Quarterly Digest
Volume 8 - Number 3 March 1999

• From 1990 to 1992, the Age Standardized Mortality Rates (ASMRs) decreased continuously for males which can be attributed directly to a decline in AIDS/HIV mortality in recent years. 1993 presented the highest rates of ASMRs for males and females at 10.14 and 7.39 respectively. From 1994 until 1997, the rates continuously declined for males and were at their lowest in 1997 at 8.37. For females, the rates declined from 1993 and was only up slightly in 1996. The lowest ASMR rates for females were in 1991 at 6.63.

Note: SMR - Standardized Mortalilty Ratio

Based on Standard Mortality Ratios (SMRs), twelve Local Health Areas (LHAs) showed statistically significantly more infectious disease deaths (direct and indirect) than were expected. These were: Central Coast (2.15), Grand Forks (1.43), Princeton (1.43), Terrace (1.42), Merritt (1.37), Prince Rupert (1.31), Vancouver (1.26), Cowichan (1.26), Mission (1.22), Prince George (1.20), New Westminster (1.08) and North Vancouver (1.08).

The areas that showed statistically significantly fewer deaths than were expected were: Windermere (0.53), Creston (0.58), Smithers (0.66), Lake Cowichan (0.67), Salmon Arm (0.69), Howe Sound (0.71), Revelstoke (0.72), Gulf Islands (0.74), Keremeos (0.74), Castlegar (0.75), Sechelt (0.76), Kimberley (0.77), Delta (0.79), Peace River South (0.81), Qualicum (0.83), Central Okanagan (0.83), Campbell River (0.83), Surrey (0.84), Langley (0.86), Penticton (0.86), Saanich (0.87), Courtenay (0.90) and Abbotsford (0.92).

The shaded area represents all those who died directly of an infectious disease but also had at least one other infectious disease at the time of their death.

⁺The proportion of deaths from AIDS/HIV infections that involved other infectious diseases may appear lower than expected (65.6%). This is due to underreporting of the additional infectious conditions on the Medical Certifications of death.

In addition to being significant as a direct cause of death, infectious diseases also had a considerable impact on mortality as secondary or opportunistic factors. Table 10 illustrates the total number of deaths with the underlying cause of death as well as the number and the proportion of those deaths that involved at least one infectious disease. For example, between 1990 and 1997, 1,734 individuals died of Leukemias. Over all, 506 of these deaths involved at least one infectious disease meaning that 29.2 percent of all those that died of leukemias had at least one infectious disease at the time of their death.

The highest proportion of deaths with infectious disease as a contributing factor was skin/connective tissue diseases with 65.7 percent. This is partially due to the fact that skin and subcutaneous abscesses (included in this category) are frequently accompanied by infectious disease codes (eg. Septicemia). AIDS/HIV infections were closely behind at 65.6 percent. (This proportion may be lower than expected and is mostly due to underreporting of some of the infectious diseases on the AIDS/HIV death records). Other relatively high proportions included cystitis /UTI at 61 percent, autoimmune disorders at 57.1 percent, tuberculosis at 45.5 percent and alcohol related at 44 percent. Aside from deaths caused by AIDS, cystitis and skin disease (where one would expect to find related infectious diseases as complicating factor), there were relatively higher proportions of infectious diseases associated with chronic debilitating conditions such as Alzheimer’s disease, MS and dementias.

Conclusion

Notwithstanding the concentration of AIDS deaths in Vancouver, infectious disease related mortality is a significant concern in many areas scattered throughout the province.

From 1990 to 1997, the mortality patterns of infectious diseases have shown a significant change in British Columbia. There has been a decline in the mortality of major infectious conditions such as AIDS/HIV. On the other hand, new conditions such as clostridium difficile, Creutzfeldt-Jacob disease, necrotizing fasciitis (flesh eating disease) and hepatitis C have become a major concern for medical researchers. The emergence of new conditions can be attributed to an increase in the portion of population with compromised immune systems and chronic disabilities.

Glossary

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Age Standardized Mortality Rate (ASMR):
A summary of age adjusted death rates by gender which have been standardized to a specific population for the purpose of rate comparisons of different time periods or different geographical locations. In this report, ASMRs for females were standardized using Canada Census female population. Rates prepared by the British Columbia Vital Statistics Agency and those obtained from BC Cancer Agency reports were derived using 1971 Canada Census as a standard. Provincial/national ASMR comparisons from Statistics Canada publications utilized 1991 Canada Census population.

Alcohol-Related:
This category includes all deaths stated as being directly or indirectly related to alcohol. It should be noted that where alcohol is an indirect cause of death (i.e. not primary) and the direct underlying cause of death falls within one of our selected causes (e.g. motor vehicle accidents), then this death may be counted in both columns. That is, not all of "alcohol related" are exclusive. This category includes ICD-9 codes - 291, 303, 305.0, 357.5, 425.5, 535.3, 571.0-571.3, 571.5, 577.1, 648.4, 760.7, E860, 790.3.

Assignment of Health Region:
Cases are assigned to Health Regions by the aggregation of appropriate LHAs.

Assignment of Local Health Area (LHA):
Allocation of LHA, in the case of births and deaths is based upon the usual residence (by postal code) of the mother and deceased respectively. Marriages are assigned to LHAs according to the place of event. Standard Geographical Code (SGC), derived from community name, is used in the absence of postal code.

Elderly Gravida:
Any mother who was 35 years of age or older at the time of delivery of a live born infant.

External Causes of Death:
Deaths due to environmental events, circumstances and conditions as the cause of injury, poisoning, and other adverse effects. Broad categories include accidents, suicide, medical or abnormal reactions, homicide, legal intervention, misadventures and injury from war operations. Standard tables under this heading include deaths due to accidents, suicide, homicide and other. Accidents are subdivided by the following categories; motor vehicle accidents (MVA) (ICD-9 E810-E825, E929.0), poisoning (E850-E869, E929.2), falls (E880-E888, E929.3), burns/fire (E890-E899, E924, E929.4), drowning (E830, E832, E910), other accidents - all codes from E800-E949 not already noted. Suicide ICD-9 codes are E950-E959; homicide (E960-E969); "other" consists of legal intervention (E970-E978), undetermined if accidental or purposely inflicted (E980-E989) and war operations (E990-E999).

Heart Disease:
Tables under this heading include deaths due to:

• rheumatic/valvular: 391-398, 424
  
• hypertension: 401-405
  
• ischemic: 410-414, 429.2
  
• conductive & dysrythmic: 426-427
  
• heart failure: 428
  
• congenital: 745-746
  
• other: pulmonary - 415-417, inflammatory - 420-423, 429.0, cardiomyopathy - 425, 429.3,
  degenerative - 429.1, other, ill-defined or unspecified - 429.4-429.9

ICD-9:
The ninth revision of International Classification of Diseases, World Health Organization, Geneva, 1977. An internationally used system of approximately 12,000 four digit numbers representing a system of categories to which morbid entities are assigned according to an established criteria. ICD provides a common basis of disease and injury classification that facilitates storage, retrieval, and tabulation of statistical data.

Infant Deaths:
Deaths of children under one year of age.

Low Birth Weight:
Any liveborn infant weighing less than 2500 grams.

Neoplasms (ICD-9 140-239):
Although the vast majority of deaths in this category are due to malignant cancer, also included are benign, in-situ, and unspecified "tumours". Detailed ICD-9 breakdown used in "Neoplasm Deaths" tables are;

• lung: includes trachea, bronchus, lung (162) and pleura (163).
  
• female breast: (174).
  
• colorectal: includes colon (153) and rectum, rectosigmoid junction and anus (154).
  
• other G.I. (Gastrointestinal): includes esophagus (150), stomach (151), small intestine and duodenum (152), liver & intrahepatic bile ducts (155), gallbladder and extra-hepatic ducts (156), pancreas (157), peritoneum (158), other and ill-defined within digestive organs (159).
  
• female reproductive: includes uterus (179), cervix (180, 182), placenta (181), ovary and adnexa (183), vagina & external genitalia (184).
• prostate (185).
  
• blood lymph: includes lymphatic and haematopoietic tissue (200-208).
  
• other malignancy: includes malignant neoplasms of other (e.g. lip, oral cavity, pharynx, nose, ear, larynx, heart, bone and connective tissue, urinary tract, eye, brain, endocrine glands), ill-defined or unspecified sites (140-149, 160, 161, 164, 165, 170-173, 175, 186-199).
  
• non-malignant & unspecified: includes benign (210-229), in-situ (230-234), and neoplasms of unspecified nature (e.g. "tumor" - 239).

Other Selected Death Statistics:
Tables under this heading include deaths due to:

• diabetes (250).
  
• alcohol related - see above.
  
• AIDS: includes AIDS and HIV infections (042-044).
  
• other infectious diseases (0010 to 0419, 0450-1398).
  
• cerebro and other vascular: includes cerebrovascular disease (430-438), disease of arteries and veins (440-456),
  hypotension (458), and other circulatory system disease (459).
  
• liver disease: (570-573).
  
• ALS/MS: amyotrophic lateral sclerosis and multiple sclerosis (3352 & 340).
  
• Alzheimer's disease (3310).
  
• Parkinson's disease (3320).
  

Premature / Pre-term:
Any live born infant less than 37 weeks gestation at delivery.

Respiratory Disease Death Statistics:
Tables under this heading include deaths due to the following:

• emphysema (492).
  
• COPD - chronic obstructive pulmonary disease (496).
  
• pneumonia (480-486).
  
• influenza (4870-4879).
  
• asthma (4930-4939).
  
• lung disease due to external agents, e.g. aspiration pneumonia, asbestosis, silicosis (500-5089).
  
• pulmonary fibrosis (515).
  
• other respiratory diseases (460-4789, 490-4919, 494-4959, 5100-514, 5160-5199).
  

Standardized Mortality Ratio (SMR):
The ratio of the number of deaths occurring to residents of a geographic area (e.g. LHA) to the expected number of deaths in that area based on provincial age specific mortality rates.

Stillbirth:
The complete expulsion or extraction from its mother after at least 20 weeks of pregnancy or after attaining a weight of at least 500 grams, of a product of conception in which, after expulsion or extraction, there is no breathing, beating of the heart, pulsation of the umbilical cord or unmistakable movement of voluntary muscle.

Teenage Mother:
Any mother who was age 19 or less at the time of delivery.

UCOD:
Underlying cause of death - based upon application of standard international coding rules for determining consequential relationships of conditions and diseases from immediate cause backwards to underlying cause.

Contributors' Note:

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