) post 0.353, 95 % CI 0.105−0.892). Drivers in the 35−54 year age range underwent a significant but smaller reduction of 22.9 %; no significant changes were seen for drivers in other age groups, or for pedestrians of any age. Conclusions and relevanceThe physical distancing measures that aimed to reduce the spread of COVID-19 resulted in a marked reduction in driver injuries and fatalities in the oldest old, illustrating the impact of physical distancing recommendations in this population. The excess mortality burden faced by the oldest adults during the COVID-19 pandemic, by direct exposure to the virus, may be indirectly mitigated by the reduction in road-related deaths in this cohort.

Using race- and age-specific COVID-19 case data to investigate the determinants of the excess COVID-19 mortality burden among Hispanic Americans

Age-adjusted COVID-19 mortality estimates have exposed a previously hidden excess mortality burden for the US Hispanic population. Multiple explanations have been put forth, including unequal quality/access to health care, higher proportion of pre-existing

Comparison of All-Cause Mortality in England With European Countries and the USA: January 2020 Through to February 2021: A Secondary Analysis of Routine Administrative Data

Background: Assessments of mortality continue to inform public health strategies and policy making during the COVID-19 pandemic. All-cause excess mortality is a robust measure of the impact of the pandemic. Our study assesses the relative burden of excess mortality in England during the pandemic compared with 28 European countries and the USA. Methods: Weekly deaths and population estimates were obtained from Eurostat or directly from national statistical and public health agencies. Contextual information on COVID-19 case rates and population-level risk factors were obtained from open-source databases. Weekly directly age-standardised mortality rates (ASMRs) during week 1 2020 to week 7 2021 were calculated and summed cumulatively. These were compared with weekly sums of mean ASMRs observed between 2015 and 2019 and presented relative to the mean cumulative 2015-2019 ASMR averaged over an equivalent period. Findings: By February 2021, England had an overall relative excess mortality of 10·05%. This was the fifth highest out of 29 countries, the USA (14·82%) being the highest. Five countries showed below average mortality, with Norway the lowest (-6·76%). The same statistic for deaths under 65 years showed substantial international variation, with England having the second highest excess of 11·46%. Cumulative COVID-19 case rates explained about half of the international variation in relative excess mortality. Interpretation: England has experienced comparably high all-cause excess mortality during the COVID-19 pandemic. Factors contributing to England’s relative position should be further explored, particularly the association of health inequalities and wider determinants of health on the mortality risk of younger age groups. Funding Information: This study was carried out as part of the PHE’s work during the pandemic and therefore funded by PHE. Declaration of Interests: All authors declare no conflicts of interest. Ethics Approval Statement: This study was carried out as part of the PHE responsibility to manage the COVID-19 pandemic. PHE has legal permission, provided by Regulation 3 of The Health Service (Control of Patient Information) Regulations 2002 to process confidential patient information (http://www.legislation.gov.uk/uksi/2002/1438/regulation/3/made) under Sections 3(i) (a) to (c), 3(i)(d) (i) and (ii) and 3(3) as part of its outbreak response activities. As such this work falls outside the remit for ethical review. The study was subject to an internal review by the PHE Research Ethics and Governance Group and was found to be fully compliant with all regulatory requirements. As a full ethical review is not a requirement for this type of study and as no ethical or regulatory issues had been identified the study was approved.

Projection of Temperature-Related Excess Mortality by Integrating Population Adaptability Under Changing Climate — China, 2050s and 2080s

What is already known about this topic?An increasing number of studies have projected temperature-related mortality, but few consider the change of population’s adaptability to future temperature and mortality burden from cold and heat effects.What is added by this report?This study offers a comprehensive characterization of human adaptability and excess mortality burden of temperature across various regions of China.What are the implications for public health practice?The temperature-related excess mortality was projected to increase in the 2050s and decrease in the 2080s. Heat adaptability was projected to increase in the future, but along with the rising temperatures, the heat-related excess mortality continuously rose, except for the low-speed rising scenario. Although the excess mortality of cold was projected to decrease in the nearer future, it might not keep declining in the long run, due to the decreasing cold-adaptability, which deserves more attention.

SUN-046 CARDIAC MORTALITY IN PEOPLE WITH END STAGE KIDNEY DISEASE IN AUSTRALIA AND NEW ZEALAND; A COHORT STUDY FROM 1980 TO 2013

The presence of cardiac disease is an important predictor of mortality in people with end-stage kidney disease (ESKD). Secondary prevention and treatment of cardiac events may be less effective in people with ESKD. We aimed to review the rates and standardised mortality ratios from cardiovascular disease for people with ESKD compared to the Australian and New Zealand general population. Cohort study of incident people with ESKD in Australia and New Zealand, 1980-2013. Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) was linked with Australian and New Zealand death registers to obtain date and cause of death. We estimated mortality rates for cardiovascular disease using ICD codes (Table 1) and standardised mortality ratios (SMRs with 95% confidence intervals [CI]) using indirect standardisation, by age, sex and calendar year to the general population. There were 60,823 participants contributing 381,874 person-years of follow-up. Overall, there were 6847 cardiac deaths, of which 5947 (86.9%) were from ischaemic heart disease. Cardiac mortality rates were higher in men (2002.5/100,000 person-years, 95%CI: 1944.5-2062.2) than women (1502.5/100,000person-years, 95%CI: 1443.6-1563.8), where rates in both sexes increased with age. The relative rate was higher in women (women: SMR 8.3, 95%CI: 8.0-8.6; men: SMR 5.6, 95%CI: 5.5-5.8). The burden of excess mortality was greatest for younger women with ESKD (aged 30-49 years: women SMR 59.7, 95%CI: 51.8-69.0; men SMR 17.7, 95%CI: 15.9-19.7) Subgroup analysis showed this was largely driven by ischaemic heart disease deaths (Figure 3).Table 1ICD 10 CodesICD 10 CodeGrouped outcomesI20-I25Ischaemic heart diseasesI34-I37Valvular diseasesI42-I43CardiomyopathyI44-I49ArrhythmiasI50Heart failure Open table in a new tab View Large Image Figure ViewerDownload Hi-res image Download (PPT)View Large Image Figure ViewerDownload Hi-res image Download (PPT) The cardiac mortality rates in the Australian and New Zealand ESKD population are substantially higher than the general population. Young women with ESKD have an excessive relative risk of dying from cardiac disease, in particular IHD, compared to young females in the general population.

Burden of excess mortality after implementation of the new kidney allocation system may be borne disproportionately by middle-aged recipients.

Under the new kidney allocation system (KAS), implemented in 2014, the distribution of the best quality donor kidney grafts shifted between age groups, but it is unclear whether this change translates to meaningful differences in post-transplant outcomes. We conducted a retrospective cohort study of 20,345 deceased donor kidney transplant recipients before and 4,605 recipients after implementation of the KAS using data from the United Network of Organ Sharing. Overall, two-year mortality was greater among recipients in the post-KAS era compared with the pre-KAS era (6.31% vs 5.91% respectively, [p = 0.01]), and two-year graft loss was not significantly different between eras (9.95% and 9.65%, respectively [p = 0.13]). In analysis stratified by age group (18–45, 46–55, 56–65, and ≥66 years), relative risk of mortality was 1.48 (95% confidence interval [CI] 1.09–1.98) among recipients 46–55 years old and 1.47 (95% CI 1.18–1.81) among recipients 56–65 years old. Relative risk of all-cause graft loss was 1.43 (95% CI 1.20–1.70) among recipients 56–65 years old. There were no significant differences in relative risk of mortality or graft loss associated with the KAS era among other age groups. After adjustment for recipient characteristics and characteristics of the changing donor pool, relative risk of two-year mortality and graft loss associated with the post-KAS era was attenuated for recipients aged 46–55 and 56–65 years, but remained statistically significant. In this early analysis after implementation of the KAS, there is suggestion that increased risk of mortality and graft loss may be disproportionately borne by middle-aged recipients, which is only partially accounted for by changes in recipient and donor characteristics. These findings signal a need to continue to monitor the effects of the KAS to ensure that allocation practices both maximize utility of the kidney graft pool and respect fairness between age groups.

Sex-Based Differences in Rates, Causes, and Predictors of Death Among Injection Drug Users in Vancouver, Canada

In the present study, we sought to identify rates, causes, and predictors of death among male and female injection drug users (IDUs) in Vancouver, British Columbia, Canada, during a period of expanded public health interventions. Data from prospective cohorts of IDUs in Vancouver were linked to the provincial database of vital statistics to ascertain rates and causes of death between 1996 and 2011. Mortality rates were analyzed using Poisson regression and indirect standardization. Predictors of mortality were identified using multivariable Cox regression models stratified by sex. Among the 2,317 participants, 794 (34.3%) of whom were women, there were 483 deaths during follow-up, with a rate of 32.1 (95% confidence interval (CI): 29.3, 35.0) deaths per 1,000 person-years. Standardized mortality ratios were 7.28 (95% CI: 6.50, 8.14) for men and 15.56 (95% CI: 13.31, 18.07) for women. During the study period, mortality rates related to infection with human immunodeficiency virus (HIV) declined among men but remained stable among women. In multivariable analyses, HIV seropositivity was independently associated with mortality in both sexes (all P < 0.05). The excess mortality burden among IDUs in our cohorts was primarily attributable to HIV infection; compared with men, women remained at higher risk of HIV-related mortality, indicating a need for sex-specific interventions to reduce mortality among female IDUs in this setting.

The development of a localised HIV epidemic and the associated excess mortality burden in a rural area of South Africa.

The human immunodeficiency virus (HIV) epidemic in South Africa rapidly developed into a major pandemic. Here we analyse the development of the epidemic in a rural area of the country. The data used were collected between 1992 and 2013 in a longitudinal population survey, the Agincourt Health and Demographic Surveillance Study, in the northeast of the country. Throughout the period of study mortality rates were similar in all villages, suggesting that there were multiple index cases evenly spread geographically. These were likely to have been returning migrant workers. For those aged below 39 years the HIV mortality rate was higher for women, above this age it was higher for men. This indicates the protective effect of greater access to HIV testing and treatment among older women. The recent convergence of mortality rates for Mozambicans and South Africans indicates that the former refugee population are being assimilated into the host community. More than 60% of the deaths occurring in this community between 1992 and 2013 could be attributed directly or indirectly to HIV. Recently there has been an increasing level of non-HIV mortality which has important implications for local healthcare provision. This study demonstrates how evidence from longitudinal analyses can support healthcare planning.

Dermatology

Melanoma survival literature predominantly represents patients >65 years of age. Study of younger patients may reveal potential age-group-specific differences in survival outcome.Identify factors associated with differences in melanoma survival in two age groups, adolescents and young adults (AYAs; ages 15-39) and older adults (ages 40-64).This population-based registry study included all cases (n=81,597) of cutaneous melanoma diagnosed at ages 15-64 from 2004-2015 in California. Age-group-specific multivariable Cox hazard regressions were used.In the adjusted, age-group-specific models, AYA patients with Stage IV melanoma had worse survival (HR: 20.39, 95%CI: 13.30-31.20) than was observed among older adults (HR: 10.79, 95%CI: 9.33-12.48). Thicker tumors and public insurance were also associated with worse survival for AYAs than observed in models for older adults. AYAs experienced better survival when detected at earlier stages.Registry data does not routinely collect behavioral information or family history of melanoma.Survival was much worse for AYAs with stage IV melanoma than observed among older adults. To improve AYA survival, early melanoma detection is critical. Greater awareness, suspicion, and screening for AYA melanoma may disrupt delays in diagnosis and reduce the excess burden of mortality from Stage IV melanoma in young patients.