Mortality and displaced mortality during heat waves in the Czech Republic

The aims of this study were to assess impacts of hot summer periods on mortality in the Czech Republic and to quantify the size of the short-term displacement effect which resulted in lower than expected mortality after heat waves. The analysis covered the period 1982–2000 when several extraordinarily hot summers occurred in central Europe. Daily total all-cause mortality and mortality due to cardiovascular diseases (CVD) in the entire population of the Czech Republic (approximately 10 million inhabitants) were examined. The daily death counts were standardized to account for the long-term decline in mortality and the seasonal and weekly cycles. Heat-related mortality is better expressed if 1-day lag after temperature is considered compared to the unlagged relationship. With the 1-day lag, both excess total mortality and excess CVD mortality were positive during all 17 heat waves, and in 14 (12) heat waves the increase in total (CVD) mortality was statistically significant (P=0.05). The mean relative rise in total mortality during heat waves was 13%. The response was greater in females than males and similar regardless of whether total or CVD mortality was used. The largest relative increases, exceeding 20% in both total and CVD mortality, were associated with heat waves which occurred in early summer (the first half of July 1984 and June 1994). The mortality displacement effect played an important role since mortality tended to be lower than expected after hot periods. The mean net mortality change due to heat waves was estimated to be about a 1% increase in the number of deaths. The large relative increases during some heat waves were particularly noteworthy since the study (in contrast to most analyses of the heat stress/mortality relationship) was not restricted to an urban area and/or an elderly population.     

The impact of the 2008 cold spell on mortality in Shanghai, China

No prior studies in China have investigated the health impact of cold spell. In Shanghai, we defined the cold spell as a period of at least seven consecutive days with daily temperature below the third percentile during the study period (2001–2009). Between January 2001 and December 2009, we identified a cold spell between January 27 and February 3, 2008 in Shanghai. We investigated the impact of cold spell on mortality of the residents living in the nine urban districts of Shanghai. We calculated the excess deaths and rate ratios (RRs) during the cold spell and compared these data with a winter reference period (January 6–9, and February 28 to March 2). The number of excess deaths during the cold spell period was 153 in our study population. The cold spell caused a short-term increase in total mortality of 13 % (95 % CI: 7–19 %). The impact was statistically significant for cardiovascular mortality (RR?=?1.21, 95 % CI: 1.12–1.31), but not for respiratory mortality (RR?=?1.14, 95 % CI: 0.98–1.32). For total mortality, gender did not make a statistically significant difference for the cold spell impact. Cold spell had a significant impact on mortality in elderly people (over 65 years), but not in other age groups. Conclusively, our analysis showed that the 2008 cold spell had a substantial effect on mortality in Shanghai. Public health programs should be tailored to prevent cold-spell-related health problems in the city.     

The main trends in the palaeodemography of the 7th-18th century population of Latvia

The study represents palaeodemographic research of osteological material of 3304 individuals from the funds of the Anthropological Laboratory of the Institute of History of the University of Latvia in Riga, dating from the 7th to the 18th century AD. Compensated life expectancy at birth is varying between 20.3 and 22.2 years during the research period. Crude mortality has changed between 49.3 and 45% per hundred. In the early period (7th-13th century) there is a significant male prevalence (2.2-1.4); female life expectancy at the age of 20 is on average 6.6 years less than for males. This difference decreases to 5.4 years in the 13th-18th century. According to historical demography, female life span exceeded male only in the 2nd half of 19th century. The palaeodemographic data indicate that in the 7th-18th century, women in Latvia gave birth to a mean of 4-5 children (the figure includes childless women), of whom half, at most 2-2.5, reached reproductive age, on account of high child mortality. The net reproductive rate R0 (the number of descendants per individual of the parents' generation) varies between 1 and 1.25 in the study period. Concerning the completely excavated cemeteries of Lejasbiteni (7th-10h century) and Daudziesi (16th-17th century), it was possible to calculate the size and structure of the populations that had used these cemeteries. They were similar, having 45.3-49.9% of children up to an age of 14 and 24-28% individuals over the age of 30. According to historical demography, radical improvement of the demographic situation in Latvia began in the second half of the 19th century, when the process of demographic transition in Latvia started.     

Study on the Trend and Disease Burden of Injury Deaths in Chinese Population, 2004–2010

Injuries are a growing public health concern in China, accounting for more than 30% of all Person Years of Life Lost (PYLL) due to premature mortality. This study analyzes the trend and disease burden of injury deaths in Chinese population from 2004 to 2010, using data from the National Disease Surveillance Points (DSPs) system, as injury deaths are classified based on the International Classification of Disease-10^th Revision (ICD-10). We observed that injury death accounted for nearly 10% of all deaths in China throughout the period 2004–2010, and the injury mortality rates were higher in males than those in females, and higher in rural areas than in urban areas. Traffic crashes (33.79–38.47% of all injury deaths) and suicides (16.20–22.01%) were the two leading causes of injury deaths. Alarmingly, suicide surpassed traffic crashes as the leading cause of injury mortality in rural females, yet adults aged 65 and older suffered the greatest number of fatal falls (20,701 deaths, 2004–2010). The burden of injury among men (72.11%) was about three times more than that of women''s (28.89%). This study provides indispensible evidence that China Authority needs to improve the surveillance and deterrence of three major types of injuries: Traffic-related injury deaths should be targeted for injury prevention activities in all population, people aged 65+ should be encouraged to take individual fall precautions, and prevention of suicidal behavior in rural females should be another key priority for the government of China.     

Effectiveness of the 10-Valent Pneumococcal Conjugate Vaccine (PCV-10) in Children in Chile: A Nested Case-Control Study Using Nationwide Pneumonia Morbidity and Mortality Surveillance Data

BackgroundThe ten-valent pneumococcal conjugate vaccine (PCV10) was introduced into the Chilean National Immunization Program (NIP) in January 2011 with a 3+1 schedule (2, 4, 6 and 12 months) without catch-up vaccination. We evaluated the effectiveness of PCV10 on pneumonia morbidity and mortality among infants during the first two years after vaccine introduction.MethodsThis is a population-based nested case-control study using four merged nationwide case-based electronic health data registries: live birth, vaccination, hospitalization and mortality. Children born in 2010 and 2011 were followed from two moths of age for a period of two years. Using four different case definitions of pneumonia hospitalization and/or mortality (all-cause and pneumonia related deaths), all cases and four randomly selected matched controls per case were selected. Controls were matched to cases on analysis time. Vaccination status was then assessed. Vaccine effectiveness (VE) was estimated using conditional logistic regression.ResultsThere were a total of 497,996 children in the 2010 and 2011 Chilean live-birth cohorts. PCV10 VE was 11.2% (95%CI 8.5–13.6) when all pneumonia hospitalizations and deaths were used to define cases. VE increased to 20.7 (95%CI 17.3–23.8) when ICD10 codes used to denote viral pneumonia were excluded from the case definition. VE estimates on pneumonia deaths and all-cause deaths were 71.5 (95%CI 9.0–91.8) and 34.8 (95% CI 23.7–44.4), respectively.ConclusionPCV10 vaccination substantially reduced the number of hospitalizations due to pneumonia and deaths due to pneumonia and to all-causes over this study period. Our findings also reinforce the importance of having quality health information systems for measuring VE.     

Deaths from heat-stroke in Japan: 1968–1994

Global warming is increasingly recognized as a threat to the survival of human beings, because it could cause a serious increase in the occurrence of diseases due to environmental heat during intermittent hot weather. To assess the direct impact of extremely hot weather on human health, we investigated heat-related deaths in Japan from 1968 through 1994, analyzing the data to determine the distribution of the deaths by age and their correlation to the incidence of hot days in summer. Vital Statistics of Japan, published by the Ministry of Health and Welfare of Japan, was the source of the heat-related mortality data employed in this study. Meteorological data were obtained from the District Meteorological Observatories in Tokyo and Osaka, the two largest cities in Japan. Heat-related deaths were most prone to occur on days with a peak daily temperature above 38°C, and the incidence of these deaths showed an exponential dependence on the number of hot days. Thus, even a small rise in atmospheric temperature may lead to a considerable increase in heat-related mortality, indicating the importance of combating global warming. Furthermore, half (50.1%) of the above-noted deaths occurred in children (4 years and under) and the elderly (70 years and over) irrespective of gender, indicating the vulnerability of these specific age groups to heat. Since a warmer climate is predicted in the future, the incidence of heat waves will increase, and more comprehensive measures, both medical and social, should be adopted for children of 4 years and younger the elderly to prevent heat-related deaths in these age groups. Received: 20 January 1999 / Accepted: 15 June 1999     

A general and flexible methodology to define thresholds for heat health watch and warning systems, applied to the province of Québec (Canada)

Several watch and warning systems have been established in the world in recent years to prevent the effects of heat waves. However, many of these approaches can be applied only in regions with perfect conditions (e.g., enough data, stationary series or homogeneous regions). Furthermore, a number of these approaches do not account for possible trend in mortality and/or temperature series, whereas others are generally not adapted to regions with low population densities or low daily mortality levels. In addition, prediction based on multiple days preceding the event can be less accurate if it attributes the same importance to each of these days, since the forecasting accuracy actually decreases with the period. The aim of the present study was to identify appropriate indicators as well as flexible and general thresholds that can be applied to a variety of regions and conditions. From a practical point of view, the province of Québec constitutes a typical case where a number of the above-mentioned constraints are present. On the other hand, until recently, the province’s watch and warning system was based on a study conducted in 2005, covering only the city of Montreal and applied to the whole province. The proposed approach is applied to each one of the other health regions of the province often experiencing low daily counts of mortality and presenting trends. The first constraint led to grouping meteorologically homogeneous regions across the province in which the number of deaths is sufficient to carry out the appropriate data analyses. In each region, mortality trends are taken into account. In addition, the proposed indicators are defined by a 3-day weighted mean of maximal and minimal temperatures. The sensitivity of the results to the inclusion of traumatic deaths is also checked. The application shows that the proposed method improved the results in terms of sensitivity, specificity and number of yearly false alarms, compared to those of the existing and other classical approaches. An additional criterion based on the Humidex is applied in a second step and a local validation is applied to historical observations at reference forecasting stations. An integrated heat health watch and warning system with thresholds that are adapted to the regional climate has thus been established for each sub-region of the province of Quebec and became operational in June 2010.     

Trends in malaria cases, hospital admissions and deaths following scale-up of anti-malarial interventions, 2000-2010, Rwanda

ABSTRACT: BACKGROUND: To control malaria, the Rwandan government and its partners distributed insecticide-treated nets (ITN) and made artemisinin-based combination therapy (ACT) widely available from 2005 onwards. The impact of these interventions on malaria cases, admissions and deaths was assessed using data from district hospitals and household surveys. METHODS: District records of ITN and ACT distribution were reviewed. Malaria and non-malaria indictors in 30 district hospitals were ascertained from surveillance records. Trends in cases, admissions and deaths for 2000 to 2010 were assessed by segmented log-linear regression, adjusting the effect size for time trends during the pre-intervention period, 2000-2005. Changes were estimated by comparing trends in post-intervention (2006-2010) with that of pre-intervention (2000-2005) period. All-cause deaths in children under-five in household surveys of 2005 and 2010 were also reviewed to corroborate with the trends of deaths observed in hospitals. RESULTS: The proportion of the population potentially protected by ITN increased from nearly zero in 2005 to 38% in 2006, and 76% in 2010; no major health facility stock-outs of ACT were recorded following their introduction in 2006. In district hospitals, after falling during 2006- 2008, confirmed malaria cases increased in 2009 coinciding with decreased potential ITN coverage and declined again in 2010 following an ITN distribution campaign. For all age groups, from the pre-intervention period, microscopically confirmed cases declined by 72%, (95% Confidence Interval [CI], 12-91%) in 2010, slide positivity rate declined 58%, (CI, 47%-68%), malaria inpatient cases declined 76% (CI, 49%-88%); and malaria deaths declined 47% (CI, 47%-81%). In children below five years of age, malaria inpatients decreased 82% (CI, 61%-92%) and malaria hospital deaths decreased 77% (CI, 40%-91%). Concurrently, outpatient cases, admissions and deaths due to non-malaria diseases in all age groups either increased or remained unchanged. Rainfall and temperature remained favourable for malaria transmission. The annual all-cause mortality in children under-five in household surveys declined from 152 per 1,000 live births during 2001-2005, to 76 per 1,000 live births in 2006-2010 (55% decline). The five-year cumulative number of all-cause deaths in hospital declined 28% (8,051 to 5,801) during the same period. CONCLUSIONS: A greater than 50% decline in confirmed malaria cases, admissions and deaths at district hospitals in Rwanda since 2005 followed a marked increase in ITN coverage and use of ACT. The decline occurred among both children under-five and in children five years and above, while hospital utilization increased and suitable conditions for malaria transmission persisted. Declines in malaria indicators were more striking than in the older age groups. The resurgence in cases associated with decreased ITN coverage in 2009 highlights the need for sustained high levels of anti-malarial interventions in Rwanda and other malaria endemic countries.     

Heat-Attributable Deaths between 1992 and 2009 in Seoul,South Korea

BackgroundClimate change may significantly affect human health. The possible effects of high ambient temperature must be better understood, particularly in terms of certain diseases’ sensitivity to heat (as reflected in relative risks [RR]) and the consequent disease burden (number or fraction of cases attributable to high temperatures), in order to manage the threat.PurposeThis study investigated the number of deaths attributable to abnormally high ambient temperatures in Seoul, South Korea, for a wide range of diseases.MethodThe relationship between mortality and daily maximum temperature using a generalized linear model was analyzed. The threshold temperature was defined as the 90^th percentile of maximum daily temperatures. Deaths were classified according to ICD-10 codes, and for each disease, the RR and attributable fractions were determined. Using these fractions, the total number of deaths attributable to daily maximum temperatures above the threshold value, from 1992 to 2009, was calculated. Data analyses were conducted in 2012–2013.ResultsHeat-attributable deaths accounted for 3,177 of the 271,633 deaths from all causes. Neurological (RR 1.07; 95% CI, 1.04–1.11) and mental and behavioral disorders (RR 1.04; 95% CI, 1.01–1.07) had relatively high increases in the RR of mortality. The most heat-sensitive diseases (those with the highest RRs) were not the diseases that caused the largest number of deaths attributable to high temperatures.ConclusionThis study estimated RRs and deaths attributable to high ambient temperature for a wide variety of diseases. Prevention-related policies must account for both particular vulnerabilities (heat-sensitive diseases with high RRs) and the major causes of the heat mortality burden (common conditions less sensitive to high temperatures).     

Causes of Mortality for Indonesian Hajj Pilgrims: Comparison between Routine Death Certificate and Verbal Autopsy Findings

Background

Indonesia provides the largest single source of pilgrims for the Hajj (10%). In the last two decades, mortality rates for Indonesian pilgrims ranged between 200–380 deaths per 100,000 pilgrims over the 10-week Hajj period. Reasons for high mortality are not well understood. In 2008, verbal autopsy was introduced to complement routine death certificates to explore cause of death diagnoses. This study presents the patterns and causes of death for Indonesian pilgrims, and compares routine death certificates to verbal autopsy findings.

Methods

Public health surveillance was conducted by Indonesian public health authorities accompanying pilgrims to Saudi Arabia, with daily reporting of hospitalizations and deaths. Surveillance data from 2008 were analyzed for timing, geographic location and site of death. Percentages for each cause of death category from death certificates were compared to that from verbal autopsy.

Results

In 2008, 206,831 Indonesian undertook the Hajj. There were 446 deaths, equivalent to 1,968 deaths per 100,000 pilgrim years. Most pilgrims died in Mecca (68%) and Medinah (24%). There was no statistically discernible difference in the total mortality risk for the two pilgrimage routes (Mecca or Medinah first), but the number of deaths peaked earlier for those traveling to Mecca first (p=0.002). Most deaths were due to cardiovascular (66%) and respiratory (28%) diseases. A greater proportion of deaths were attributed to cardiovascular disease by death certificate compared to the verbal autopsy method (p<0.001). Significantly more deaths had ill-defined cause based on verbal autopsy method (p<0.001).

Conclusions

Despite pre-departure health screening and other medical services, Indonesian pilgrim mortality rates were very high. Correct classification of cause of death is critical for the development of risk mitigation strategies. Since verbal autopsy classified causes of death differently to death certificates, further studies are needed to assess the method’s utility in this setting.     

The impact of heat waves on children’s health: a systematic review

Young children are thought to be particularly sensitive to heat waves, but relatively less research attention has been paid to this field to date. A systematic review was conducted to elucidate the relationship between heat waves and children’s health. Literature published up to August 2012 were identified using the following MeSH terms and keywords: “heatwave”, “heat wave”, “child health”, “morbidity”, “hospital admission”, “emergency department visit”, “family practice”, “primary health care”, “death” and “mortality”. Of the 628 publications identified, 12 met the selection criteria. The existing literature does not consistently suggest that mortality among children increases significantly during heat waves, even though infants were associated with more heat-related deaths. Exposure to heat waves in the perinatal period may pose a threat to children’s health. Pediatric diseases or conditions associated with heat waves include renal disease, respiratory disease, electrolyte imbalance and fever. Future research should focus on how to develop a consistent definition of a heat wave from a children’s health perspective, identifying the best measure of children’s exposure to heat waves, exploring sensitive outcome measures to quantify the impact of heat waves on children, evaluating the possible impacts of heat waves on children’s birth outcomes, and understanding the differences in vulnerability to heat waves among children of different ages and from different income countries. Projection of the children’s disease burden caused by heat waves under climate change scenarios, and development of effective heat wave mitigation and adaptation strategies that incorporate other child protective health measures, are also strongly recommended.     

Simulation-Based Evaluation of the Performances of an Algorithm for Detecting Abnormal Disease-Related Features in Cattle Mortality Records

We performed a simulation study to evaluate the performances of an anomaly detection algorithm considered in the frame of an automated surveillance system of cattle mortality. The method consisted in a combination of temporal regression and spatial cluster detection which allows identifying, for a given week, clusters of spatial units showing an excess of deaths in comparison with their own historical fluctuations. First, we simulated 1,000 outbreaks of a disease causing extra deaths in the French cattle population (about 200,000 herds and 20 million cattle) according to a model mimicking the spreading patterns of an infectious disease and injected these disease-related extra deaths in an authentic mortality dataset, spanning from January 2005 to January 2010. Second, we applied our algorithm on each of the 1,000 semi-synthetic datasets to identify clusters of spatial units showing an excess of deaths considering their own historical fluctuations. Third, we verified if the clusters identified by the algorithm did contain simulated extra deaths in order to evaluate the ability of the algorithm to identify unusual mortality clusters caused by an outbreak. Among the 1,000 simulations, the median duration of simulated outbreaks was 8 weeks, with a median number of 5,627 simulated deaths and 441 infected herds. Within the 12-week trial period, 73% of the simulated outbreaks were detected, with a median timeliness of 1 week, and a mean of 1.4 weeks. The proportion of outbreak weeks flagged by an alarm was 61% (i.e. sensitivity) whereas one in three alarms was a true alarm (i.e. positive predictive value). The performances of the detection algorithm were evaluated for alternative combination of epidemiologic parameters. The results of our study confirmed that in certain conditions automated algorithms could help identifying abnormal cattle mortality increases possibly related to unidentified health events.     

Heat stress and mortality in Lisbon part I. model construction and validation

Global climate change will have direct impacts on human health, including increased mortality due to heat stress and heat waves. An empirical-statistical model for heat stress is constructed for the city of Lisbon using the June-August months of the observational period 1980-1998. The model uses the regression of an aggregate dose-response relationship between maximum temperature and excess heat-related deaths, based on the difference between observed and expected deaths. The model is validated by correlation and residual analysis. The mean annual heat-related mortality for the period 1980-1998 was between 5.4 and 6 deaths per 100,000 depending on the method used to calculate expected deaths. Both validation methods show that the model has a moderate to high accuracy in modelling heat-related deaths compared to the observed record.     

Years of Life Lost (YLL) in Colombia 1998-2011: Overall and Avoidable Causes of Death Analysis

ObjectiveEstimate the Years of Life Lost (YLL) for overall and avoidable causes of death (CoD) in Colombia for the period 1998-2011.MethodsFrom the reported deaths to the Colombian mortality database during 1998-2011, we classified deaths from avoidable causes. With the reference life table of the Global Burden of Disease (GBD) 2010 study, we estimated the overall YLL and YLL due to avoidable causes. Calculations were performed with the difference between life expectancy and the age of death. Results are reported by group of cause of death, events, sex, year and department. Comparative analysis between number of deaths and YLL was carried out.ResultsA total of 83,856,080 YLL were calculated in Colombia during period 1998-2011, 75.9% of them due to avoidable CoD. The year 2000 reported the highest number of missed YLL by both overall and avoidable CoD. The departments with the highest YLL rates were Caquetá, Guaviare, Arauca, Meta, and Risaralda. In men, intentional injuries and cardiovascular and circulatory diseases had the higher losses, while in women YLL were mainly due to cardiovascular and circulatory diseases.ConclusionsThe public health priorities should focus on preventing the loss of YLL due to premature death and differentiated interventions by sex.     

The impact of the summer 2003 heat wave in Iberia: how should we measure it?

We present a new approach to improve the reliability of quantifying the impact of a heat wave on mortality rates. We show, for the recent European summer 2003 heat wave, that the use of absolute maximum temperature values, or number of days above a given threshold, can be misleading. Here, we have assessed the impact of the heat wave on Iberian mortality by applying a four step procedure: (1) calculating, for each observatory, the local maximum temperature (T _max) distributions, (2) calculating the corresponding 95th percentile values (T _threshold), (3) locally defining extremely hot days (EHD) as those days on which the local threshold of the 95th percentile of the series is exceeded, and (4) calculating the total degrees-days (DD) of exceedance, by calculating the difference T _max−T _threshold and summing these values for all days above T _threshold. We show that the relationship between summer mortality rates and the DD index is non-linear and can be described by a logarithmic function, with a correlation coefficient of 0.78, which explains 60.6% of the mortality variance (F value of 24.64, significant at P<0.0001). Using maximum temperatures, no significant relationship is found with mortality, whereas the EHD frequency shows a significant association with mortality, albeit weaker than that obtained with DD.     

Comparing pandemic to seasonal influenza mortality: moderate impact overall but high mortality in young children

Background

We assessed the severity of the 2009 influenza pandemic by comparing pandemic mortality to seasonal influenza mortality. However, reported pandemic deaths were laboratory-confirmed – and thus an underestimation – whereas seasonal influenza mortality is often more inclusively estimated. For a valid comparison, our study used the same statistical methodology and data types to estimate pandemic and seasonal influenza mortality.

Methods and Findings

We used data on all-cause mortality (1999–2010, 100% coverage, 16.5 million Dutch population) and influenza-like-illness (ILI) incidence (0.8% coverage). Data was aggregated by week and age category. Using generalized estimating equation regression models, we attributed mortality to influenza by associating mortality with ILI-incidence, while adjusting for annual shifts in association. We also adjusted for respiratory syncytial virus, hot/cold weather, other seasonal factors and autocorrelation. For the 2009 pandemic season, we estimated 612 (range 266–958) influenza-attributed deaths; for seasonal influenza 1,956 (range 0–3,990). 15,845 years-of-life-lost were estimated for the pandemic; for an average seasonal epidemic 17,908. For 0–4 yrs of age the number of influenza-attributed deaths during the pandemic were higher than in any seasonal epidemic; 77 deaths (range 61–93) compared to 16 deaths (range 0–45). The ≥75 yrs of age showed a far below average number of deaths. Using pneumonia/influenza and respiratory/cardiovascular instead of all-cause deaths consistently resulted in relatively low total pandemic mortality, combined with high impact in the youngest age category.

Conclusion

The pandemic had an overall moderate impact on mortality compared to 10 preceding seasonal epidemics, with higher mortality in young children and low mortality in the elderly. This resulted in a total number of pandemic deaths far below the average for seasonal influenza, and a total number of years-of-life-lost somewhat below average. Comparing pandemic and seasonal influenza mortality as in our study will help assessing the worldwide impact of the 2009 pandemic.     

Direct and indirect mortality in Florida during the 2004 hurricane season

Previous studies have shown that natural disasters, and hurricanes in particular, have led to more deaths than those usually documented in short post-storm surveys. Such indirect deaths, thought to be related to dietary, stress or pre-existing medical conditions, can exceed the number of direct deaths and may persist for weeks or even months beyond the event itself. In the present study, cumulative sum of deviations plots are used to quantify the number of direct and indirect deaths resulting from Hurricanes Charley, Frances, Ivan and Jeanne that made landfall in Florida in 2004. Results suggest that there was an elevated mortality for up to 2 months following each storm, resulting in a total of 624 direct and indirect deaths attributable to the storm. Trauma-related deaths that can be associated directly with the storm account for only ∼4% of the total storm-related mortality, while indirect mortality accounts for most storm-related deaths. Specifically, a large percentage of the elevated mortality was associated with heart (34%) and cancer-related deaths (19%), while diabetes (5%) and accident-related deaths (9%) account for a smaller but still significant percentage of the elevated mortality. The results further suggest that the elevated mortality was the result of additional deaths that would not have otherwise occurred within that 5 month period, and not simply a clustering of deaths that were inevitable between 1 August and 31 December 2004. The elevated mortality identified in this study is significantly greater than the official count of 31 direct and 113 indirect deaths resulting from the four hurricanes combined. This suggests a need for improved mortality counts and surveillance in order to better evaluate and identify effective prevention policies, and to identify preventable deaths.     

Mortality risk in a historical cohort of nuclear power plant workers in Germany: results from a second follow-up

Possible health effects of low and protracted doses of ionizing radiation are relevant for persons who are exposed to an occupational context like nuclear industry workers. A historical cohort study was therefore conducted to examine mortality risks following occupational radiation exposure among 4,844 German nuclear power plant workers. This cohort included workers from ten nuclear power plants with an observational period from 1991 until 1997. The results of an enlarged cohort with 8,972 workers from all 17 nuclear power plants in West Germany are now available. During the extended follow-up period from 1991 to 2008, a total of 310 deaths among men were observed. The standardized mortality ratio (SMR) from all causes of deaths was estimated at 0.50 [95 % confidence interval (CI) 0.45–0.56]. A total of 126 deaths due to cancer occurred (SMR = 0.65; 95 % CI 0.51–0.82) and seven deaths due to leukemia (SMR = 1.23; 95 % CI 0.42–2.84). Overall, a reduced mortality compared to the general population of West Germany was observed indicating a healthy worker effect. In the dose–response analysis, no statistically significant risk due to ionizing radiation was seen. The hazard ratio (HR/mSv) for leukemia excluding chronic lymphocytic leukemia was estimated at 1.004 (95 % CI 0.997–1.011). In conclusion, the cohort is small and made up of young workers, most of whom were still employed at the end of the observational period in 2008. Results of the external analysis are difficult to interpret as influenced by a healthy worker effect. In the internal analysis, no excess of risk due to radiation was detected.     

Age-specific breast,uterine and ovarian cancer mortality trends in Spain: Changes from 1980 to 2006

Introduction: Cancers of the breast, uterus and ovary are responsible for 30% of the cancer deaths in Spanish women. In recent decades, Spain has experienced important socioeconomic transformations, which may have affected mortality trends. We present the current situation of mortality in Spain due to cancers of the breast, uterus and ovary, as well as trends over 1980–2006. Methods: Data on population and deaths due to cancers of the breast, uterus and ovary were obtained from records of the National Statistics Institute. Overall and age-specific changes in mortality of these tumors were studied using change-point Poisson regression models. Results: Breast cancer was responsible for more than 140,000 deaths of females in 1980–2006. Trend analysis of breast cancer mortality of women of all ages showed that rates increased 2.9% annually until 1992 (95% confidence interval (CI) = 2.5, 3.3). After 1992, mortality declined steadily at a rate of ?2.1% per year (95% CI = ?2.4, ?1.8). The number of deaths due to cancers of the uterus was 49,287 between the years 1980 and 2006. Uterine cancer mortality registered a steady decrease of ?1.9% every year since 1980 (95% CI = ?2.1, ?1.8). Ovarian cancer caused 36,157 deaths during the same period, with rates in women older than 50 years more than ten-fold those of younger women. Trend analysis showed a sharp increase of mortality up to 1998 (4.4% annually; 95% CI = 3.9, 4.8) followed by a stabilization. Conclusion: The downturn observed in mortality for these tumors mainly reflects improved survival as a result of earlier diagnosis and better cancer treatments. Cancer management is moving in the right direction in Spain.