Leading Causes of Death Profile

Leading Causes of Death Profile St. Louis County, Missouri Mortality is an indicator of the health of a population. Cause of death ranking is the standard method that is useful for illustrating the relative burden of particular diseases or injuries that cause mortality. 1 This report presents data from 2010 through 2014 for Saint Louis County, giving a broad overview of mortality for all causes overall and the 10 leading causes of death by sex, age, race and Hispanic origin, poverty level, and geographic area. The data are derived from death certificates from St. Louis County residents. During 2010 2014, there were a total of 46,261 resident deaths in St. Louis County. The age adjusted death rate in 2014 was 717.3 deaths per 100,000 U.S. standard population. For 2010 2014, the 10 leading causes of St. Louis County resident deaths were: heart disease, cancer, cerebrovascular diseases (stroke), accidents (unintentional injuries), chronic lower respiratory disease (), Alzheimer s disease, influenza and pneumonia, nephritis, nephrotic syndrome and nephrosis (kidney disease), diabetes, and septicemia. Seven of the 10 leading causes of death during 2010 2014 were chronic diseases, accounting for 66 percent of all deaths. Mortality from All Causes Figure 1. Age adjusted death rates for all cause mortality, St. Louis County, Missouri, and United States, 2010 2014 Age Adjusted Rate per 100,000 Population 840 820 800 780 760 740 720 700 680 660 640 Missouri United States St. Louis County 2010 2011 2012 2013 2014 Year Figure 1 shows trends in death rates for all causes that have been adjusted for differences in age distribution between populations, also called age adjusted, for St. Louis County, Missouri through 2013, and the United States. All cause mortality rates declined in recent years for all three populations. St. Louis County rates decreased 1.8%, from 721.0 deaths per 100,000 population in 2010 to 708.3 deaths per 100,000 in 2013. Appendix 1 includes details about these death counts and rates.

Leading Causes of Death Page 2 of 19 The following table breaks down average, all cause mortality rates for St. Louis County by demographic characteristics for 2010 2014. Table 1. Deaths from All Causes per 100,000 population, St. Louis County, 2010 2014 average. Rate 95% Confidence Interval Count per year St Louis County 711.7 705 to 718 9,252 Age Group < 18 years 49.9 45.9 to 54.1 114 18 24 years 96.8 87.8 to 106.2 85 25 44 years 144.4 137.7 to 151.2 353 45 64 years 546.4 534.3 to 558.6 1,547 65 years and over 4561.6 4514.4 to 4609 7,153 Gender Male 851.4 840 to 863 4,362 Female 606.8 598.9 to 614.8 4,889 Race/Ethnicity Asian 402.3 356.7 to 450.5 73 Black/African American 929.4 909.5 to 949.6 1,788 Hispanic/Latino 316.5 271.8 to 364.4 44 Multiple Races 162 126.6 to 202 19 White 668.3 661.2 to 675.4 7,326 Neighborhood Poverty Very High 941.0 903.3 to 979.7 485 High 949.7 924.2 to 975.8 1,075 Medium 741.1 727.1 to 755.3 2,250 Low 655.4 647.4 to 663.4 5,442 Geographic Area Central 608.2 591.5 to 625.3 1,086 Inner North 943.4 923.5 to 963.6 1,776 Outer North 642.0 628.5 to 655.5 1,791 South 701.4 687.7 to 715.3 2,146 West 593.4 582.7 to 604.3 2,452 Comparisons: Higher than St. Louis County rate Lower than St. Louis County rate Notes: Source: Missouri Department of Health and Senior Services (DHSS), Bureau of Vital Statistics. Case Definition: All deaths to St. Louis County residents between 2010 and 2014 from all causes. Rates are age adjusted to the 2000 US population (not including Age Group rates).

Leading Causes of Death Page 3 of 19 Figure 2. Age Adjusted Death Rates by Neighborhood Poverty, St. Louis County Residents, 2010 and 2014. Age adjusted Death Rate per 100,000 Polulation Very High (>=30 %) High (20 to <30%) Medium (10 to <20%) Low (< 10%) County wide 1000 800 600 400 200 0 957.8 964.5 976.8 996.2 738.0 721.0 758.3 717.3 645.9 658.9 2010 Year 2014 In 2010 and 2014 age adjusted all cause death rates were 1.5 times greater in areas with very high poverty compared to areas with low poverty (957.8 vs 645.9 deaths per 100,000 population in 2010 and 976.8 vs 658.9 in 2014, respectively). Figure 3. Age Adjusted Death Rates by Sex, St. Louis County Residents, 2010 to 2014. From 2010 to 2014, ageadjusted all cause death rates increased 2.2% among males, but decreased 1.7% among females. The age adjusted allcause death rates for males were higher than the St. Louis County rates. Age adjuste Death Rate per 100,000 Population 1000 800 600 400 200 0 860.6 Male 879.2 721.0 St. Louis County 717.3 615.8 Female 605.2 2010 2011 2012 2013 2014 Year Age adjusted Death Rate per 100,000 Population Figure 4. Age Adjusted Death Rates by Race and Ethnicity, St. Louis County Residents, 2010 2014. 1200 1000 800 600 400 200 0 Black/African American White Hispanic/Latino Multiple Races Asian 2010 2011 2012 2013 2014 Year From 2010 2014, ageadjusted all cause death rates among Asians and whites decreased 4% and 2%, respectively. Hispanic/Latinos and multiple race groups rates increased 35% and 44%, respectively. Black/African American rates increased 4%.

Leading Causes of Death Page 4 of 19 Map 1. All Cause age adjusted death rate per 100,000 population by zip code, St. Louis County, 2010 2014 average. Age-Adjusted Death Rate per 100,000 Population for All Causes, 2010-2014 0.0-240 250-450 460-700 710-1000 63042 63031 Í 63034 63033 Í Uq 63138 1100-1700 Zip Codes Unpopulated UN 364 63146 63045 63044!"f$ 63043 Í 63074 Í %&h(!"f$ 63134 63114 63135 63121 63136 63137 Un Iy!"e$ 63005 63141 63017 Iy!"e$ Un 63131 63011 U U Í 63122 63038 63040 63021 63133 63132 Un 63130 %&h( 63105 63124 Iy!"e$ 63117 63144 63119!"b$!"f$ City of St. Louis Iy!"e$!"b$ Iz!"c$ 63088!"b$ 63126 63123 Iz Iz!"c$ 63127 63026 63069 63025 63125 63049!"b$ Iz 63128 Iz %&j(. 0 2 4 8 Miles!"c$ 63129 Data Source: Missouri Department of Health and Senior Services The 2010 2014 average age adjusted death rates for all causes were highest in the northern parts of St. Louis County, although some zip codes in the western and southern parts of the county had high all cause death rates. The lowest rates were among zip codes in the central part of the county. Appendix 1 includes details about all cause mortality rates for St. Louis County by year (2010 to 2014) and demographic characteristics.

Leading Causes of Death Page 5 of 19 Leading Causes of Death Table 2 shows the 10 leading causes of death in St. Louis County, in ranked order, during 2010 2014. Seven of the 10 leading causes were chronic diseases and conditions. Chronic diseases, including heart disease, cancer, stroke, chronic lung diseases, and diabetes, have modifiable risk factors that can lead to premature mortality. Table 2. Deaths, age adjusted rates, 95% confidence intervals, and percentage of total deaths 10 Leading Causes of Death, St. Louis County, 2010 2014 average. Rank Cause of Death ICD 10 Codes Deaths Rate 1 95% Confidence Interval Percent of total deaths All Causes 46,261 711.7 705.0 718.0 100 1 Heart I00 I09, I11, I13, I20 I51 11,913 176.2 173.0 179.4 25.8 2 C00 C97 10,383 163.0 159.8 166.2 22.4 3 I60 I69 2,553 37.5 36.0 39.0 5.5 4 V01 X59,Y85 Y86 2,183 39.4 37.7 41.1 4.7 Chronic Lower Respiratory 5 J40 J47 2,120 32.5 31.2 34.0 4.6 6 Alzheimer's G30 1,443 19.8 18.8 20.8 3.1 7 Influenza and J09 J18 1,111 15.9 15.0 16.9 2.4 8 Kidney N00 N07,N17 N19,N25 N27 1,044 15.7 14.8 16.7 2.3 9 E10 E14 1,021 15.8 14.8 16.8 2.2 10 A40 A41 702 10.8 10.0 11.6 1.5 1 Rates are age adjusted to the 2000 U.S. population per 100,000 population. Rank based on number of deaths among St. Louis County Residents; International Classification of s, Tenth Revision (ICD 10). Cause of death statistics are based on the underlying cause of death. Figure 5. Age adjusted death rates for the 10 leading causes of death in St Louis County, comparing rates for Missouri and United States, 2013. Heart * Alzheimer's Influenza and Kidney St. Louis County Missouri United States 0 20 40 60 80 100 120 140 160 180 200 Age adjusted Death Rates per 100,000 * injury rate for Missouri is a 3 year average, 2011 2013.

Leading Causes of Death Page 6 of 19 The burden of chronic disease in St. Louis County is highlighted by the majority of the 10 leading causes of death are chronic diseases and conditions. The St. Louis County Department of Public Health established the Chronic Epidemiology (CDE) program to address chronic diseases among county residents. The program aims to publish more detailed surveillance reports on the most burdensome chronic diseases and their risk factors. Chronic diseases dominant in the 10 leading causes of death in St. Louis County Rank 2010 2011 2012 2013 2014 2010 2014 1 Heart 187.1 Heart 176.4 Heart 178.8 Heart 172.5 Heart 167.5 Heart 176.2 2 169.4 159.6 165.0 160.2 161.4 163.0 3 40.5 39.3 37.3 35.6 45.2 37.5 4 30.2 41.2 34.1 40.4 35.1 39.4 5 35.2 32.0 34.8 33.4 33.4 32.5 6 Alzheimer s 17.8 Alzheimer s 16.4 Alzheimer s 17.5 Alzheimer s 20.2 Alzheimer s 27.2 Alzheimer s 19.8 7 Kidney 16 16.7 Kidney 17.5 Influenza/ 16.3 Influenza/ 18.4 Influenza/ 15.9 8 16.3 Influenza/ 15.1 17.8 Kidney 15.2 Kidney 16.2 Kidney 15.7 9 Influenza/ 14.1 Kidney 13.7 Influenza/ 15.9 14.4 14 15.8 10 10.1 11.6 10.9 12.2 Suicide 13.7 10.8 Source: Missouri Department of Health and Senior Services (DHSS), Bureau of Vital Statistics. Rates are per 100,000 2000 US Standard population. Case Definition: International Classification of s, Tenth Revision (ICD 9) codes: I00 I09, I11, I13, I20 I51 (Heart ); C00 C97 (); I60 I69 (); V01 X59, Y85 Y86 ( ); J40 J47 (Chronic Lower Respiratory ); G30 (Alzheimer's ); J09 J18 (Influenza and ); N00 N07, N17 N19,N25 N27 (nephritis, nephrotic syndrome and nephrosis; kidney ); E10 E14 (); A40 A41 (), *U03, X60 X84, Y87.0 (Intentional self harm; suicide).

Leading Causes of Death Page 7 of 19 Differences by Sex Figure 6 shows similarities in the ranking of certain causes of death among males and females for 2010 2014. For both populations, heart disease and cancer accounted for the highest percentages of death, 24.6% and 22.0% for women, and 27.0% and 23% for men, respectively. Males and females diverged in other causes of death. injury was the third leading cause of death and suicide ranked eighth among men, accounting for 5.9% and 2.4% of deaths to males, respectively. Females had a higher relative burden from stroke and Alzheimer s disease, 6.4% and 4.2%of deaths to females, respectively. Figure 6. Percent distribution of the 10 leading causes of death by sex: St. Louis County, 2010 2014 average. Women Other 26.0 Heart 24.6 Kidney Influenza and 1.6 2.0 2.1 2.5 3.6 Alzheimer's 4.2 5.0 6.4 22.0 Men Alzheimer's Influenza and Suicide Kidney 2.0 2.3 2.4 2.4 2.5 4.1 Other 24.0 4.5 5.9 Heart 27.0 23.0

Leading Causes of Death Page 8 of 19 Differences by Age Group Table 4. Leading Causes of Death by Age Group, St Louis County, 2010 2014 average. Less than 18 Years Rank Cause of Death Deaths Percent Rate 95% CI 1 Perinatal Causes 204 35.9 16.1 14 18.5 2 Injuries 92 16.2 8.1 6.5 9.8 3 Congenital Malformations 69 12.1 5.5 4.2 6.9 4 Assault (Homicide) 32 5.6 2.8 1.9 3.9 5 28 4.9 2.5 1.6 3.4 6 Suicide 22 3.9 1.9 1.2 2.8 7 Heart 10 1.8 0.9 0.4 1.5 8 6 1.1 0.5* 0.2 1 9 5 0.9 0.4* 0.1 0.9 10 5 0.9 0.4* 0.1 0.9 All Other Causes 96 16.9 Total 569 100.0 49.9 45.9 54.1 18 24 Years Rank Cause of Death Deaths Percent Rate 95% CI 1 Injuries 146 34.4 33.2 28.1 38.8 2 Assault (Homicide) 120 28.2 27.3 22.7 32.4 3 Suicide 68 16.0 15.5 12 19.4 4 Heart 12 2.8 2.7 1.4 4.5 5 10 2.4 2.3* 1.1 3.9 6 Congenital Malformations 6 1.4 1.4* 0.5 2.7 7 4 0.9 0.9* 0.2 2 8 3 0.7 0.7* 0.1 1.6 9 Anemias 3 0.7 0.7* 0.1 1.6 10 2 0.5 0.5* 0.1 1.3 All Other Causes 51 12.0 Total 425 100.0 96.8 87.8 106.2 25 44 Years Rank Cause of Death Deaths Percent Rate 95% CI 1 Injuries 524 29.7 42.9 39.3 46.6 2 215 12.2 17.6 15.3 20 3 Heart 188 10.7 15.4 13.3 17.7 4 Assault (Homicide) 182 10.3 14.9 12.8 17.1 5 Suicide 178 10.1 14.6 12.5 16.8 6 Chronic Liver and Cirrhosis 40 2.3 3.3 2.3 4.4 7 30 1.7 2.5 1.7 3.4 8 HIV/AIDS 27 1.5 2.2 1.5 3.1 9 22 1.2 1.8 1.1 2.6 10 21 1.2 1.7 1.1 2.5 All Other Causes 338 19.2 Total 1,765 100.0 144.4 137.7 151.2

Leading Causes of Death Page 9 of 19 Table 4. Leading Causes of Death by Age Group, St Louis County, 2010 2014 average (Continued) 45 64 Years Rank Cause of Death Deaths Percent Rate 95% CI 1 2,630 34.0 185.7 178.7 192.9 2 Heart 1,822 23.6 128.7 122.8 134.7 3 Injuries 420 5.4 29.7 26.9 32.6 4 Suicide 271 3.5 19.1 16.9 21.5 5 263 3.4 18.6 16.4 20.9 6 234 3.0 16.5 14.5 18.7 7 216 2.8 15.3 13.3 17.4 8 Chronic Liver and Cirrhosis 214 2.8 15.1 13.2 17.2 9 Kidney 162 2.1 11.4 9.7 13.3 10 125 1.6 8.8 7.3 10.4 All Other Causes 1,379 17.8 Total 7,736 100.0 546.4 534.3 558.6 65 Years and over Rank Cause of Death Deaths Percent Rate 95% CI 1 Heart 9,881 27.6 1260.2 1235.5 1285.2 2 7,500 21.0 956.5 935 978.3 3 2,253 6.3 287.3 275.6 299.3 4 1,873 5.2 238.9 228.2 249.8 5 Alzheimer's 1,425 4.0 181.7 172.4 191.3 6 Injuries 1,001 2.8 127.7 119.9 135.7 7 Influenza and 995 2.8 126.9 119.1 134.9 8 Kidney 862 2.4 109.9 102.7 117.4 9 761 2.1 97.1 90.3 104.1 10 549 1.5 70 64.3 76 All Other Causes 8,666 24.2 Total 35,766 100.0 4561.6 4514.4 4609 Notes: Source: Missouri Department of Health and Senior Services (MoDHSS), Bureau of Vital Statistics. Case Definition: International Classification of s, 10th Revision (ICD 10) codes: I00 I09, I11, I13, I20 I51 (Heart ); C00 C97 (); I60 I69 (); V01 X59, Y85 Y86 ( ); J40 J47 (Chronic Lower Respiratory ); G30 (Alzheimer's ); J09 J18 (Influenza and ); N00 N07, N17 N19,N25 N27 (nephritis, nephrotic syndrome and nephrosis; kidney ); E10 E14 (); A40 A41 (), *U03, X60 X84, Y87.0 (Intentional self harm; suicide), D50 D64 (Anemias) K70, K73 K74 (Chronic Liver s and Cirrhosis), Human immunodeficiency virus(hiv)disease (B20 B24), Perinatal causes (P00 P96), Congenital Malformations (Q00 Q99). *Too few cases to meet precision standard (relative standard error <30%); interpret with caution.

Leading Causes of Death Page 10 of 19 Differences by Race and Hispanic Origin Figure 7 shows selected chronic disease causes of death that were among the 10 leading causes of death by race and ethnicity. Some racial or ethnic groups do not have a bar for a particular disease because that disease was not among the ten leading causes of death for the population. Heart disease and cancer were the two leading causes of death for all groups. However, the age adjusted death rates among Black/African Americans were the highest for all causes of death except for chronic lower respiratory disease (), Alzheimer s disease, and chronic liver disease. Alzheimer s disease was only a top ten leading cause of death for Black/African Americans and whites. Figure 7. Chronic s: age adjusted death rates for the leading causes of death by Race and Ethnicity, St. Louis County, Missouri, 2010 2014 average. 280 240 240.2 211.4 Black/African American White Asian Multiple Race Hispanic Rate per 100,000 Population 200 160 120 80 40 164.2 88 42.0 76.0 154.4 95.7 37.5 75.9 52 34.5 33.3 7.3* 21.6 25.8 33.8 7.4* 10.4* 9.7* 19.9 20.1 33.2 12.6 9.2* 5..3* 11.7* 35.6 12.2 9.4* 7.3* 11.4* 4.9* 0 Heart Alzheimer's Kidney Chronic Liver *Too few cases to meet precision standard (relative standard error <30%); interpret with caution.

Leading Causes of Death Page 11 of 19 Figure 8 similarly shows selected external causes of death that were among the 10 leading causes of death by race and ethnicity. Some racial or ethnic groups do not have a bar for particular diseases because that disease was not among the ten leading causes of death for the population. Figure 8. External Causes of Death: age adjusted death rates for the leading causes by Race and Ethnicity, St. Louis County, Missouri, 2010 2014 60 Black/African American White Asian Multiple Race Hispanic Rate per 100,000 Population 50 40.8 40 37.2 30 28.1 24.8 20 16.2 12.1 13.8 10 1.7* 3.2* 4.1 3.5* 0 Homicide Injuries Suicide *Too few cases to meet precision standard (relative standard error <30%); interpret with caution.

Leading Causes of Death Page 12 of 19 Differences by Poverty Level Figure 9 shows similarities and differences in the ranking of certain causes of death by poverty level for 2010 2014. Figure 9. Percent distribution of the 10 leading causes of death by poverty level: St. Louis County, 2010 2014 average. Low Poverty Medium Poverty Other 25.5 Heart 25.3 Other 24.9 Heart 26.3 Kidney Influenza and Alzheimer's 1.4 1.8 2.2 2.7 3.7 4.5 4.7 5.8 22.5 Kidney Influenza and Alzheimer's 1.6 2.1 2.3 2.4 2.5 5.0 5.0 5.2 22.7 High Poverty Very High Poverty Influenza and Homicide Alzheimer's Kidney 24.8 1.8 2.4 2.6 2.9 2.9 3.7 5.0 Other 5.1 Heart 26.7 22.1 Alzheimer's Kidney Homicide Other 24.4 1.6 1.9 2.7 3.3 3.5 3.8 4.7 5.5 Heart 26.6 21.9

Leading Causes of Death Page 13 of 19 Differences by Geographic Area Map 2. Top 5 Leading Causes of Death by geographic area, St. Louis County, 2010 2014. 1. Heart 2. 3. 4. 5. Injuries Iy 1. Heart 2. 3. 4. Injuries 5.!"e$ Un West U Í Un Iy!"e$!"b$!"f$ U Í Iy Iz Iz!"c$!"b$ Iz Iz South %&j(!"c$. 0 2 4 8 Miles Data Source: Missouri Department of Health and Senior Services UN 364!"f$ Í!"e$ Outer North %&h(!"b$ %&h( Un Central Í Inner North Í!"f$ Uq City of St. Louis Iy!"e$!"b$ Iz!"c$ 1. Heart 2. 3. Injuries 4. 5. 1. Heart 2. 3. 4. 5. Alzheimer s 1. Heart 2. 3. 4. 5. Injuries

Leading Causes of Death Page 14 of 19 Methods Data was obtained from the Missouri Department of Health and Senior Services, Bureau of Vital Statistics for the years 2010 to 2014. Causes of death classified using the International Classification of s, Tenth Revision (ICD 10) underlying cause codes are ranked according to the number of deaths assigned to rankable causes. The List of 113 Selected Causes of Death and Enterocolitis due to Clostridium difficile is used to select rankable causes for the leading causes presented in this report. 1 Data for rates of the leading cause of death in the United States were obtained from 2013 Mortality Multiple Cause Micro data Files, from the National Vital Statistics System (NVSS), National Center for Health Statistics (NCHS). 2 The data received captures all deaths of St. Louis County residents (within or outside of St. Louis County). The American Community Survey (ACS) was used to generate 1 year and 5 year estimates for the St. Louis County population by age, gender, race and Hispanic origin for 2010 2014. The percent of residents living below the federal poverty level for each census tract was also obtained from ACS using the 5 year estimate for 2009 to 2013. In the analysis, neighborhood poverty level was assigned to each death based on residence within each St. Louis County 2010 census tract. Each census tract was assigned one of four categories of percent below federal poverty level 3 : Low (0 to < 10 percent); Medium (10 to <20 percent); High (20 to <30 percent); and Very high (30 to 100 percent). Age adjusted and age specific rates and 95% confidence intervals were calculated in Microsoft Excel using population estimates from ACS. The rates were ageadjusted to the 2000 U.S. population 4. Geographic regions were determined from St. Louis County Planning division region maps by assigning each census tract a matching region. Maps were generated using ArcGIS for the vital statistics data for rates by zip code, and geographic regions. Chronic Epidemiology Program The Chronic Epidemiology (CDE) program is responsible for analysis, interpretation, and presentation of health data related to chronic and their risk factors. The CDE program supports the Saint Louis County Department of Public Health (DPH) by providing the following services: Develop study designs, questionnaires, and case definitions. Evaluate chronic disease programs. Locate or develop surveillance systems, and analyze epidemiologic data sets. Provide county, state, and national comparison data. Interpret St. Louis County chronic disease and risk factor data. Conduct epidemiologic investigations and special studies of chronic diseases and chronic disease risk factors of public health importance. Monitor St. Louis County chronic disease trends. Provide scientific advice and technical assistance to community groups and outside partners with respect to surveillance and other epidemiology data expertise. Publish reports and web pages on chronic disease and risk factors.

Leading Causes of Death Page 15 of 19 For more information about the CDE program please contact us at: Chronic.DOH@stlouisco.com References 1. Heron M. Deaths: Leading causes for 2012. National vital statistics reports; vol 64 no 10. Hyattsville, MD: National Center for Health Statistics. 2015. 2. 2013 Mortality Multiple Cause Micro data Files. Deaths: Final Data for 2013. NVSR Volume 64, Number 2 will be published later. Accessed online February 3, 2016 at: http://www.cdc.gov/nchs/deaths.htm 3. Toprani A, Hadler JL. Selecting and applying a standard area based socioeconomic status measure for public health data: Analysis for New York City. New York City DOHMH: Epi Research Report, May 2013. 4. Klein RJ, Schoenborn CA. Age adjustment using the 2000 projected U.S. population. Healthy People Statistical Notes, no. 20. Hyattsville, Maryland: National Center for Health Statistics. January 2001. Suggested citation Kret JE, Dalidowitz L, DeClue R. Leading Causes of Death Profile, St. Louis County Missouri. Chronic Epidemiology (CDE) program profile, no 2. St. Louis County, MO: Department of Public Health. February 2016.

Leading Causes of Death Page 16 of 19 Appendix 1: Mortality from All Causes Appendix 1.1. Number of deaths and age adjusted death rates for all causes, St. Louis County, Missouri, and United States, 2010 2014. Year St. Louis County Missouri United States Rate Deaths Rate Deaths Rate Deaths 2010 721.0 9,145 816.0 55,054 747.0 2,468,435 2011 705.3 9,048 810.1 55,599 741.3 2,515,458 2012 709.7 9,241 798.2 55,783 732.8 2,543,279 2013 708.3 9,362 804.9 57,256 731.9 2,596,993 2014 717.3 9,465 724.6 Sources: Missouri Department of Health and Senior Services (MoDHSS), Bureau of Vital Statistics and National Center for Health Statistics (NCHS), National Vital Statistics System (NVSS). Rates are age adjusted to the 2000 US population.

Leading Causes of Death Page 17 of 19 Appendix 1: Mortality from All Causes (cont.) Appendix 1.2. Deaths from all causes per 100,000 population, St. Louis County, 2010 2014. 2010 2011 2012 2013 2014 Rate 95% CI Count Rate 95% CI Count Rate 95% CI Count Rate 95% CI Count Rate 95% CI Count St. Louis County 721.0 706 to 736.2 9,145 705.3 690.4 to 720.4 9,048 709.7 694.9 to 724.7 9,241 708.3 693.6 to 723.1 9,362 717.3 702.6 to 732.2 9,465 Age Group < 18 years 49.3 40.7 to 58.7 123 54.8 45.7 to 64.8 100 46.2 37.8 to 55.5 0 44.3 36.1 to 53.4 126 55 45.7 to 65.1 115 18 24 years 112 90.9 to 135.4 97 84.3 66.1 to 104.7 73 89.4 70.8 to 110.2 79 94.4 75.3 to 115.6 84 103.7 83.6 to 126 92 25 44 years 152.7 137.6 to 168.3 373 148.8 133.9 to 164.4 364 143.2 128.6 to 158.6 350 137.2 122.9 to 152.3 335 140 125.5 to 155.1 343 45 64 years 568 540.7 to 596 1,620 555.5 528.5 to 583.1 1,591 538 511.3 to 565.3 1,524 543.1 516.2 to 570.6 1,528 526.8 500.1 to 554 1,473 65 years and over 4844.8 4734 to 4957 7,252 4784.3 4674.7 to 7,234 4571.6 4466.5 to 7,183 4326 4225.1 to 6,975 4320.8 4221.1 to 7,122 4895.2 4677.9 4428.1 4421.8 Sex Male 860.6 834.7 to 887 4,273 830.4 805.2 to 856.2 4,236 848.5 823.1 to 874.3 4,387 852.4 827.1 to 878.3 4,393 879.2 853.3 to 905.5 4,521 Female 615.8 597.9 to 634.1 4,869 607.3 589.4 to 625.5 4,812 602.7 585.1 to 620.6 4,853 604.9 587.3 to 622.8 4,968 605.2 578.7 to 623.1 4,943 Race/Ethnicity Asian** 331.5 244.9 to 430.7 60 241.2 182.4 to 309.1 61 372.6 292.1 to 465.2 81 440.1 338.9 to 553.2 88 317.3 245.7 to 400.7 76 Black/African American 927.1 881.5 to 974.3 1,705 906.3 862.1 to 951.9 1,700 970.1 921.4 to 1020.3 1,752 949.9 905.2 to 996 1,853 965.3 920.7 to 1011 1,930 Hispanic or Latino 332.7 231.6 to 456.3 41 303.2 191.8 to 442.9 28 436.1 277.4 to 630.3 44 328.2 228.5 to 447.1 43 449.1 333.3 to 585.4 64 Multiple 101.6 43.8 to 189.2 12 526.7 176 to 1001 19 346.3 159.6 to 590.2 23 172.1 95.6 to 272.5 21 146.2 80.6 to 253.6 19 White 682.0 665.9 to 698.3 7,322 666.6 650.6 to 682.9 7,234 668.7 652.7 to 684.9 7,344 659.3 643.6 to 675.3 7,359 668.2 652.4 to 684.3 7,371 Neighborhood Poverty Very High 872.5 to 957.8 1047.2 487 921.2 838.7 to 1008.1 479 995.9 909.2 to 1087 507 853.1 774.1 to 937.6 441 976.8 892.5 to 1066.5 510 High 907.2 to 964.5 1024.2 1,086 878.6 824 to 935.6 993 993.0 934.7 to 1053.5 1,116 916.4 860.9 to 974.4 1,044 996.2 938.3 to 1056.4 1,138 Medium 738.0 706.8 to 770 2,238 736.0 704.8 to 768.2 2,218 721.5 690.8 to 753.1 2,210 751.6 720.3 to 784 2,293 758.3 726.6 to 790.9 2,291 Low 645.9 628.2 to 663.9 5,334 648.9 631.2 to 667.1 5,358 652.4 634.7 to 670.5 5,408 670.8 652.8 to 689.1 5,584 658.9 641.2 to 677 5,526 Geographic Area Central 606.7 569.6 to 645.2 1,081 624.5 587 to 663.6 1,124 606.6 569.7 to 645.1 1,083 598.8 561.9 to 637.2 1,068 604.7 567.6 to 643.3 1,076 Inner North 931.2 886.9 to 976.6 1,741 928.4 884.5 to 973.8 1,744 968.1 923.2 to 1014.6 1,810 920.4 876.7 to 965.4 1,740 968.9 924.4 to 1014.8 1,844 Outer North 654.6 624.4 to 685.6 1,823 609.7 580.6 to 639.7 1,698 639.7 610 to 670.4 1,791 657.5 627.3 to 688.6 1,835 648.2 618.3 to 679.2 1,807 South 687.5 657.4 to 718.6 2,098 711.2 680.2 to 743.3 2,144 682.3 652 to 713.5 2,071 722.2 691.5 to 754 2,237 703.9 673.5 to 735.3 2,178 West 588.8 564.8 to 613.5 2,402 570.1 546.6 to 594.4 2,338 597.6 573.7 to 622.2 2,485 596.3 572.4 to 620.8 2,482 614.3 590.1 to 639.3 2,553 Notes: Source: Missouri DHSS, Bureau of Health Care Analysis and Data Dissemination. Case Definition: Deaths from all causes to St. Louis County residents between 2010 and 2014. Rates are age adjusted to the 2000 US population (not including Age Group rates). CI = Confidence Interval. *Too few cases to meet precision standard (relave standard error <30%); interpret with cauon. Too few cases to protect confidentiality and/or report reliable rates. ** Where 1 Year ACS estimates were zero, two adjacent years were averaged to calculate a non zero population denominator.

Leading Causes of Death Page 18 of 19 Appendix 2: Leading Causes of Death Appendix 2.1. Age adjusted death rates for the 10 leading causes of death in St Louis County compared to Missouri and United States, 2013. St. Louis County Missouri United States Cause of Death Rank Deaths Rate Rank** Deaths Rate Rank Rate Heart 1 2,379 172.5 1 14,036 193.8 1 169.8 2 2,070 160.2 2 12,902 178.7 2 163.2 3 494 35.6 4 2,913 40.3 5 36.2 * 4 447 40.4 5 N/A 48.4 4 39.4 5 437 33.4 3 3,800 52.9 3 42.1 Alzheimer's 6 303 20.2 6 2,018 27.4 6 23.5 Influenza and 7 232 16.3 8 1,347 18.6 8 15.9 Kidney 8 207 15.2 9 1,298 17.9 9 13.2 9 190 14.4 7 1,477 20.5 7 21.2 10 162 12.2 11 802 11.1 11 10.7 All Causes 9,362 708.3 57,256 804.9 731.9 Rates are age adjusted to the 2000 US population. *Missouri rate for unintentional injury (accidents) is a 3 year average 2011 13. **Ranking of Missouri leading causes of death was based on the number of total deaths in the state for 2003 2013.

Leading Causes of Death Page 19 of 19 Appendix 2.2. Leading causes of death, age adjusted rates, 95% Confidence Intervals (CI) by year, St. Louis County, 2010 2014 Cause of Death Rate 95% CI Count Cause of Death Rate 95% CI Count 2010 2013 Heart 187.1 179.6 to 194.7 2,470 Heart 172.5 165.5 to 179.8 2,379 169.4 162.2 to 177 2,088 160.2 153.2 to 167.4 2,070 40.5 37.1 to 44.1 535 35.6 32.4 to 39 494 30.2 27.2 to 33.5 385 40.4 36.6 to 44.5 447 35.2 31.6 to 39.1 380 33.4 30.2 to 36.7 437 Alzheimer's 17.8 15.7 to 20.2 253 Alzheimer's 20.2 18 to 22.7 303 Kidney 16 13.9 to 18.4 210 Influenza and 16.3 14.2 to 18.6 232 16.3 14.1 to 18.8 205 Kidney 15.2 13.1 to 17.4 207 Influenza and 14.1 12.1 to 16.2 191 14.4 12.4 to 16.7 190 10.1 8.4 to 11.9 130 12.2 10.4 to 14.3 162 2011 2014 Heart 176.4 169.1 to 183.8 2,358 Heart 167.5 160.6 to 174.6 2,294 159.6 152.5 to 166.9 1,989 161.4 154.4 to 168.5 2,129 39.3 35.9 to 42.8 527 45.2 41.2 to 49.4 512 41.2 37.3 to 45.3 453 35.1 32 to 38.4 485 32 28.9 to 35.3 408 33.4 30.3 to 36.7 443 Alzheimer's 16.4 14.3 to 18.7 236 Alzheimer's 27.2 24.6 to 30.1 396 16.7 14.5 to 19.1 215 Influenza and 18.4 16.2 to 20.8 256 Influenza and 15.1 13 to 17.3 211 Kidney 16.2 14 to 18.5 214 Kidney 13.7 11.7 to 15.9 181 14 12 to 16.2 186 11.6 9.8 to 13.7 149 Suicide 13.7 11.5 to 16.1 148 2012 Heart 178.8 171.5 to 186.2 2,412 165 157.9 to 172.4 2,107 37.3 34.1 to 40.8 512 34.1 30.9 to 37.4 447 34.8 31.3 to 38.6 391 Alzheimer's 17.5 15.3 to 19.8 255 Kidney 17.5 15.3 to 20 232 17.8 15.5 to 20.4 225 Influenza and 15.9 13.8 to 18.2 221 10.9 9.1 to 12.9 139 Notes: Rates are age adjusted to the 2000 US population (not including Age Group rates). CI = Confidence Interval. = Chronic Lower Respiratory. Source: Missouri DHSS, Bureau of Health Care Analysis and Data Dissemination. International Classification of s, Tenth Revision (ICD 9) codes: I00 I09, I11, I13, I20 I51 (Heart ); C00 C97 (); I60 I69 (); V01 X59, Y85 Y86 ( ); J40 J47 (Chronic Lower Respiratory ); G30 (Alzheimer's ); J09 J18 (Influenza and ); N00 N07, N17 N19,N25 N27 (nephritis, nephrotic syndrome and nephrosis; kidney ); E10 E14 (); A40 A41 (), *U03, X60 X84, Y87.0 (Intentional self harm; suicide).