Download Trends in Enteric Disease as a Cause of Death in the United States

American Journal of Epidemiology
Copyright © 2003 by the Johns Hopkins Bloomberg School of Public Health
All rights reserved
Vol. 157, No. 1
Printed in U.S.A.
DOI: 10.1093/aje/kwf172
Trends in Enteric Disease as a Cause of Death in the United States, 1989–1996
Christina A. Peterson1,2,3 and Rebecca L. Calderon2
1
Department of Epidemiology, School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC.
National Health and Environmental Effects Laboratory, Environmental Protection Agency, Research Triangle Park, NC.
3 Department of Environmental Sciences and Engineering, School of Public Health, University of North Carolina at Chapel Hill,
Chapel Hill, NC.
2
Received for publication December 13, 2001; accepted for publication July 24, 2002.
The authors examined rates of and trends in enteric disease as a cause of death in the United States. The
National Center for Health Statistics Multiple Cause of Death databases for 1989–1996 were analyzed for
International Classification of Diseases, Ninth Revision, codes for gastroenteritis due to infectious agents and
codes describing illness with other enteric pathogens. The highest rates of death related to enteric diseases were
seen among people older than 75 years, followed by children under 1 year of age. Rates increased markedly over
time in the 65- to 74-year age group for bacterial enteric pathogens and in the 35- to 44-year age group for viral
enteric pathogens. Enteric diseases were the underlying cause of death for an average of 2,740 deaths during
each year of this study, and the rate of death due to enteric-related disease is increasing.
gastroenteritis; intestinal diseases; mortality
Abbreviations: AIDS, acquired immunodeficiency syndrome; CI, confidence interval; HIV, human immunodeficiency virus; ICD9, International Classification of Diseases, Ninth Revision; MCD, multiple cause of death; RR, relative risk.
sification of Diseases, Ninth Revision (ICD-9), code group
002). By 1920, typhoid and paratyphoid fever death rates
had been reduced more than threefold to only 7.6 deaths per
100,000 population, partly because of disinfection and filtration of community water supplies. Deaths from typhoid and
paratyphoid fever dropped below 0.05 per 100,000 population in 1953 and have remained at that level since then (5).
During that same time span, deaths due to gastritis, duodenitis, enteritis, and colitis dropped from a high of 142.7 per
100,000 population in 1900 to less than 1 per 100,000 population beginning in 1968 (and continuing through 1996) (5).
Thus, the impact of enteric diseases on mortality has been
greatly reduced over the last century. However, the proportion of Americans who are at high risk for severe enteric
disease because of low immunity or advanced age is
increasing each year.
Using national mortality data, we made a quantitative estimate of the numbers of endemic and epidemic deaths related
to microbial-enteric disease in the United States from 1989
to 1996. Specific goals of this study were to estimate agespecific reporting rates of microbial-enteric diseases as
Enteric diseases continue to contribute to the overall
burden of human disease. In vulnerable populations such as
young children, the elderly, and the immunocompromised,
enteric diseases are especially prevalent and more often result
in serious outcomes. It has been estimated that the cost of
acute intestinal infections in the United States, including
medical costs and lost productivity, exceeds $20 billion annually (1, 2). A recent report from the FoodNet surveillance
system estimated that there are 76 million cases of foodborne
disease each year in the United States (3). Many foodborne
pathogens are enteric in origin, but these infections represent
a fraction of all enteric infections, which may also occur
through waterborne or person-to-person transmission.
During the 20th century, rates of death due to enteric
diseases plummeted, largely because of disinfection of
drinking water. In 1900, 8.3 percent of all deaths were due to
the broad cause of gastritis (including diarrhea, enteritis, and
colitis), but by 1990 all infectious diseases (respiratory as
well as gastrointestinal) accounted for only 1.8 percent of
deaths (4). In 1900, 31.3 deaths per 100,000 population were
due to typhoid and paratyphoid fever (5) (International Clas-
Reprint requests to Dr. Rebecca L. Calderon, National Health and Environmental Effects Laboratory, US Environmental Protection Agency,
MD-58C, Research Triangle Park, NC 27711 (e-mail: [email protected]).
58
Am J Epidemiol 2003;157:58–65
Enteric Disease as a Cause of Death 59
causes of death and to investigate regional and etiologic
trends in reporting rates of these diseases in relation to deaths
in the United States.
MATERIALS AND METHODS
Data
The National Center for Health Statistics Multiple Cause
of Death (MCD) data sets (6–13) include data on all recorded
deaths that occur in the United States, Puerto Rico, Guam,
and the US Virgin Islands within specified years. Each
record includes information from the decedent’s death certificate about the underlying cause of death, multiple conditions that contributed to the death, and the place and date of
death, as well as demographic data on the decedent. Each
record may contain up to 20 causes of death that were coded
using the ICD-9. For the years 1989–1996, every recorded
death in the United States was included within these data
sets. Deaths that occurred outside of the 50 states, such as
those in Guam, the Virgin Islands, and Puerto Rico, were
excluded from this analysis.
Two sets of codes on conditions considered contributing
causes of death are included for each data record in the MCD
files. The original death certificate coding is preserved in the
entity-axis codes, while the record-axis codes have been
edited by the National Center for Health Statistics to eliminate contradictions and to define the condition most
precisely within the limitations of ICD-9 coding and the
available medical information on the death certificate (6).
Record-axis codes are used by the National Center for
Health Statistics for the published MCD statistics. The
ordering of codes within each record is not the same as it
appeared on the death certificate, and this should not be
considered relevant information. Record-axis codes represent the most meaningful codes for the reported condition,
but some detail has been removed from the entity code for
that record. ICD-9 category titles apply directly to recordaxis codes. For example, a decedent with entity codes ICD-9
571.5 (cirrhosis of the liver without mention of alcohol) and
ICD-9 303 (alcohol dependence syndrome) would have
those codes replaced in the record-axis data by ICD-9 571.2
(alcoholic cirrhosis of the liver) (6). This analysis used the
record-axis codes from the MCD files.
Poisson regression was used to estimate relative risks for
possible predictors of enteric disease, including age group,
sex, race, and US Census region.
Analysis
The MCD data were categorized by decedent age, race,
and US Census region and then analyzed for reports of
enteric disease. Four broad ICD-9 code categories based on
the etiologic agents responsible for disease were used in the
analysis. “Bacterial deaths” include decedents whose death
certificates mentioned certain ICD-9 codes in the 001–004,
008, and 041 groups; “viral deaths” include decedents whose
death certificates mentioned certain ICD-9 codes in the 8.6,
045, 047–049, 070, 074, 079, 138, and 139 groups; “protozoal deaths” include decedents whose death certificates
Am J Epidemiol 2003;157:58–65
mentioned certain ICD-9 codes in the 006, 007, and 127
groups; and “other microbial deaths” include decedents
whose death certificates mentioned certain ICD-9 codes in
the 008, 009, and 139 groups. The category “all enteric
disease deaths” includes the sum of the bacterial, viral,
protozoal, and other microbial categories.
Each record was examined for the presence of any of the
designated ICD-9 codes in any position (from the underlying
cause of death through the 20th contributing cause of death)
within the record. An indicator variable was indexed for each
type of microbe for each diagnosed disease. These cases
were then summed within the microbial categories to create
national estimates of the number of bacterial, viral, protozoal, and other microbial diseases that contributed to deaths.
Each enteric diagnosis was counted separately, so that the
number of diseases could be estimated. For example, if an
individual died with an intestinal Campylobacter infection
(ICD-9 code 8.43) as well as giardiasis (ICD-9 code 7.1) and
hepatitis A (ICD-9 code 70.1), the individual would be
counted under each of the three enteric diseases rather than
as just one decedent with multiple diseases.
The MCD data do not include population figures, so the
Census Bureau’s Population Estimates Program (14) was
used to obtain population denominators for calculation of
region-, age-, and race/ethnicity-specific rates. For these
analyses, the “White” ethnicity category includes nonHispanic Whites and the “Black” category includes nonHispanic Blacks. The “Other” category includes Hispanics
and all other reported racial and ethnic designations,
including but not limited to Native Americans, Aleuts,
Inuits, Pacific Islanders, and Asians.
Age- and race-specific rates of death related to enteric
disease were calculated by summing the diseases in each
category and then dividing by the corresponding population
total. For example, the number of reported bacterial enteric
diseases contributing to the deaths of Black children under 5
years of age in 1996 was calculated from the MCD database
(number of deaths = 10). This value was then divided by the
estimated number of Black children under age 5 years in the
United States in 1996 from the US Census data (population =
2,770,999) and multiplied by 100,000 to arrive at a rate of
0.36 deaths due to bacterial enteric diseases per 100,000
population. Thus, the specific death rate for Black children
under 5 years of age is 0.36 deaths per 100,000 population
(10 deaths × 100,000/2,770,999 population = 0.36 per
100,000).
For each death, the underlying cause and up to 20 contributing causes were analyzed. During the years studied, no
decedents had more than 15 causes of death included in their
record. The majority of decedents with an enteric disease had
either one or two enteric diseases listed as causes of death,
and no decedents had more than four enteric diseases listed
as causes of death during the study years (table 1).
RESULTS
Examination of the MCD data from 1989–1996 indicated
a steady increase in the rate of reported deaths associated
with enteric viral diseases (figure 1). During the same
period, reports of bacterial and other microbial enteric
60 Peterson and Calderon
TABLE 1. Frequency and prevalence of enteric disease as a contributing cause of death in the
United States, 1989–1996
No. of deaths, according to no. of enteric
disease diagnoses
Year(s)
One
diagnosis
Two
Three
Four
diagnoses diagnoses diagnoses
Total no.
of deaths
% of decedents
whose death
was related to
enteric disease
1989
1,319
1,768
19
0
3,106
2,153,859
0.14
1990
1,463
1,792
18
0
3,273
2,151,890
0.15
1991
1,757
2,020
20
0
3,797
2,173,060
0.18
1992
2,114
2,231
23
0
4,368
2,179,187
0.20
1993
2,801
2,739
34
0
5,574
2,271,947
0.25
1994
3,375
3,402
38
0
6,815
2,282,288
0.30
1995
3,870
3,843
46
1
7,760
2,315,251
0.34
1996
1989–1996
% of total no. of
decedents
with enteric
disease
diagnoses
4,308
4,247
32
2
8,589
2,318,212
0.37
21,007
22,042
230
3
43,282
17,845,694
0.24
49
51
1
0
diseases as causes of death approximately doubled (bacterial: 0.37 per 100,000 in 1989, 0.73 per 100,000 in 1996;
other microbial: 0.30 per 100,000 in 1989, 0.56 per 100,000
in 1996), while reports of deaths associated with protozoal
diseases remained nearly constant at approximately 0.01–
0.02 reports per 100,000 population. Reports of enteric viral
FIGURE 1.
1996.
Total no. of
deaths
related to
enteric
disease
disease as a cause of death increased approximately threefold over the study period, from a minimum of about 1.3 per
100,000 in 1989 to a maximum of just over 3.5 per 100,000
in 1996. Between 1989 and 1996, the fraction of deaths
related to enteric diseases of any etiology increased each
year, with an average percentage increase of 116 percent.
Rate of reporting of enteric disease as a contributing cause of death in the United States, by year and microorganism group, 1989–
Am J Epidemiol 2003;157:58–65
Enteric Disease as a Cause of Death 61
FIGURE 2.
Rate of reporting of bacterial and viral enteric diseases as contributing causes of death in the United States, by age, 1989–1996.
Age-specific rates
The rate of reported deaths associated with bacterial
diseases increased with age beginning with the 55- to 64year age group and increased sharply in the older age categories (figure 2). Infants and children under 5 years of age
experienced rates similar to those of people aged 25–45
years and higher than those of people aged 5–24 years.
Reported rates of bacterial disease death for the older age
categories were higher each year than in the preceding year.
Viral enteric disease was also more frequently reported as a
cause of death in the oldest age categories, but the increase in
reports of viral enteric disease as a cause of death started at a
younger age level than that for reported deaths associated
with bacterial disease (figure 2). The rates of reported death
associated with viral disease began to increase with the 35to 44-year age group, while bacterial disease death reports
began to increase with the 55- to 64-year age group. In the
most recent years, the rise in the number of reported deaths
associated with viral enteric diseases was most rapid among
decedents aged 65 years or more, while 35- to 64-year-olds
experienced a smaller increase, and the rates of viral enteric
disease for people younger than age 34 years at death were
nearly constant (figure 3).
Age- and race/ethnicity-specific rates
In general, enteric infections were reported more
frequently as a cause of death for Blacks than for persons of
other racial/ethnic categories (figure 4). The disparity among
death rates in the under-5 age category was due to Black
Am J Epidemiol 2003;157:58–65
children and infants dying with other microbial infections at
a rate nearly four times that of children in other racial/ethnic
categories (annual average rate of reporting: Black = 5.8 per
100,000 population; White = 1.6 per 100,000 population;
Other = 1.7 per 100,000 population). In the oldest age category, the racial/ethnic differences in rate are driven by the
rates of bacterial infection: Black elderly suffer from enteric
bacterial infections more than three times as often as White
decedents and five times as often as Other decedents (annual
average rate of reporting of bacterial enteric infection as a
contributing cause of death: Black = 16.9 per 100,000 population; White = 5.2 per 100,000 population; Other = 3.0 per
100,000 population).
Etiologic trends
A frequency analysis of the ICD-9 codes listed for each
death in each microbial category indicated that the increased
rates were due to increased rates of reporting within certain
code groups rather than to an increase in reports of all enteric
diseases. For the bacterial pathogens, the increase in reports
was driven by an increase in the 008 codes (intestinal infection due to other organisms), along with a slight increase in
the 041 codes (bacterial infection in conditions classified
elsewhere). The most commonly reported subcategory
within the bacterial disease diagnoses was the 008.4 code,
which includes Staphylococcus, Pseudomonas, Campylobacter, Yersinia enterocolitica, and Clostridium difficile, as
well as other anaerobes and Gram-negative bacteria. Within
the viral category, the increase was due almost completely to
a rise in reports of the 070 code (viral hepatitis).
62 Peterson and Calderon
FIGURE 3.
Rate of reporting of viral enteric disease as a contributing cause of death in the United States, by age, 1989–1996.
FIGURE 4. Mean annual rate of reporting of all microbial enteric disease as a contributing cause of death in the United States, by age and
ethnicity, 1989–1996.
Am J Epidemiol 2003;157:58–65
Enteric Disease as a Cause of Death 63
TABLE 2. Relative risk associated with Poisson regression model parameters for enteric diseases as causes of death in the United
States, 1989–1996
All enteric infections
Predictor
Bacterial enteric infections
95% CL*
RR*
Viral enteric infections
95% CL
RR
Lower Upper
Protozoal enteric
infections
95% CL
RR
Lower Upper
Other enteric microbial
infections
95% CL
RR
Lower Upper
95% CL
RR
Lower Upper
Lower Upper
Age group
(years)
<5
1.18
1.14
1.23
1.48
1.31
1.67
0.25
0.23
0.27
0.30
0.16
0.56
11.34
10.56 12.18
5-24
1.13
1.07
1.21
2.17
1.82
2.59
0.93
0.86
1.00
1.43
0.84
2.45
2.63
2.25
3.07
25-34
1.00
0.96
1.04
1.68
1.48
1.90
0.83
0.79
0.87
2.37
1.77
3.16
2.21
1.98
2.47
55-64
1.02
0.99
1.05
1.58
1.44
1.74
0.99
0.96
1.02
0.46
0.32
0.66
0.94
0.84
1.04
65-74
1.03
1.01
1.06
2.28
2.11
2.46
0.94
0.91
0.96
0.23
0.15
0.35
1.12
1.02
1.22
≥75
0.99
0.96
1.01
4.62
4.31
4.94
0.62
0.61
0.64
0.39
0.29
0.53
1.95
1.81
2.10
Other
0.98
0.62
1.58
1.02
0.89
1.17
1.00
0.95
1.05
1.19
0.67
2.09
0.87
0.76
1.00
0.97
0.95
0.99
1.22
1.15
1.29
0.88
0.85
0.90
1.19
0.92
1.55
1.19
1.13
1.25
Northeast
0.98
0.96
1.01
1.98
1.87
2.09
0.82
0.80
0.84
0.63
0.46
0.87
1.02
0.96
1.09
Midwest
0.97
0.95
0.99
1.40
1.32
1.49
0.86
0.84
0.89
0.89
0.66
1.20
1.23
1.15
1.31
South
1.02
0.99
1.04
1.33
1.25
1.41
0.95
0.93
0.97
0.85
0.65
1.10
1.16
1.10
1.23
0.96
0.94
0.98
0.91
0.88
0.95
0.98
0.96
1.00
1.57
1.25
1.98
0.91
0.88
0.95
0.99
0.99
1.00
0.97
0.97
0.98
1.00
1.00
1.01
0.88
0.84
0.92
0.98
0.97
0.99
35-54†
Race
Black
White†
Region
West†
Gender
Male
Female†
Year
* RR, relative risk; CL, confidence limits.
† Reference category.
Rates of reported hepatitis infection and intestinal bacterial
infection contributing to death both increased more than threefold over the study period (hepatitis range: from 0.46 reports
per 100,000 population in 1989 to 1.68 reports per 100,000
population in 1996, a 363 percent increase; code 008.4 intestinal bacterial infection range: from 0.076 reports per 100,000
population in 1989 to 0.32 reports per 100,000 population in
1996, a 429 percent increase). During that same time, the fraction of all bacterial codes belonging to the ICD-9 code 008.4
increased by 220 percent (from 20 percent of all deaths related
to enteric bacterial disease in 1989 to 44 percent in 1996).
Risk factor modeling
Poisson regression analysis was performed for each microbial category separately and then for all enteric infections
together. Age group, gender, race, and region were included
as categorical predictors, and year was entered into the
models as a continuous variable (table 2). In every case, age
categories were the most significant predictors of risk, with
different age groups being at highest risk for different types
of pathogens. Children under age 5 years were at highest risk
of death due to other microbial infections (relative risk
Am J Epidemiol 2003;157:58–65
(RR) = 11.34, 95 percent confidence interval (CI): 10.56,
12.18) and all enteric infections combined (RR = 1.18, 95
percent CI: 1.14, 1.23), while people over age 75 years were
at highest risk of death due to bacterial enteric infections
(RR = 4.62, 95 percent CI: 4.31, 4.94). Children under age 5
years and infants had the lowest risk of death due to viral
enteric pathogens (RR = 0.25, 95 percent CI: 0.23, 0.27) as
compared with the 35- to 54-year-old reference group. Risk
of death due to protozoal enteric infection was high in both
persons aged 5–24 years (RR = 1.43, 95 percent CI: 0.84,
2.45) and persons aged 25–34 years (RR = 2.37, 95 percent
CI: 1.77, 3.16), though small numbers of deaths in this
microbial category led to imprecise estimates with wide
confidence intervals.
DISCUSSION
Enteric disease burden in the US population
We estimate that an average of 8,224 enteric infections are
reported as contributing causes of death in the United States
each year. The National Vital Statistics Report for 1997
listed 5,086 deaths due to shigellosis, amebiasis, other intes-
64 Peterson and Calderon
tinal infections, and viral hepatitis along with 6,820 deaths
due to “all other infectious and parasitic diseases” not
including human immunodeficiency virus (HIV) (15).
Because the National Vital Statistics Report includes nonenteric infectious diseases (e.g., pneumonia and influenza) in
the same category as the enteric pathogens we examined, its
reported numbers are higher.
The steady increase in reports of viral enteric disease as a
cause of death in the MCD data could be due to several
factors: 1) over time, physicians may be coding more contributing causes of death; 2) the US population is aging, and
increasing numbers of aged and immunocompromised Americans are susceptible to viral enteric diseases; and 3) techniques for diagnosing specific enteric viruses have improved
since 1989, so it is more likely that decedents could have been
diagnosed with viral enteric infections before death and the
code was then included as a contributing cause of death. The
difference in the rate of increase for viral as opposed to bacterial pathogens supports the hypothesis of changing diagnostic
techniques that allow for more detection of viral infections.
An analysis of the number of causes of death coded for each
record during the years under study indicated that the mean
number of causes of death coded was 3.11 per decedent, with
a variance between years of 0.0008. This indicates that the
number of codes recorded for each decedent was nearly
constant over time, and the increased number of reports of
enteric disease related to death was not due to a change in the
usual number of causes of death coded for each decedent.
Analysis of the underlying cause of death separate from all
contributing causes combined revealed that the rate of viral
enteric diseases’ being reported as the underlying cause of
death more than doubled during the study period (from 0.48
deaths per 100,000 population in 1989 to 1.20 deaths per
100,000 population in 1996). The rate of reporting of any
enteric disease as the underlying cause of death is also
increasing and is being driven by the increased reports of
viral enteric deaths. Rates of reporting of bacterial and other
microbial enteric infections as the underlying cause of death
approximately doubled over the study period (bacterial
infections: from 0.12 deaths per 100,000 population in 1989
to 0.21 deaths per 100,000 population in 1996; other microbial infections: from 0.11 deaths per 100,000 population in
1989 to 0.21 deaths per 100,000 population in 1996). Bacterial and other enteric microbial deaths represent a small fraction of the deaths related to viral enteric infections.
Determining the true cause behind observed differences in
enteric disease burden within population groups or for
specific pathogens is beyond the scope of this analysis.
hood morbidity and mortality from 1948–1986 estimated
that 325–425 US children under 5 years of age die from diarrhea each year (16). Since different International Classification of Diseases codes were used, our death estimates cannot
be directly compared with those of other studies, but our estimates were similar in magnitude to those of the previous
review.
Black children under 5 years of age have enteric infections
listed as a cause of death more than four times as often as
children of other races in the same age group. This suggests
that factors other than pathogen virulence are responsible for
the greater risk of mortality associated with these infections
in some children. Black decedents less than 5 years old had
ICD-9 codes for disorders relating to short gestation and low
birth weight (ICD-9 codes 765.0 and 765.1) included on
their death certificates twice as often as decedents from the
White and Other racial categories (Black, 19.5 percent;
White, 8.8 percent; Other, 10.9 percent). Other factors and
exposures not captured on the death certificate may also
contribute to increased risk of death from enteric disease.
Enteric disease burden in children
Impact of enteric disease
Generally, children have high rates of viral infection
because they have not yet acquired immunity to viral pathogens. The low reporting rates for viral disease associated
with children’s deaths, however, suggest that while children
may experience higher rates of enteric viral infection, these
infections are rarely so serious as to cause or contribute to
death. We estimated that enteric diseases are reported as a
contributing cause of death for 456 children under age 5 each
year. A review of studies of the impact of diarrhea on child-
In 1996, 0.37 percent of deaths were related to enteric
disease (8,589 deaths out of 2,318,212). This is 2.6 times the
1989 value of 0.14 percent. The average percentage increase
from one year to the next in the fraction of deaths related to
enteric disease from 1989 to 1996 was 116 percent (range,
111–122 percent). As the population ages and as more
Americans live with compromised immune systems, the
fraction of deaths related to enteric disease will continue to
increase.
Enteric disease in the immunocompromised
The immune status of persons infected with HIV makes
them more susceptible to enteric infections and more likely
to be suffering from a serious enteric infection at the time of
their death. The most interesting trend possibly affecting this
subpopulation is the increasing rate of reported viral enteric
disease associated with death among people aged 25–45
years (figure 2). The rate was fairly linear in 1989, but by
1996 there was a distinct rise in the rates of reported viral
enteric disease associated with death. It is possible that this
is a direct result of the acquired immunodeficiency
syndrome (AIDS) epidemic in those age groups. Peak
mortality associated with AIDS occurs among persons aged
30–34 years (17).
The rates of reported death associated with protozoal
enteric diseases increased similarly in both Blacks and
Whites, centered at the 35- to 44-year age group. This
finding agrees with current prevalence figures for HIV and
AIDS indicating that the age category with both the highest
incidence of AIDS and the highest mortality from AIDS is
30–34 years in all racial/ethnic groups (17). A similar
increase in the rate of reported other enteric microbial infections associated with death is slightly evident among Blacks.
This increase may also be due to HIV infection, because the
prevalence of HIV infection is higher among minority Americans than in the White population (17).
Am J Epidemiol 2003;157:58–65
Enteric Disease as a Cause of Death 65
Deaths related to bacterial enteric disease in the elderly, a
quickly growing segment of the US population, are
increasing at a greater rate than in any other age category.
This also suggests that enteric disease will be a continuing
and expanding burden on the health care system unless better
prevention and control measures are found and implemented. The fact that hepatitis A, a vaccine-preventable
disease, is contributing to the deaths of more people each
year should not go unnoticed. Vaccination against hepatitis
A may be one public health intervention strategy for
reducing preventable deaths.
Another factor affecting the number of deaths related to
enteric disease each year is the number of Americans living
with HIV infection (ICD-9 code 042). Of the deaths related
to enteric disease in 1989, 3.3 percent also included HIV as
a cause of death (161 deaths out of 4,912); by 1996, this fraction had increased to 4.6 percent (592 deaths out of 12,906).
In summary, the rate of reporting of enteric diseases as
contributing causes of death more than doubled between
1989 and 1996. People over age 65 years have the highest
rates of reporting of enteric diseases as causes of death. Viral
enteric diseases contributed to an increasing number of
deaths among people in the 35- to 55-year age groups during
the study period, probably because of the impact of HIV and
AIDS in that population. Nonwhite Americans are most
affected by enteric diseases as contributing causes of death.
While enteric disease caused many fewer deaths in the 1990s
than in the 1920s, these diseases remain an important and
often preventable contributor to mortality in the United
States.
ACKNOWLEDGMENTS
Funding for this analysis was provided by a Biostatistics
for Research in Environmental Health training grant from
the National Institute of Environmental Health Sciences and
by an NHEERL-DESE Cooperative Training Agreement in
Environmental Sciences Research (EPA CT826513) from
the Environmental Protection Agency.
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