Annual Mortality Report

Transcription

1 Department of Health Information and Research Annual Mortality Report National Mortality Registry 2013

2 Document Information Document reference Current version Release date Document owner Document type Personal data Website Telephone number Compilation DHIR/MNMR/ January 2015 Directorate of Health Information and Research National mortality statistics No personal data Dr. Kathleen England Comments The accuracy of this document may be limited by factors beyond the author s control. Some data in this document may be subject to interpretation. Data in this document is based on information obtained from the death certificate, in some cases additional information has been sought. Users should always acknowledge the source in all works based on information supplied in this document. Acknowledgements The compiler of this document would like to acknowledge the support of colleagues and the Director, Dr. Neville Calleja at the Directorate of Health Information and Research. Close collaboration with certifying doctors, pathologists, public health specialists, the Police Statistics Office, the Medical Records Department at Mater Dei Hospital, the Mortuary Department and the National Statistics Office were vital to the maintenance of an updated mortality register whose aim is to always improve accuracy and timeliness. Special thanks go to Ms Connie Scicluna and Ms Desire D Amato who work unremittingly on the National Mortality Registry. II

3 Table of Contents Comments... II Acknowledgements... II Table of Contents... III List of Tables... V List of Figures... VI Summary Statistics for Mortality during the year VIII Introduction... IX Glossary... XI Definitions... XII Section 1: Overview... 1 Distribution by gender and age group... 3 Distribution by type of place of death... 5 Distribution by month of death... 6 Causes of death.. 8 Leading causes of death: number, rate and percent... 9 Leading causes of death in males Leading causes of death in females Commonest causes of death by age group Potential years of life lost (PYLL) Section 2: Individual diseases Diseases of the circulatory system (ICD 10 codes I00-I99) Neoplasms (ICD-10 codes C00-D48) Diseases of the respiratory system (ICD 10 code J00-J98) Smoking attributable mortality Diseases of the digestive system (ICD 10 codes K00-K93) Some infectious and parasitic diseases (ICD 10 codes A00-B99 (excluding A41.9), G00, G03-G04, N70-N73) III

4 External causes of morbidity and mortality (ICD 10 codes V01-Y98) Section 3: Perinatal and infant mortality Section 4: Deaths in non-residents who died in Malta during Number of deaths in non residents by country of residence Section 5: Statistical tables IV

5 List of Tables Table 1: Mid-year resident population XII Table 2: European Standard Populations... XIII Table 3: Leading causes of death by number, rate and percent.9 Table 4: Commonest causes of death in the age group Table 5: Commonest causes of death in the age group Table 6: Commonest causes of death in the age group Table 7: Commonest causes of death in the 85+ age group Table 8: Potential years of life lost under 65 years of age during the year 2013 (PYLL-65) by major category Table 9: Potential years of life lost under 65 years during the year 2013 (PYLL-65) by MTL1 subgrouping Table 10: Average age at death from diseases of the circulatory system & diabetes mellitus in Table 11: Average age at death from the commonest neoplasms Table 12: Deaths from infectious diseases..30 Table 13: Average age at death from some external causes Table 14: EMCDDA definition of codes used in illicit drug overdose Table 15: Foetal, neonatal & infant deaths by birth weight, age group & presence or absence of malformation as UCD Table 16: Foetal, neonatal & infant deaths by weeks of gestation & presence or absence of malformation as UCD Table 17: Deaths in non-residents by country of residence Table 18: Standardised mortality rate (ESP) per 100,000 population by gender & cause Table 19: Deaths by specific cause, age group and gender V

6 List of Figures Figure 1: Temporal trends in the life expectancy and crude mortality rate per 100,000 population in males and females in Malta from 1980 to Figure 2: Temporal trends in standardised mortality rates (ESP) in Malta in males and females from 1980 to Figure 3: Age-specific mortality rates in males and females... 3 Figure 4: Percentages of deaths in each gender by age group... 4 Figure 5: Distribution of deaths by type of place of death... 5 Figure 6: Distribution of deaths by month of death and age group... 6 Figure 7: Distribution of deaths by main cause of death and season in persons 65 years and over.7 Figure 8: Percentage of main causes of death by season in persons aged 65 years and over 8 Figure 9: Commonest causes of death using broad categories... 8 Figure 10: Percentages of leading causes of death in males Figure 11: Percentages of leading causes of death in females Figure 12: Trends in SDR (ESP), diseases of the circulatory system per 100,000 in Malta and the EU over the past 20 years in males and females Figure 13: Trends in SDR, Ischaemic heart disease in Malta compared to the EU in males and females Figure 14: Trends in SDR, Diabetes in Malta compared to the EU in males and females Figure 15: Trends SDR, Cerebrovascular disease in Malta compared to the EU in males and females.20 Figure 16: Trends SDR, malignant neoplasms per 100,000 in Malta compared to EU by gender Figure 17: Most common cancer deaths in both sexes Figure 18: Most common cancer deaths in males Figure 19: Most common cancer deaths in females Figure 20: Trends in SDR, malignant neoplasm of trachea, bronchus & lung per 100,000 in Malta compared to EU in males and females Figure 21: Trends in SDR, malignant neoplasm of female breast per 100,000 in Malta compared to the EU in females Figure 22: Trends in SDR, all respiratory conditions per 100,000 in Malta compared to the EU in males and females VI

7 Figure 23: Trends in SDR, chronic bronchitis/emphysema/asthma, in males per 100,000, in Malta compared to the EU in males and females Figure 24: Trends in SDR, chronic liver disease & cirrhosis per 100,000 in Malta compared to the EU in males and females Figure 25: Number of deaths due to external causes, in males and females Figure 26: Trends in SDR, motor vehicle accidents, all ages, in Malta compared to the EU by gender Figure 27: Deaths due to falls by gender and age group Figure 28: Trends in SDR, Intentional self harm, all ages, per , in Malta compared to the EU by gender Figure 29: Trends in perinatal mortality weight specific (1000g and over) and infant mortality in Malta compared to the EU Figure 30: Causes of death in non-residents Figure 31: Deaths in non-residents by gender and age group VII

8 Summary Statistics for Mortality during the year 2013 There were 3236 deaths in residents of the Maltese Islands during the year Of these, 1636 were male and 1600 were female deaths. The age-standardised death rate has been showing a decreasing trend over the whole period from , despite the relative stable crude mortality rates from the early 1990s, indicating that people are dying at older age groups. In 2013, the life expectancy at birth for Maltese males was 78.9 years and for females was 83.2 years. 1 The vast majority of deaths (85.0%) occurred in hospitals or in residential homes. Over half of all deaths (52.0%) occurred at Mater Dei Hospital. Diseases of the circulatory system and neoplasms accounted for the vast majority of deaths, accounting for 40.1% and 26.9% respectively. Ischaemic heart disease, other heart diseases (including heart failure) and cerebrovascular diseases were the leading causes of death. An overall decreasing trend in mortality due to ischaemic heart disease is seen in both males and females in both Malta and the EU. However EU rates for both males and females are consistently lower than those for Malta. Diabetes as underlying cause of death accounted for 3.2% of all deaths or 105 deaths. It is also an important risk factor for circulatory diseases. The overall trend shows that mortality from diabetes in both males and females in Malta is consistently higher than that of the EU average. Lung cancer is the leading cause of death due to malignancy accounting for 17.7% of all cancer deaths and 4.8% of all deaths. While lung, colorectal, pancreas and prostate were the leading causes of death in males; breast, colorectal and pancreas were the leading causes of death in females. A downward trend in standardised mortality rates from malignant neoplasms can be observed for Malta as well as the EU. In males rates for Malta compare favourably with the EU, and are similar in females in both Malta and the EU. The average age at death from neoplasms was 7.7 years less than that from circulatory diseases. External causes of death (mainly transport accidents and suicides) accounted for the largest number of deaths in year age group, followed by neoplasms. Neoplasms followed by diseases of the circulatory system were the commonest causes of death in the year age group. In the older age groups diseases of the circulatory system were the commonest causes of death. 1 Source: National Statistics Office, Malta VIII

9 Introduction The Annual Mortality Report 2013 presents mortality statistics for the year 2013 by cause of death in residents of the Maltese Islands, and includes residents dying abroad for which we have information. Data Analysis The information used is based on details obtained from death certificates. This is supplemented by reviewing of deceased patients records, newspaper cuttings as well as collaboration with pathologists, public health doctors, police and certifying doctors. Data is also cross-checked with other registries at the Department of Health Information & Research and databases held by other entities. These additional sources of information are needed for verification. They add detail and ensure that mortality data is as reliable and as accurate as possible. The International Statistical Classification of Diseases and Related Health Problems- ICD 10 is used to translate diagnoses of diseases from words into alphanumeric codes in order to permit easier storage, retrieval and analysis of the data. This also allows comparison between different countries and over different periods of time. Additional Sources of Data The National Statistics Office of Malta was the source from which information about mid-year population 2013 by age group and gender was obtained. Number of births and live births were obtained from the National Obstetrics Information system (NOIS). The European Health for All database - HFA-DB, (WHO Regional Office for Europe, Copenhagen, Denmark) was used as a source of data for some of the figures in this report. Quality of Mortality Data The quality of mortality data depends on a number of entities/persons and processes. The Certificate of Death and Cause thereof is filled in by the certifying doctor or, in the case of autopsies, by the pathologist. An underlying cause of death is chosen from the causes of death in the certificate by the registry manager and the registry leader at the Directorate of Health Information & Research (DHIR). This is done in collaboration with certifying doctors where the underlying cause of death is unclear. Deceased patient medical records and information obtained from ISOFT database are also examined in a number of cases to ascertain the underlying cause of death. Data in the death certificate is then coded and inputted in a database. The quality of the information on death certificates varies according to the certifying habits and knowledge of the certifying doctors. Moreover, data coding depends to a certain degree on the coding practices of the registry manager and the registry leader. This inevitably affects quality of data, especially when analysing trends over time. Finally, a degree of human error as regards data inputting always persists albeit small. Data is double-checked and cross-checked both internally and with other databases. A number of validation processes and quality checks are done by the National Mortality Registry in order to produce data that is as accurate as possible. Validation of data coding is also undertaken to ensure that coding is done as accurately as possible and the choice of the underlying cause of death IX

10 is correct. The database is also cross-checked against the Patient Administration System (CPAS) at Mater Dei Hospital (MDH), NOIS at DHIR and data received from the Midwifery Services at MDH. X

11 Glossary DHIR ECHI ESP EU EU-13 EU-15 HFA-DB ICD-10 MDH NOIS NSO CPAS SDR/SMR WHO Directorate Health Information and Research European Community Health Indicators European Standard Population 28 European Union Member States 13 EU Member States after May 2004: Poland (PL), Czech Republic (CZ), Cyprus (CY), Latvia (LV), Lithuania (LT), Slovenia (SI), Estonia (EE), Slovakia (SK), Hungary (HU), Malta (MT), Bulgaria (BG), Romania (RO), Croatia (HR) 15 EU Member States before May 2004: Austria (AT), Belgium (BE), Finland (FI), Greece (EL), Luxembourg (LU), Denmark (DK), Spain (ES), Netherlands (NL), Germany (DE), France (FR), Portugal (PT), Ireland (IE), Italy (IT), United Kingdom (UK), Sweden (SE) European Health For All Database International Statistical Classification of Diseases and Related Health Problems: Tenth Revision Mater Dei Hospital National Obstetrics Information System National Statistics Office Patient Administration System Age-standardised death/mortality rate on the European Standard Population (see more in Chapter: Definitions) World Health Organisation XI

12 Definitions Crude Death Rate This is equal to the total number of registered deaths divided by the estimated resident mid-yearly population of that year multiplied by 1000 (or 100,000). The following mid-year population of 2013, provided by the National Statistics Office has been used for this annual report. Table 1: Mid-year resident population 2013 Age group Males Females Total Total Births Total number of births weighing 500g or over at birth during 2013 = 4141 Total number of live births weighing 500g or over at birth during 2013 = 4125 Total number of births weighing 1000g or over at birth = 4124 Total number of live births weighing 1000g or over at birth = 4112 XII

13 Total number of births of 22 weeks gestation or more during 2013 = 4146 Total number of live births of 22 weeks gestation or more during 2013 = 4127 Total number of births of 28 weeks gestation or over at birth = 4118 Total number of live births of 28 weeks gestation or over at birth = 4106 Source: National Obstetric Information System Age-Standardised Death/Mortality Rate The age-standardised death/mortality rate for a particular condition is that which would have occurred if the observed age-specific death rates for the condition were applied in a given standard population. The European Standard Population as reported by WHO has been used in this report. A new European Standard Population has been developed by Eurostat. In the section on statistical tables, rates have been reported using both the WHO ESP and the Eurostat ESP. Table 2: European Standard Populations Age groups (yrs) European standard population (ESP developed by WHO) New European standard population (ESP developed by Eurostat) XIII

14 / Total 100, ,000 European Health for All Database The European Health for All Database provides easy and rapid access to a wide range of basic health statistics for the 52 Member States of the WHO European Region. It was developed by the WHO Regional Office for Europe in the mid-1980s to support the monitoring of health trends in the region. This database has been used to produce a number of charts for the report comparing Malta with other European regions. XIV

15 The definitions described below are those presented in the International Statistical Classification of Diseases and Related Health Problems ICD-10 volume 2. Birth Weight The first weight of the foetus or newborn obtained after birth. Low birth weight is less than 2500g (up to and including 2499g). Very low birth weight is less than 1500g (up to and including 1499g). Extremely low birth weight is less than 1000g (up to and including 999g) Gestational Age The duration of gestation is measured from the first day of the last menstrual period. Gestational age is expressed in complete days or completed weeks. For the purposes of calculation of gestational age from the date of the first day of the last normal menstrual period to the date of delivery, it should be borne in mind that the first day is day zero and not day one; days 0-6 therefore correspond to completed week zero; Foetal Death Foetal death is the death prior to the complete expulsion or extraction from its mother of a product of conception, irrespective of the duration of the pregnancy; the death is indicated by the fact that after such separation, the foetus does not breathe or show any other evidence of life, such as beating of the heart, pulsation of the umbilical cord, or definite movement of voluntary muscles. Foetal Death Rate The number of foetal deaths in a year expressed as a proportion of the total number of births (live births plus foetal deaths) in the same year. All foetuses with a gestational age of 22 weeks and over or a birth weight of 500g and over, are considered. Rates are usually expressed per 1000 total births. Foetal death rate = no. of foetal deaths in a year weighing 500g or more *1000 Number of live births plus foetal deaths in that year weighing 500g or more Foetal death rate = no. of foetal deaths in a year weighing 1000g or more *1000 (weight specific) Number of live births plus foetal deaths in that year weighing 1000g or more Live Birth Live birth is the complete expulsion or extraction from its mother of a product of conception, irrespective of the duration of pregnancy, which, after separation, breathes or shows any evidence of life, such as beating of the heart, pulsation of the umbilical cord, or definite movement of the voluntary muscles, whether or not the umbilical cord has been cut or the placenta is attached; each product of such a birth is considered live born. XV

16 Neonatal Period The neonatal period commences at birth and ends 28 completed days after birth. Neonatal deaths (deaths among live births during the first 28 completed days of life) may be subdivided into early neonatal deaths, occurring during the first seven days of life, and late neonatal deaths, occurring after the seventh day but before 28 completed days of life. Age at death during the first day of life (day 0) should be recorded in units of completed minutes or hours of life. For the second (day 1), third (day 2) and through 27 completed days of life, age at death should be recorded in days. Neonatal Mortality Rate The number of deaths during the neonatal period in that year expressed as a proportion of the total number of live births in the same year. Rates are expressed per 1000 live births. Neonatal mortality rate = no. of neonatal deaths in a year * 1000 no. of live births in that year Neonatal mortality rate = no. of neonatal deaths in a year (1000g or over) * 1000 (weight specific) no. of live births in that year (1000g or over) Perinatal Period The perinatal period commences at 22 completed weeks (154 days) of gestation and ends at seven completed days after birth. Perinatal Mortality Rate The number of deaths during the perinatal period in a year expressed as a proportion of the total number of births (live births plus foetal deaths) in the same year. Perinatal mortality rate = no. of perinatal deaths in a year *1000 no. of live births plus foetal deaths in that year Perinatal mortality rate = no. of perinatal deaths in a year (weight 1000g or over) *1000 (weight specific) no. of live births plus foetal deaths in that year (weight 1000g or over) Infant Mortality Rate The number of deaths in children less than 1 year of age in a year expressed as a proportion of the total live births in the same year. Rates are usually expressed per 1000 live births. XVI

17 Infant mortality rate = no. of infant deaths (under 1 year of age) in a year * 1000 No. of live births in that year Infant mortality rate = no. of infant deaths (under 1 year of age) in a year (weight 1000g or over) * 1000 (weight specific) No. of live births in that year (weight over 1000g) Potential Years of Life Lost (PYLL) A measure of the relative impact of various diseases on society, PYLL highlights the loss to society as a result of youthful or early deaths. The figure for potential years of life lost due to a particular cause is the sum of the years of life lost due to that cause for all individuals dying before a particular age (65 years in the case of PYLL-65). Smoking Attributable Mortality Mortality caused by tobacco smoking. Death rates from combined, selected causes of death which are related to smoking, as per 100,000 of the population. This indicator was obtained from the European Community Health Indicators Monitoring). The smoking-attributable mortality (SAM) is to be calculated via the formula given below (Shultz et al., ) by using available mortality data and disease-specific relative mortality risks of current and former smokers, each compared to never-smokers (reference group). Relative mortality risks (RRs) are obtained from the Cancer Prevention Study II, which have been published and utilized in Schultz et. al. 2. Finally, the rates of current, former and never-smokers are required. The formula provides the tobacco-attributable fraction (TAF) per cause of death, which is multiplied by the number of total deaths (per cause) to yield the tobacco-attributable mortality (TAM) per cause of death. The summed TAMs of all considered causes equal the smoking-attributable mortality (SAM) and shall be expressed as per 100,000 of the population under investigation. TAF = (P 0 +(P 1 *RR 1 )+(P 2 *RR 2 )-1) / (P 0 +(P 1 *RR 1 +(P 2 *RR 2 )) TAM = TAF * number of death cases per cause; SAM = sum TAMs (all causes) P 0 = prevalence of never-smokers; P 1 = prevalence of current smokers; P 2 = prevalence of former smokers; RR 1 = relative risk of death for current smokers; RR 2 = relative risk of death for former smokers. Prevalence data need decimal expressions to be used for TAF calculation (e.g. P 0 = 25% = 0.25; P 0 +P 1 +P 2 = 1). Disease categories according to ICD-10 definition to be included are: Neoplasms (C00-14, C15-16, C25, C32-34, C53, C64-68), Cardiovascular diseases (I00-09, I10-15 I20-51, I60-78) and Respiratory diseases (J10-18, J40-43, J44-46). Smoking prevalence data need to be obtained e.g. from EHIS; percentage of current smokers (SK.1[1-2]), percentage of former smokers (SK.1[3]+4[1]), percentage of never-smokers (SK.1[3]+4[2]). 2 Schultz et. al. (1991); Quantifying the disease impact of cigarette smoking with SAMMEC II software. Public Health Reports 106; XVII

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19 Life expectancy Crude mortality rate/100,000 Annual Mortality Report 2013 Section 1: Overview During the year 2013, there were 3236 deaths among residents dying in Malta or abroad. There were 1636 male deaths and 1600 female deaths in residents, a decrease of 110 males and 73 females over the previous year. Deaths in residents included twelve residents who died abroad. In addition, 77 non-residents died in Malta. The remainder of this report concentrates on deaths in residents unless otherwise specified. There were also 19 foetal deaths (stillbirths 22+ weeks gestation). The crude death rate for males was 775 deaths per 100,000 and for females it was 754 deaths per 100,000. The overall crude death rate was 764 per 100,000 population. The period between 1980 and early 1990s has shown a steady decrease in the crude mortality rate which has reached a steady level after that (figure 1). Life expectancy shows a steady gradual increase over the whole period from 1980 to The age-standardised death rate (SDR) has been showing a decreasing trend over the whole period from (figure 2), despite the relative stable crude mortality rates from the early 1990s, indicating that people are dying at older age groups year 0 Life expectancy in males CMR/100,000 males Life expectancy in females CMR/100,000 females Figure 1: Temporal trends in the life expectancy and crude mortality rate per 100,000 population in males and females in Malta from 1980 to

20 Standardised mortality rate/ Annual Mortality Report year SMR/ 100,000 males SMR/ 100,000 females Figure 2: Temporal trends in standardised mortality rates (ESP) in Malta in males and females from 1980 to 2013 In 2013, the life expectancy at birth for Maltese males was 78.9 years and for females was 83.2 years 3. The oldest male death was 101 years and the oldest female death was 104 years. The average age at death was 73.5 years in males (median 76 years) and 79.3 years (median 82 years) in females. 3 Source: National Statistics Office, Malta 2

21 age specific rate/1000 Annual Mortality Report 2013 Distribution by gender and age group age group males females Figure 3: Age-specific mortality rates in males and females Age-specific mortality rates shows a small rise in the zero age group (infants), followed by very low rates up to middle age. It starts to rise again in the 70+ age group with age specific mortality rates consistently higher for males when compared to females. 3

22 % in each gender Annual Mortality Report age group males females Figure 4: Percentages of deaths in each gender by age group The and year age groups accounted for the largest number of deaths in both sexes (35.5% of all deaths). Whereas the year age group accounted for the largest number of deaths in males (17.1% of all male deaths), the year age group accounted for the largest number of deaths in females (21.4% of female deaths). 41.0% of female deaths (in comparison with 23.0% of male deaths) occurred in the 85+ year age group. In contrast, 21.7% of male deaths (in comparison to 11.6% of female deaths) occurred in the 0-64 year age group. 4

23 Annual Mortality Report 2013 Distribution by type of place of death Other residential homes 5% Usual residence 12% Other 3% SVPR 11% Other hospitals 12% GGH 6% MDH 51% Figure 5: Distribution of deaths by type of place of death There was a slight increase in the percentage of people dying at Mater Dei Hospital and St Vincent de Paule Residence. Conversely, there was a slight decrease in the percentage of people dying at their usual residence, other hospitals and other residential homes between 2012 and

24 Number of deaths Annual Mortality Report 2013 Distribution by month of death Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec Month of death Grand Total Figure 6: Distribution of deaths by month of death and age group Figure 6 shows the seasonal variation in the number of deaths. There were more deaths in the cold winter months. This variation is more pronounced in deaths of those aged 65 years and over. Low ambient temperatures, while often not the underlying cause of death, contribute to death in older people. As seen in figure 7 below, there is an increase in deaths in the major causes of deaths in the winter months. The percentage increase is similar in all major groupings as seen in figure 8 below with 30-35% of all deaths in each major grouping occurring between January and March, while between 20-25% of all deaths in each major grouping occurring similarly in the remaining seasons. 6

25 % of deaths in each major group Number of deaths Annual Mortality Report Circulatory Respiratory Neoplasms All other Main groups of death Jan-Mar Apr-Jun Jul-Sep Oct-Dec Figure 7: Distribution of deaths by main cause of death and season in persons 65 years and over Jan-Mar Apr-Jun Jul-Sep Oct-Dec Season Circulatory Respiratory Neoplasms All other Figure 8: Percentage of main causes of death by season in persons aged 65 years and over 7

26 Annual Mortality Report 2013 Causes of death The main source of information as to the causes of death is obtained from the death certificate. Accuracy is increased by collaboration with certifying doctors, pathologists and police as well as other sources of information. The value of the mortality register depends on its level of accuracy and completeness. The cause of death is often clearer in the younger and middle-aged persons than in older persons. Older persons tend to have a number of contributory causes of death making it difficult for the data coder to decide on the underlying cause of death. The International Statistical Classification of Diseases and Related Health Problems: ICD-10 is used to code the underlying cause of death. This helps to increase comparability between different countries worldwide. External 3.3% Digestive 3.1% Remainder 9.0% Neoplasms 26.9% Respiratory 10.6% Circulatory 40.1% Diabetes 3.2% Mental & behavioural 3.7% Figure 9: Commonest causes of death using broad categories There were 1298 deaths due to diseases of the circulatory system, a decrease of 298 deaths from the year Diseases of the circulatory system were the leading cause of death and accounted for 40% of the total number of deaths in The number of deaths from neoplasms totalled 870, a decrease of 55 deaths over 2012 and accounted for 27% of all deaths. There were 344 deaths due to respiratory conditions mainly chronic obstructive airways disease and chest infections. Mental and behavioural disorders which represented 3.7% of all deaths or 121 deaths and was mainly due to dementia. Diabetes as underlying cause of death accounted for 3.2% of all deaths or 105 deaths. It is also an important risk factor for circulatory diseases. 8

27 Annual Mortality Report 2013 Leading causes of death: number, rate and percent The Mortality Tabulation List 1 (MTL) of the International Classification of Diseases ICD-10 was used as the source for grouping diseases in the following tables. Remainder categories were sometimes excluded, as these tend to group several less common conditions together and would give them undeserved importance. Remainder categories were however used when the number of deaths from an individual cause constitutes a large part of the respective category or when this was deemed to be important information. (The full list of the mortality tabulation list is found in Section 5 of this report, Table 18 and Table 19) Table 3: Leading causes of death by number, rate and percent Cause of death (ICD-10 code) Number of deaths SDR/100,000 (ESP)* % of total M F T M F T deaths Ischaemic heart diseases (I20- I25) Cerebrovascular diseases (I60- I69) Other heart diseases (I26-I51) including heart failure (I50) Malignant neoplasm of trachea, bronchus and lung (C33-C34) Pneumonia (J12-J18) Dementia (F01-F03) Malignant neoplasm of colon, rectum and anus (C18-C21) Diabetes mellitus (E10-E14) Malignant neoplasm of breast (C50) Chronic lower respiratory diseases (J40-J47) Malignant neoplasm of pancreas (C25) All other causes Total *Standardised death rate per 100,000 (on the European Standard Population) Diseases of the circulatory system, mainly ischaemic heart disease, heart failure and cerebrovascular disease, ranked as the most common causes of death. Malignant neoplasms of the lung, colorectal, breast and pancreas were still among the leading causes of death as in 2012 and comprised 13% of all causes of deaths. 9

28 Annual Mortality Report 2013 Leading causes of death in males Ischaemic heart diseases (I20-I25) 23.7% Malignant neoplasm of trachea, bronchus and lung (C33-C34) 7.2% Cerebrovascular diseases (I60-I69) 6.9% Other heart diseases (I26-I51) including heart failure (I50) 6.0% Chronic lower respiratory diseases (J40-J47) 4.0% Malignant neoplasm of colon, rectum and anus (C18-C21) 3.7% Pneumonia (J12-J18) 3.7% Diabetes mellitus (E10-E14) 3.3% Malignant neoplasm of the prostate (C61) 2.3% Dementia (F01-F03) 2.2% Figure 10: Percentages of leading causes of death in males The main cause of death in males was ischaemic heart disease which accounted for 23.7% of all male deaths in 2013, a decrease of 4.6% over Decreases were also noted in deaths from heart failure (6.1% vs 8.8% in 2012). Lung cancer is the second most common cause of death in males, decreasing by 1% over Other leading cancer deaths in males include colorectal and prostate cancer. In 2013, diabetes and dementia made it to the top ten leading causes of death in males replacing other causes of death e.g. pancreatic cancer and diseases of the liver. Lung cancer and chronic lower respiratory diseases continue to feature as a commoner cause of death in males than in females. 10

29 Annual Mortality Report 2013 Leading causes of death in females Ischaemic heart diseases (I20-I25) 19.9% Cerebrovascular diseases (I60-I69) 10.1% Other heart diseases (I26-I51) 8.5% Dementia (F01-F03) 5.2% Malignant neoplasm of breast (C50) 5.2% Pneumonia (J12-J18) 4.6% Diabetes mellitus (E10-E14) 3.2% Malignant neoplasm of colon, rectum and anus (C18- C21) 3.0% Other acute lower respiratory infections (J20-J22) 2.6% Malignant neoplasm of the pancreas (C25) 2.4% Figure 11: Percentages of leading causes of death in females Diseases of the circulatory system continued to feature as the leading causes of death in females. Ischaemic heart disease however decreased in proportion by 6.8% in 2013, accounting for 19.9% of all female deaths. Malignant neoplasm of the breast is a leading cause of death specific to females. In 2013, it increased by 0.5% as a proportion of all female deaths compared to Dementia, chest infections and diabetes were also an important cause of death, especially in older females. 11

30 Annual Mortality Report 2013 Commonest causes of death by age group The relative importance of different causes of death varies in different age groups. Deaths in children below the age of one year There were 27 deaths in infants during the year 2013 accounting for 0.8% of the total deaths. Of these, 14 were male and 13 were female. This was an increase of 7 infant deaths over The most important causes of death in this age group were conditions originating in the early neonatal period (12 deaths, ICD codes: P chapter). The next commonest cause of death in infants were deaths due to congenital anomalies (8 deaths, ICD codes: Q chapter). Deaths in children between 1-14 years of age In this age group there were 3 deaths accounting for 0.09% of total deaths. There was a decrease of 4 deaths from The causes of death were diverse. Deaths in age group There were 76 deaths in this age group accounting for 2.1% of the total deaths. There was a decrease of 28 deaths from Of these, 55 were male and 21 were female. External causes of death accounted for the largest number of deaths in this age group i.e. 21 deaths. Neoplasms followed with 19 cases. 10 cases (vs. 3 cases in 2012) in this age group died from transport accidents (V01-V99). Table 4: Commonest causes of death in the age group Number Underlying cause of death M F T % of all deaths Transport accidents (V01-V99) Ischaemic heart disease (I20-I25) Intentional self harm (X60-X84) Remainder of diseases of the nervous system (G04-G25, G31- G98) Other heart diseases (I26-I51) Remainder of malignant neoplasms (C17, C23-24, C26-C31, C37-C41, C44-C49, C51-C52, C57-C60, C62-C66, C68-C69, C73- C81, C88, C96-C97)

31 Annual Mortality Report 2013 Deaths in the age group There were 434 deaths in this age group representing 13.4% of all deaths. There was a decrease of 66 from Neoplasms (46.1%) and diseases of the circulatory system (26.3%) dominate this relatively young age group. Table 5: Commonest causes of death in the age group Number Underlying cause of death M F T % of all deaths Ischaemic heart disease (I20-I25) Malignant neoplasms of trachea, bronchus and lung (C33,C34) Malignant neoplasm of colon, rectum and anus (C18-C21) Malignant neoplasm of the pancreas (C25) Malignant neoplasm of the breast (C50) Remainder of malignant neoplasms (C17, C23-24, C26-C31, C37- C41, C44-C49, C51-C52, C57-C60, C62-C66, C68-C69, C73-C81, C88, C96-C97) Diabetes mellitus (E10-E14) Cerebrovascular disease (I60-I69) Diseases Of the liver (K70-K76) Other heart diseases (I26-I51) Deaths in the age group There were deaths in this age group accounting for 51.4% of all deaths. There was a decrease of 47 deaths from Diseases of the circulatory system (39.6%) followed by neoplasms (32.1%) dominate this age group as the commonest causes of death. Table 6: Commonest causes of death in the age group Number Underlying cause of death M F T % of all deaths Ischaemic heart disease (I20-I25) Cerebrovascular disease (I60-I69) Malignant neoplasms of trachea, bronchus and lung (C33,C34) Other heart diseases (I26-I51) Remainder of malignant neoplasms (C17, C23-24, C26-C31, C37- C41, C44-C49, C51-C52, C57-C60, C62-C66, C68-C69, C73-C81, C88, C96-C97) Malignant neoplasm of colon, rectum and anus (C18-C21) Diabetes mellitus (E10-E14) Pneumonia (J12-J18) Remainder of diseases of the genito-urinary system (N17-N98) Remainder of mental and behavioural disorders, including dementia (F01-F09, F20-F99)

32 Annual Mortality Report 2013 Deaths in the 85+ age group There were deaths in this age group accounting for 31.9% of all deaths. There was a decrease of 42 deaths from Table 7: Commonest causes of death in the 85+ age group Number Underlying cause of death M F T % of all deaths Ischaemic heart disease (I20-I25) Cerebrovascular disease (I60-I69) Other heart diseases (I26-I51) Remainder of mental and behavioural disorders, including dementia (F01-F09, F20-F99) Pneumonia (J12-J18) Remainder of diseases of the genito-urinary system (N17-N98) Other acute lower respiratory infections (J20-J22) Remainder of diseases of the respiratory system (J00-J06, J30-J39, J60-J98) Remainder of diseases of the digestive system (K00-K22, K28-K66, K80-K92) Chronic lower respiratory diseases (J40-J47) Circulatory diseases again predominate in this age group. However, other conditions including dementia, respiratory infections, renal failure and urinary tract infections were important causes of mortality in older persons. It is important to note that deciding on the underlying cause of death in this age group is challenging, given that several co-morbidities are often present. Malignancies tend to be a less important cause of death in this age group. 14

33 Annual Mortality Report 2013 Potential years of life lost (PYLL) The index Potential years of life lost (PYLL) is an important indicator of premature mortality. From an economic point of view, premature mortality gives an indication of which diseases are affecting persons of working age. PYLL is defined as the sum of years lost for all individuals dying from a particular cause before a particular age (65 years in the case of PYLL-65). Table 8 and 9 list those conditions that contribute mostly to the largest number of potential years lost. Table 8: Potential years of life lost under 65 years of age during the year 2012 (PYLL-65) by major category Number of PYLL % of Underlying cause of death by major category M F T pyll Neoplasms (C00-D48) Diseases of the circulatory system (I00-I99) External causes of morbidity and mortality (V01-Y98) Certain conditions originating in the perinatal period (P00-P96) Congenital malformations, deformations and chromosomal abnormalities (Q00-Q99) Diseases of the nervous system (G00-G98) Endocrine, nutritional and metabolic diseases (E00-E88) Diseases of the respiratory system (J00-J98) Diseases of the digestive system (K00-K92) Remainder Total Neoplasms were the leading category of potential years of life lost, claiming 26.3% of the total potential years of life lost. This was followed by diseases of the circulatory system and external causes of death. Conditions originating in the perinatal period as well as congenital anomalies are only included in table 8 and not table 9 as since these conditions usually occur in the first year of life they inflate the figures disproportionately. However they are included in the total for both tables. 15

34 Annual Mortality Report 2013 Table 9: Potential years of life lost under 65 years during the year 2012 (PYLL-65) by MTL1 sub-grouping Number of PYLL % of Underlying cause of death by major category M F T pyll Ischaemic heart disease (I20-I25) Transport accidents (V01-V99) Intentional self harm (X60-X84) Remainder of diseases of the nervous system (G04- G25, G31-G98) including Huntington's disease (G10) and cerebral palsy (G80) Other heart diseases (I26-I51) Remainder of malignant neoplasms (C17, C23-C24, C26- C31, C37-C41, C44-C49, C51-C52, C57-C60, C62-C66, C68-C69, C73-C81, C88, C96-C97) Pneumonia (J12-J18) Malignant neoplasm of trachea, bronchus and lung (C33-C34) Diabetes mellitus (E10-E14) Malignant neoplasm of the breast (C50) Remainder Total More in-depth analysis showed that ischaemic heart disease, transport accidents and intentional selfharm were the most important causes of premature mortality in men. Breast cancer, transport accidents and lung cancer were the leading causes of premature mortality in females. 16

35 SMR due to diseases of the circulatory system/100,000 Annual Mortality Report 2013 Section 2: Individual diseases Diseases of the circulatory system (ICD 10 codes I00-I99) Diseases of the circulatory system accounted for 40.1% of all deaths. There were 1298 deaths, a decrease of 298 from These were mainly ischaemic heart disease, heart failure and cerebrovascular disease. Diseases of the circulatory system were of particular importance in the year age group and in the 85+ year age group in terms of leading causes of death but also an important cause of premature mortality as shown in the PYLL-65. The age-standardised death rate (SDR) from diseases of the circulatory system was , a decrease over the previous year of year Malta-M Malta-F EU-M EU-F Figure 12: Trends in SDR (ESP), diseases of the circulatory system per 100,000 in Malta and the EU over the past 20 years in males and females. Source: WHO/Europe-Health for all Database (HFA-DB) As shown in Figure 12, over the past 20 years an overall decreasing trend can be seen in both males and females in both Malta and EU 28. Rates for Malta and EU 28 follow an overall similar pattern. 17

36 SMR due to ischaemic heart disease/100, Annual Mortality Report 2013 Ischaemic heart disease (I20-I25) and Diabetes Mellitus (E10-E14) Ischaemic heart disease was the leading cause of death accounting for 21.8% of all deaths. There were 387 male deaths and 318 female deaths, a decrease of 107 male and 128 female deaths over the previous year year Malta-M Malta-F EU-M EU-F Figure 13: Trends in SDR, Ischaemic heart disease in Malta compared to the EU in males and females. Source: WHO/Europe-Health for all Database (HFA-DB) An overall decreasing trend is seen in both males and females in both Malta and the EU. However EU rates for both males and females are consistently lower than those for Malta. 18

37 SMR due to diabetes per 100,000 Annual Mortality Report year Malta-M Malta-F EU-M EU-F Figure 14: Trends in SDR, Diabetes in Malta compared to the EU in males and females Source: WHO/Europe-Health for all Database (HFA-DB) There was a change in coding practices in the years 2011 and 2012 which resulted in a drop in standardised mortality rate from diabetes mellitus. The drop was the result of diabetes mellitus increasingly seen as a contributory cause of death rather than the underlying cause of death. However this practice was changed again in 2013 according to international guidelines. The overall trend shows that mortality from diabetes in both males and females in Malta is consistently higher than that of the EU average. 19

38 SMR, Cerebrovascular disease/100,000 Annual Mortality Report 2013 Cerebrovascular diseases (ICD-10 codes I60-I69) There were 274 deaths from cerebrovascular diseases in 2013, accounting for 8.5% of all deaths. A decrease of 3 deaths was noted from the previous year. Females out-number males in the number of deaths due to cerebrovascular disease with 161 females versus 113 males having died of stroke during year Malta-M Malta-F EU-M EU-F Figure 15: Trends SDR, Cerebrovascular disease in Malta compared to the EU in males and females. Source: WHO/Europe-Health for all Database (HFA-DB) Figure 15 shows that Malta has followed an overall decreasing trend in SDRs from cerebrovascular similar to that of EU 28. This decrease in trend in the SDR from cerebrovascular disease is a reflection both of a decrease in the number of deaths due to cerebrovascular disease and an increase in the average age of death. 20

39 Annual Mortality Report 2013 Average age at death from diseases of the circulatory system and diabetes mellitus Table 10 shows that for nearly all deaths due to circulatory diseases and diabetes, the average age at death for males is lower than that for females. Average age of death for both males and females dying from circulatory diseases is more than the average age of death in the general population in 2013, however for persons dying from diabetes it is lower in both genders. Table 10: Average age at death from diseases of the circulatory system & diabetes mellitus in 2013 Average age at death (yrs) Underlying cause of death M F T Cerebrovascular diseases (I60-I69) Hypertensive diseases (I10-I14) Ischaemic heart diseases (I20-I25) Other heart diseases (I26-I51) including heart failure (I50) Atherosclerosis (I70) Remainder of diseases of the circulatory system (I71-I99) All circulatory diseases (I00-I99) Diabetes mellitus (E10-E14) * Underlying causes of death with small numbers (n<10) were not included in the table or marked as n/a 21

40 SMR, Malignant neoplasms/100,000 Annual Mortality Report 2013 Neoplasms (ICD-10 codes C00-D48) There were 870 deaths due to neoplasms accounting for 26.9% of all deaths. There was a decrease of 50 deaths from Of these, 466 were male and 404 were female. Lung cancer is the leading cause of death due to malignancy accounting for 17.7% of all cancer deaths and 4.8% of all deaths year Malta-M Malta-F EU-M EU-F Figure 16: Trends SDR, malignant neoplasms per 100,000 in Malta compared to EU by gender. Source: WHO/Europe-Health for all Database (HFA-DB) In Figure 16, a downward trend in SDRs from malignant neoplasms can be observed for Malta as well as the EU. In males rates for Malta compare favourably with the EU, and are similar in females in both Malta and the EU. 22