Examining sex differences in the completeness of Peruvian CRVS data and adult mortality estimates

The production, compilation, and publication of death registration records is complex and usually involves many institutions. Assessing available data and the evolution of the completeness of the data compiled based on demographic techniques and other available data sources is of great importance for countries and for having timely and disaggregated mortality estimates. In this paper, we assess whether it is reasonable, based on the available data, to assume that there is a sex difference in the completeness of male and female death records in Peru in the last 30 years. In addition, we assess how the gap may have evolved with time by applying two-census death distribution methods on health-related registries and analyzing the information from the Demographic and Health Surveys and civil registries. Our findings suggest that there is no significant sex difference in the completeness of male and female health-related registries and, consequently, the sex gap currently observed in adult mortality estimates might be overestimated.

The Impact of COVID-19 on Mortality in Spain: Monitoring Excess Mortality (MoMo) and the Surveillance of Confirmed COVID-19 Deaths

Measuring mortality has been a challenge during the COVID-19 pandemic. Here, we compared the results from the Spanish daily mortality surveillance system (MoMo) of excess mortality estimates, using a time series analysis, with those obtained for the confirmed COVID-19 deaths reported to the National Epidemiological Surveillance Network (RENAVE). The excess mortality estimated at the beginning of March 2020 was much greater than what has been observed in previous years, and clustered in a very short time. The cumulated excess mortality increased with age. In the first epidemic wave, the excess mortality estimated by MoMo was 1.5 times higher than the confirmed COVID-19 deaths reported to RENAVE, but both estimates were similar in the following pandemic waves. Estimated excess mortality and confirmed COVID-19 mortality rates were geographically distributed in a very heterogeneous way. The greatest increase in mortality that has taken place in Spain in recent years was detected early by MoMo, coinciding with the spread of the COVID-19 pandemic. MoMo is able to identify risk situations for public health in a timely manner, relying on mortality in general as an indirect indicator of various important public health problems.

Global, regional and national burden of bladder cancer and its attributable risk factors in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease study 2019

IntroductionThe current study determined the level and trends associated with the incidence, death and disability rates for bladder cancer and its attributable risk factors in 204 countries and territories, from 1990 to 2019, by age, sex and sociodemographic index (SDI; a composite measure of sociodemographic factors).MethodsVarious data sources from different countries, including vital registration and cancer registries were used to generate estimates. Mortality data and incidence data transformed to mortality estimates using the mortality to incidence ratio (MIR) were used in a cause of death ensemble model to estimate mortality. Mortality estimates were divided by the MIR to produce incidence estimates. Prevalence was calculated using incidence and MIR-based survival estimates. Age-specific mortality and standardised life expectancy were used to estimate years of life lost (YLLs). Prevalence was multiplied by disability weights to estimate years lived with disability (YLDs), while disability-adjusted life years (DALYs) are the sum of the YLLs and YLDs. All estimates were presented as counts and age-standardised rates per 100 000 population.ResultsGlobally, there were 524 000 bladder cancer incident cases (95% uncertainty interval 476 000 to 569 000) and 229 000 bladder cancer deaths (211 000 to 243 000) in 2019. Age-standardised death rate decreased by 15.7% (8.6 to 21.0), during the period 1990–2019. Bladder cancer accounted for 4.39 million (4.09 to 4.70) DALYs in 2019, and the age-standardised DALY rate decreased significantly by 18.6% (11.2 to 24.3) during the period 1990–2019. In 2019, Monaco had the highest age-standardised incidence rate (31.9 cases (23.3 to 56.9) per 100 000), while Lebanon had the highest age-standardised death rate (10.4 (8.1 to 13.7)). Cabo Verde had the highest increase in age-standardised incidence (284.2% (214.1 to 362.8)) and death rates (190.3% (139.3 to 251.1)) between 1990 and 2019. In 2019, the global age-standardised incidence and death rates were higher among males than females, across all age groups and peaked in the 95+ age group. Globally, 36.8% (28.5 to 44.0) of bladder cancer DALYs were attributable to smoking, more so in males than females (43.7% (34.0 to 51.8) vs 15.2% (10.9 to 19.4)). In addition, 9.1% (1.9 to 19.6) of the DALYs were attributable to elevated fasting plasma glucose (FPG) (males 9.3% (1.6 to 20.9); females 8.4% (1.6 to 19.1)).ConclusionsThere was considerable variation in the burden of bladder cancer between countries during the period 1990–2019. Although there was a clear global decrease in the age-standardised death, and DALY rates, some countries experienced an increase in these rates. National policy makers should learn from these differences, and allocate resources for preventative measures, based on their country-specific estimates. In addition, smoking and elevated FPG play an important role in the burden of bladder cancer and need to be addressed with prevention programmes.

Subnational mortality estimates for India in 2019: a baseline for evaluating excess deaths due to the COVID-19 pandemic

BackgroundEstimates of excess mortality are required to assess and compare the impact of the COVID-19 pandemic across populations. For India, reliable baseline prepandemic mortality patterns at national and subnational level are necessary for such assessments. However, available data from the Civil Registration System (CRS) is affected by incompleteness of death recording that varies by sex, age and location.MethodsUnder-reporting of CRS 2019 deaths was assessed for three age groups (< 5 years, 15–59 years and ≥60 years) at subnational level, through comparison with age-specific death rates from alternate sources. Age-specific corrections for under-reporting were applied to derive adjusted death counts by sex for each location. These were used to compute life expectancy (LE) at birth by sex in 2019, which were compared with subnational LEs from the Global Burden of Disease (GBD) 2019 Study.ResultsA total of 9.92 million deaths (95% UI 9.70 to 10.02) were estimated across India in 2019, about 2.28 million more than CRS reports. Adjustments to under-five and elderly mortality accounted for 30% and 56% of additional deaths, respectively. Adjustments in Bihar, Jharkhand, Madhya Pradesh, Maharashtra, Rajasthan and Uttar Pradesh accounted for 75% of all additional deaths. Adjusted LEs were below corresponding GBD estimates by ≥2 years for males at national level and in 20 states, and by ≥1 year for females in 12 states.ConclusionsThese results represent the first-ever subnational mortality estimates for India derived from CRS reported deaths, and serve as a baseline for assessing excess mortality from the COVID-19 pandemic. Adjusted life expectancies indicate higher mortality patterns in India than previously perceived. Under-reporting of infant deaths and those among women and the elderly is evident in many locations. Further CRS strengthening is required to improve the empirical basis for local mortality measurement across the country.

Mortality estimates for WHO SEAR countries: problems and prospects

Cause-specific mortality estimates for 11 countries located in the WHO’s South East Asia Region (WHO SEAR) are generated periodically by the Global Burden of Disease (GBD) and the WHO Global Health Estimates (GHE) analyses. A comparison of GBD and GHE estimates for 2019 for 11 specific causes of epidemiological importance to South East Asia was undertaken. An index of relative difference (RD) between the estimated numbers of deaths by sex for each cause from the two sources for each country was calculated, and categorised as marginal (RD=±0%–9%), moderate (RD=±10%–19%), high (RD=±20%–39%) and extreme (RD>±40%). The comparison identified that the RD was >10% in two-thirds of all instances. The RD was ‘high’ or ‘extreme’ for deaths from tuberculosis, diarrhoea, road injuries and suicide for most SEAR countries, and for deaths from most of the 11 causes in Bangladesh, DPR Korea, Myanmar, Nepal and Sri Lanka. For all WHO SEAR countries, mortality estimates from both sources are based on statistical models developed from an international historical cause-specific mortality data series that included very limited empirical data from the region. Also, there is no scientific rationale available to justify the reliability of one set of estimates over the other. The characteristics of national mortality statistics systems for each WHO SEAR country were analysed, to understand the reasons for weaknesses in empirical data. The systems analysis identified specific limitations in structure, organisation and implementation that affect data completeness, validity of causes of death and vital statistics production, which vary across countries. Therefore, customised national strategies are required to strengthen mortality statistics systems to meet immediate and long-term data needs for health policy and research, and reduce dependence on current unreliable modelled estimates.

How to measure premature mortality? A proposal combining “relative” and “absolute” approaches

Background The concept of “premature mortality” is at the heart of many national and global health measurement and benchmarking efforts. However, despite the intuitive appeal of its underlying concept, it is far from obvious how to best operationalise it. The previous work offers at least two basic approaches: an absolute and a relative one. The former—and far more widely used— approach sets a unique age threshold (e.g. 65 years), below which deaths are defined as premature. The relative approach derives the share of premature deaths from the country-specific age distribution of deaths in the country of interest. The biggest disadvantage of the absolute approach is that of using a unique, arbitrary threshold for different mortality patterns, while the main disadvantage of the relative approach is that its estimate of premature mortality strongly depends on how the senescent deaths distribution is defined in each country. Method We propose to overcome some of the downsides of the existing approaches, by combining features of both, using a hierarchical model, in which senescent deaths distribution is held constant for each country as a pivotal quantity and the premature mortality distribution is allowed to vary across countries. In this way, premature mortality estimates become more comparable across countries with similar characteristics. Results The proposed hierarchical models provide results, which appear to align with related evidence from specific countries. In particular, we find a relatively high premature mortality for the United States and Denmark. Conclusions While our hybrid approach overcomes some of the problems of previous measures, some issues require further research, in particular the choice of the group of countries that a given country is assigned to and the choice of the benchmarks within the groups. Hence, our proposed method, combined with further study addressing these issues, could provide a valid alternative way to measure and compare premature mortality across countries.

Mortality, Length of Stay, and Healthcare Costs Associated With Multidrug-Resistant Bacterial Infections Among Elderly Hospitalized Patients in the United States

Background This study reports estimates of the healthcare costs, length of stay, and mortality associated with infections due to multidrug-resistant bacteria among elderly individuals in the United States. Methods We conducted a retrospective cohort analysis of patients aged ≥65 admitted for inpatient stays in the Department of Veterans Affairs healthcare system between 1/2007–12/2018. We identified those with positive cultures for multidrug-resistant bacteria and matched each infected patient to ≤10 control patients. We then performed multivariable regression models to estimate the attributable cost and mortality due to the infection. We also constructed multistate models to estimate the attributable length of stay due to the infection. Finally, we multiplied these pathogen-specific attributable cost, length of stay, and mortality estimates by national case counts from hospitalized patients in 2017. Results Our cohort consisted of 87 509 patients with infections and 835 048 matched controls. Costs were higher for hospital-onset invasive infections, with attributable costs ranging from $22 293 (95% confidence interval: $19 101–$24 485) for methicillin-resistant Staphylococcus aureus (MRSA) to $57 390 ($34 070–$80 710) for carbapenem-resistant (CR) Acinetobacter. Similarly, for hospital-onset invasive infections, attributable mortality estimates ranged from 14.2% (12.2–16.2%) for MRSA to 24.1% (12.1–36.0%) for CR Acinetobacter. The aggregate cost of these infections was an estimated $1.9 billion ($1.3 billion–$2.5 billion) with 11 852 (8719–14 985) deaths and 448 224 (354 513–541 934) inpatient days in 2017. Conclusions Efforts to prevent these infections due to multidrug-resistant bacteria could save a significant number of lives and healthcare resources.