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<span>Surveillance Report #118</span>
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<div><p><strong>LIVER CIRRHOSIS MORTALITY IN THE UNITED STATES: NATIONAL, STATE, AND REGIONAL TRENDS, 2000–2019</strong></p>
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<p>Chiung M. Chen, M.A.<br>
|
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Young-Hee Yoon, Ph.D.</p>
|
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<p>CSR, Incorporated<sup>1</sup><br>
|
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Suite 220<br>
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22375 Broderick Drive<br>
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Sterling, VA 20166</p>
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<p>February 2022</p>
|
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<p><br>
|
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U.S. Department of Health and Human Services<br>
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Public Health Service<br>
|
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National Institutes of Health</p>
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<p><sup>1</sup> CSR, Incorporated, operates the Alcohol Epidemiologic Data System (AEDS) under Contract No. HHSN275201800004C for the National Institute on Alcohol Abuse and Alcoholism (NIAAA). Dr. Michael E. Hilton (Division of Epidemiology and Prevention Research) serves as the NIAAA Contracting Officer's Representative on the contract.</p>
|
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<h2>HIGHLIGHTS</h2>
|
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|
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<p>This surveillance report, prepared biennially by the Alcohol Epidemiologic Data System (AEDS), National Institute on Alcohol Abuse and Alcoholism (NIAAA), presents trends in liver cirrhosis mortality in the United States. Data on the underlying cause of death were compiled from public use data files published annually by the National Center for Health Statistics (NCHS). Population data from the U.S. Census Bureau and NCHS were used as denominators to calculate mortality rates.</p>
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<p>The age-adjusted death rate from liver cirrhosis in the United States increased steadily, from 11.9 deaths per 100,000 population at the end of Prohibition in 1933 to a peak of 18.1 deaths per 100,000 population in 1973, and then steadily declined for three decades until 2006, at 9.0 deaths per 100,000 population, but the long-term downward trend started to shift its course and reached 12.2 deaths per 100,000 population in 2019. Sex differences in alcohol-related liver cirrhosis mortality across ages reflected the consequences of a consistent but narrowing gender gap in alcohol consumption. The following are highlights of liver cirrhosis mortality in 2019 and its trends from 2000 through 2019.</p>
|
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<h3>Cirrhosis Mortality in 2019</h3>
|
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|
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<ul>
|
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<li>In 2019, liver cirrhosis was the 11th leading cause of death in the United States, accounting for a total of 47,919 deaths—1,947 more than in 2018. The crude death rate from all cirrhosis was 14.6 deaths per 100,000 population, up 3.8 percent from 2018, and the rate from alcohol-related cirrhosis was 7.3, slightly higher than the 2018 estimate of 7.1.</li>
|
||
<li>Among all cirrhosis deaths, 50.3 percent were alcohol related. The proportion of alcohol-related cirrhosis was highest (80.9 percent) among decedents ages 25 to 34, followed by decedents ages 35 to 44, at 75.4 percent. The gender gap in the proportion of alcohol-related cirrhosis was smaller among those who died before reaching age 55 than among those in older age groups.</li>
|
||
<li>The age-adjusted death rate from all cirrhosis for Hispanic White males was 1.4 times the rate for non-Hispanic White males and 2.2 times the rate for non-Hispanic Black males. The rate for Hispanic White females was 1.1 times the rate for non-Hispanic White females and 1.9 times the rate for non-Hispanic Black females.</li>
|
||
<li>Wide variations existed across Hispanic subgroups. The 5-year annual average of age-adjusted death rates from all cirrhosis was highest among Mexican-origin Hispanics and Puerto Rican-origin Hispanics and lowest among Cuban-origin Hispanics, in both males and females.</li>
|
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</ul>
|
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|
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<h3>Cirrhosis Mortality Trends</h3>
|
||
|
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<ul>
|
||
<li>Although the age-adjusted all-cause mortality rate declined by 18.3 percent from 2000 to 2019, the age-adjusted death rate from all liver cirrhosis increased over the same period by 26.4 percent—from 9.7 to 12.2 deaths per 100,000 population. Rates for White males and females increased by 25.4 percent and 55.2 percent, respectively, whereas rates for Black males and females declined by 25.7 percent and 13.8 percent, respectively.</li>
|
||
<li>The age-adjusted death rate from all liver cirrhosis for males was about twice that of females but varied slightly by race/Hispanic origin.</li>
|
||
<li>The age-adjusted death rate from alcohol-related liver cirrhosis increased by 47.0 percent—from 4.3 deaths per 100,000 population in 2000 to 6.4 deaths per 100,000 population in 2019. Rates for males and females increased 33.0 percent and 83.5 percent, respectively. Rates for White males and females increased by 43.5 percent and 106 percent, respectively, whereas rates for Black males and females declined by 20.7 percent and 7.9 percent, respectively.</li>
|
||
<li>From 2000 to 2019, the age-specific death rates from all liver cirrhosis increased for ages 25–34 (127 percent), 35–44 (9.4 percent), 45–54 (14.8 percent), 55–64 (48.8 percent), 65–74 (23.7 percent), 75–84 (21.7 percent), and 85 or older (27.1 percent).</li>
|
||
<li>Between 2000 and 2019, changes in the age-adjusted death rate from all liver cirrhosis included increases in 47 States and decreases in 3 States and the District of Columbia.</li>
|
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</ul>
|
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|
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<h3><em>Healthy People 2030</em> Objectives</h3>
|
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|
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<ul>
|
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<li>One of the objectives of <em>Healthy People 2030 </em>is to reduce age-adjusted death rates of liver cirrhosis, not including portal hypertension and fatty (change of) liver not elsewhere classified, to no more than 10.9 deaths per 100,000 population. To achieve this goal, the age-adjusted death rate must decrease by 0.3 percent per year from 2019 through 2030.</li>
|
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</ul>
|
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|
||
<h2>INTRODUCTION</h2>
|
||
|
||
<p>This surveillance report on liver cirrhosis mortality is one of a series of three reports published annually or biennially to monitor trends in alcohol consumption and alcohol-related mortality in the United States. These surveillance reports are prepared by the Alcohol Epidemiologic Data System (AEDS), Division of Epidemiology and Prevention Research, National Institute on Alcohol Abuse and Alcoholism (NIAAA), and are intended to be useful to researchers, policymakers, and other professionals interested in alcohol misuse and its long-term effects. The data are also essential in assessing progress toward meeting the Nation’s health promotion and disease prevention objective of reducing liver cirrhosis mortality, as stated in <em>Healthy People 2030</em> (U.S. Department of Health and Human Services [HHS] n.d.).</p>
|
||
|
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<p>Cirrhosis of the liver is an outcome caused by a variety of factors, including alcohol consumption, obesity, exposure to various drugs and toxic chemicals, viral hepatitis, and other viral and infectious diseases (Dufour et al. 1993; Goldberg and Chopra 2021a; Scaglione et al. 2015; Wahlang et al. 2013; Zakhari 2013). It has been well established that alcohol misuse is a major contributor to deaths from cirrhosis and the related condition of alcoholic hepatitis (Mann et al. 2003; Rehm et al. 2013; Szabo and Mandrekar 2010). The recent decline in Hepatitis C deaths, due to improvements in treatment options (Kim et al. 2018; Lee and Terrault 2019), has increased the relative contribution of alcohol consumption to cirrhosis mortality.</p>
|
||
|
||
<p>The level and duration of alcohol consumption are important determinants in the development of liver pathology. As the primary site for detoxification of alcohol by oxidation of its metabolites, the liver can undergo three pathologies: fatty liver, alcoholic hepatitis, and cirrhosis. Patients with cirrhosis are susceptible to infections and complications, and their prognosis is highly variable (Bajaj et al. 2021; Goldberg and Chopra 2021b). Other than liver transplantation, no method exists for repairing liver damage associated with cirrhosis in advanced stages (Singh et al. 2017). In earlier stages, if patients with cirrhosis resulting from alcohol consumption abstain from further alcohol use, the consequences of this disease can be treated, and their lives can be prolonged (Veldt et al. 2002). Liver fibrosis screening, early detection, and prevention of further damage are important in prolonging life (Ginès et al. 2021).</p>
|
||
|
||
<p>The coding scheme used in the United States to classify cause of death is the International Classification of Diseases (ICD), a statistical classification of disease and injury widely used by countries supporting mortality reporting systems. ICD codes classify the cause of death from cirrhosis as either related to alcohol or not related to alcohol. However, because of the stigma associated with excessive alcohol use, some physicians and other officials who certify causes of death may not identify alcohol in the case of a death from cirrhosis in an effort to protect the decedent’s family members. Furthermore, it is difficult to determine the alcohol-relatedness of a cirrhosis death without knowing the decedent’s history of alcohol consumption. As a result, alcohol-related cirrhosis mortality can be significantly underreported. For instance, from 2000 to 2019, the proportion of all cirrhosis deaths coded as alcohol related ranged from 44 to 51 percent (depending on year). However, some researchers believe alcohol might have contributed to a substantially higher proportion of all deaths from cirrhosis (Haberman and Weinbaum 1990; Powell and Klatskin 1968; Puffer and Griffith 1967; Ramstedt 2003; Stein et al. 2016). Therefore, this surveillance report examines all cirrhosis deaths as well as those that are explicitly coded as alcohol related.</p>
|
||
|
||
<p>This report has been presenting national data since its first issue published in 1986. Beginning with its 2014 issue, the report added data for States and Census Regions, and the report’s title was revised accordingly. Because of this addition, the report focuses on data in the 2000s and onward to closely monitor the emerging trends and patterns in cirrhosis mortality. To provide readers a quick reference of the historical trend, the report retains one table and one figure on national total cirrhosis mortality from 1910 to the present. Detailed national data for 1970–1999 are available online in the 2012 issue of this report (<a href="/sites/default/files/Cirr09.pdf">Surveillance Report#93 </a>).</p>
|
||
|
||
<h2>DATA SOURCES</h2>
|
||
|
||
<h3>Alcohol Consumption Data</h3>
|
||
|
||
<p>Death counts and rates in this report are based on a single underlying cause of each death, defined as “the disease or injury which initiated the train of morbid events leading directly or indirectly to death or circumstances of the accident or violence which produced the fatal injury” (National Center for Health Statistics [NCHS] 1982). This approach is consistent with other mortality statistics reported by NCHS.</p>
|
||
|
||
<p>Cirrhosis death records for national trends for 1970–2019 were extracted from public use mortality data files produced by NCHS. These data files contained individual records of each death occurring in the United States, with the exception of data files for 1972, which contained only a 50-percent sample of all U.S. deaths. The deaths counted in this report are for U.S. residents only. Deaths of foreign residents in the United States are not counted. Cirrhosis death data for States and Census Regions for 2000–2019 were obtained from the CDC WONDER online mortality database using its query system (<a href="https://wonder.cdc.gov/">https://wonder.cdc.gov/</a>).</p>
|
||
|
||
<p>Historical cirrhosis mortality rates for 1910–1969 (presented in Figure 1 and <a href="/sites/default/files/surveillance-report118.pdf#page=33">Table 1</a>) were calculated based on historical government documents that NCHS made available on the Internet ( <a href="https://www.cdc.gov/nchs/products/vsus.htm">https://www.cdc.gov/nchs/products/vsus.htm</a>). For 1910–1919, the data sources included the National Office of Vital Statistics special report (1956) and intercensal resident population estimates in death registration States developed by the Bureau of the Census and presented in Linder and Grove (1943). For 1920–1969, the data sources included the annual reports of the Mortality Statistics (Bureau of the Census 1922–1938) and Vital Statistics in the United States (Bureau of the Census 1939–1946; National Center for Health Statistics 1961–1974; National Office of Vital Statistics 1947–1951 and 1953–1960). Note that all historical mortality statistics were based on numbers obtained through State death registration offices. Before 1933, not all States collected death registration information. The changing number of death registration States impedes the process of obtaining comparable mortality data for the United States before 1933.</p>
|
||
|
||
<p>Population data from various estimates provided by the U.S. Census Bureau were used as denominators for calculating mortality rates in this report. Appendix A lists the detailed data sources for population estimates at the national and State levels and for Hispanic subgroups.</p>
|
||
|
||
<h2>METHODS</h2>
|
||
|
||
<h3>Definitions and Subclassifications of Liver Cirrhosis</h3>
|
||
|
||
<p>This report presents data for three major subcategories of liver cirrhosis: alcohol-related liver cirrhosis, specified liver cirrhosis without mention of alcohol, and unspecified liver cirrhosis without mention of alcohol (see the last column of the <a href="/sites/default/files/surveillance-report118.pdf#page=6">table</a> "Crosswalk of ICD-10 codes to ICD-9 codes and ICDA-8 codes" on page 4). When the case numbers are small, the latter two subcategories are combined into one and labeled as "all other cirrhosis without mention of alcohol."</p>
|
||
|
||
<p>During the long period (1910–2019) for which historical mortality statistics are shown in this report, cause of death was classified according to nine revisions of the ICD. The ICD has been revised periodically to reflect progress in medical knowledge, with later revisions generally providing greater specificity of coding.</p>
|
||
|
||
<table cellpadding="5" cellspacing="0" summary="Crosswalk of ICD 10 to ICD 9 codes">
|
||
<caption><strong>Crosswalk of ICD-10 codes to ICD-9 codes and ICDA-8 codes</strong></caption>
|
||
<thead>
|
||
<tr>
|
||
<th abbr="ICD 10"><strong>ICD-10</strong></th>
|
||
<th abbr="ICD 9"><strong>ICD-9</strong></th>
|
||
<th abbr="ICD 8"><strong>ICDA-8</strong></th>
|
||
</tr>
|
||
</thead>
|
||
<tbody>
|
||
<tr>
|
||
<td headers="un_0">
|
||
<p>K70.0 Alcoholic fatty liver</p>
|
||
</td>
|
||
<td headers="un_1">
|
||
<p>571.0 Alcoholic fatty liver</p>
|
||
</td>
|
||
<td headers="un_2" rowspan="5">
|
||
<p>571.0 Alcohol-related liver cirrhosis</p>
|
||
</td>
|
||
</tr>
|
||
<tr>
|
||
<td headers="un_0">
|
||
<p>K70.1 Alcoholic hepatitis</p>
|
||
</td>
|
||
<td headers="un_1">
|
||
<p>571.1 Acute alcoholic hepatitis</p>
|
||
</td>
|
||
</tr>
|
||
<tr>
|
||
<td headers="un_0">
|
||
<p>K70.2 Alcoholic fibrosis and sclerosis of liver</p>
|
||
|
||
<p>K70.3 Alcoholic cirrhosis of liver</p>
|
||
</td>
|
||
<td headers="un_1">
|
||
<p>571.2 Alcoholic cirrhosis of liver</p>
|
||
</td>
|
||
</tr>
|
||
<tr>
|
||
<td headers="un_0">
|
||
<p>K70.9 Alcoholic liver disease, unspecified</p>
|
||
</td>
|
||
<td headers="un_1">
|
||
<p>571.3 Alcoholic liver damage, unspecified</p>
|
||
</td>
|
||
</tr>
|
||
<tr>
|
||
<td headers="un_0">
|
||
<p>K70.4 Alcoholic hepatic failure</p>
|
||
</td>
|
||
</tr>
|
||
<tr>
|
||
<td headers="un_0">
|
||
<p>K73.0 Chronic persistent hepatitis, not elsewhere classified (n.e.c.)</p>
|
||
|
||
<p>K73.1 Chronic lobular hepatitis, n.e.c.</p>
|
||
|
||
<p>K73.2 Chronic active hepatitis, n.e.c.</p>
|
||
|
||
<p>K73.8 Other chronic hepatitis, n.e.c.</p>
|
||
|
||
<p>K73.9 Chronic hepatitis, unspecified</p>
|
||
</td>
|
||
<td headers="un_1">
|
||
<p>571.4 Chronic hepatitis</p>
|
||
</td>
|
||
<td headers="un_2" rowspan="4">
|
||
<p>571.8 Specified liver cirrhosis without mention of alcohol</p>
|
||
</td>
|
||
</tr>
|
||
<tr>
|
||
<td headers="un_0">
|
||
<p>K74.3 Primary biliary cirrhosis</p>
|
||
|
||
<p>K74.4 Secondary biliary cirrhosis</p>
|
||
|
||
<p>K74.5 Biliary cirrhosis, unspecified</p>
|
||
</td>
|
||
<td headers="un_1">
|
||
<p>571.6 Biliary cirrhosis</p>
|
||
</td>
|
||
</tr>
|
||
<tr>
|
||
<td headers="un_0">
|
||
<p>K76.0 Fatty (change of) liver, n.e.c.<sup>1</sup></p>
|
||
</td>
|
||
<td headers="un_1">
|
||
<p>571.8 Other chronic nonalcoholic liver disease</p>
|
||
</td>
|
||
</tr>
|
||
<tr>
|
||
<td headers="un_0">
|
||
<p>K76.6 Portal hypertension<sup>1</sup></p>
|
||
</td>
|
||
<td headers="un_1">
|
||
<p>572.3 Portal hypertension</p>
|
||
</td>
|
||
</tr>
|
||
<tr>
|
||
<td headers="un_0">
|
||
<p>K74.0 Hepatic fibrosis</p>
|
||
|
||
<p>K74.2 Hepatic fibrosis with hepatic sclerosis</p>
|
||
|
||
<p>K74.6 Other and unspecified cirrhosis of liver</p>
|
||
</td>
|
||
<td headers="un_1">
|
||
<p>571.5 Cirrhosis of the liver without mention of alcohol</p>
|
||
</td>
|
||
<td headers="un_2" rowspan="2">
|
||
<p>571.9 Unspecified liver cirrhosis without mention of alcohol</p>
|
||
</td>
|
||
</tr>
|
||
<tr>
|
||
<td headers="un_0">
|
||
<p>K74.1 Hepatic sclerosis</p>
|
||
</td>
|
||
<td headers="un_1">
|
||
<p>571.9 Unspecified liver cirrhosis without mention of alcohol</p>
|
||
</td>
|
||
</tr>
|
||
</tbody>
|
||
</table>
|
||
|
||
<p><sup>1</sup> Not defined as liver cirrhosis by NCHS.</p>
|
||
|
||
<p>The eighth (NCHS 1968), ninth (World Health Organization [WHO] 1978), and tenth (WHO 1992) revisions of the ICD (ICDA-8, ICD-9, and ICD-10, implemented in 1968, 1979, and 1999, respectively) provide for coding categories of cirrhosis with and without mention of alcohol. ICD-9 uses different categories for cirrhosis than does ICDA-8. ICD-10 uses twice as many categories for cirrhosis as does ICD-9. To examine trends for comparable diseases over time, ICD-9 and ICD-10 categories must be matched and recoded to those consistent with ICDA-8 categories. The relevant crosswalk of the three ICD revisions, developed by AEDS staff in collaboration with NIAAA's former Division of Biometry and Epidemiology (DBE), is shown in the <a href="/sites/default/files/surveillance-report118.pdf#page=6">table</a> "Crosswalk of ICD-10 codes to ICD-9 codes and ICDA-8 codes." As the ICD-10 column shows, this report includes portal hypertension (ICD code K76.6) and fatty (change of) liver not elsewhere classified (n.e.c.) (ICD code K76.0) among cirrhosis categories. Because NCHS counts only ICD codes K70, K73, and K74 as liver cirrhosis, numbers presented in this report are slightly larger than those reported by NCHS.</p>
|
||
|
||
<h3>Race and Hispanic Origin of Decedent</h3>
|
||
|
||
<p>Data presented in this report include White and Black race categories. Other races such as American Indian/Alaska Native and Asian/Pacific Islander are not shown separately but are subsumed within the "all races" category. In compliance with the "Revisions to the Standards for the Classification of Federal Data on Race and Ethnicity" (Office of Management and Budget 1997), the 2003 revision of the U.S. Standard Certificate of Death allows the reporting of more than one race (multiple races). The number of States reporting multiple races on death certificates increased from 7 States (California, Hawaii, Idaho, Maine, Montana, New York, and Wisconsin) in 2003 to all States and the District of Columbia by 2018 (Xu et al. 2021). Since 2003, NCHS has "bridged" multiple races to a single race to make the data uniform over time and comparable between death certificates and population estimates. In this effort, a single race was imputed for multiracial decedents according to the combination of races, Hispanic origin, sex, and age indicated on their death certificates (Weed 2004).</p>
|
||
|
||
<p>Vital statistics data also provide information on the Hispanic origin (also known as ethnicity) of decedents. From 2000 through 2019, the percentage of cirrhosis deaths with unknown Hispanic origin was less than 1 percent for both Black and White decedents. In 2019, only 0.3 percent of cirrhosis decedents had an "unknown" classification for Hispanic origin. The tables and figures showing data based on Hispanic origin excluded decedents for whom Hispanic origin could not be determined. Readers are cautioned that rates calculated for Black Hispanics are unreliable because of the small number of cirrhosis deaths in this population subgroup.</p>
|
||
|
||
<p>After continuous, rapid population growth over the past few decades, Hispanics became the largest minority group in the United States in 2001 (U.S. Census Bureau 2011). Although Hispanics often are considered one ethnic group, they are well known for heterogeneity by country of origin in terms of socioeconomic status and drinking patterns, which may well affect cirrhosis mortality. To provide information on Hispanic subgroup differences, this report presents additional data on cirrhosis mortality rates for four major Hispanic subgroups: Mexican-origin, Puerto Rican-origin, Cuban-origin, and Other Hispanics.</p>
|
||
|
||
<h3>Mortality Measures</h3>
|
||
|
||
<p>For epidemiologic purposes, mortality rates are used to compare the frequency of death from a disease or condition. The following measures are used in this report to assess trends in liver cirrhosis mortality:</p>
|
||
|
||
<ul>
|
||
<li><em>Unadjusted (or crude) death rates</em>-These are summary measures calculated by dividing the total number of deaths from cirrhosis (or subcategories) in the population in a certain year by the total number of individuals in that population in that year (i.e., population at risk). Problems can arise when comparing crude rates between various years to assess any change in mortality over time because the populations at risk may differ with respect to an underlying characteristic such as age, race, or sex. For example, an older population tends to have a higher rate of death for a target disease than a younger population because death from disease is more common in an aging population. In this case, rates in different populations should be assessed by comparing age-specific rates and age-adjusted rates.</li>
|
||
<li><em>Age-specific death rates</em>-These rates for any year refer to the number of deaths from liver cirrhosis (or subcategories) in a defined age interval, divided by the total number of persons in that age interval. For a given age interval, examining age-specific rates for various years allows comparison of mortality rates among subgroups of the population that do not differ in their age distribution. Age-specific rates also provide a basis for detailed study of the variation of mortality rates among different age intervals in any single year.</li>
|
||
<li><em>Age-adjusted death rates</em>-These are statistically constructed summary rates that account for differences in mortality, regardless of any difference in the age distribution between populations. Age adjustment assumes that populations have the same age distribution and applies a standard age distribution to the calculation of age-adjusted rates for various populations. Therefore, when comparing age-adjusted rates of two populations, any differences between the rates can no longer be attributed to the difference in the age distribution between the two populations. Age adjustment is crucial for standardizing rates over many years because the U.S. population has grown progressively older in recent decades. Without age adjustment, any apparent increases in unadjusted mortality rates for cirrhosis (or any other disease) could be due to the fact that older people are more likely to die from disease.</li>
|
||
</ul>
|
||
|
||
<p>According to the HHS requirement (1998), this report applies the year 2000 standard population to the calculation of all age-adjusted death rates (replacing the 1940 standard population used in issues published before 2002).<sup>1</sup></p>
|
||
|
||
<p><sup>1</sup> Standard population age distribution:</p>
|
||
|
||
<table border="0" cellpadding="0" cellspacing="0" summary="Footnote number one" width="50%">
|
||
<thead>
|
||
<tr>
|
||
<td> </td>
|
||
<th abbr="number" colspan="2"><strong>Number</strong></th>
|
||
</tr>
|
||
</thead>
|
||
<tbody>
|
||
<tr>
|
||
<th abbr="Age Group">Age group</th>
|
||
<th abbr="1940" headers="un_6">
|
||
<p>1940</p>
|
||
</th>
|
||
<th abbr="2000" headers="un_6">
|
||
<p>2000</p>
|
||
</th>
|
||
</tr>
|
||
<tr>
|
||
<td abbr="0-24" headers="un_3"><strong>0 to 24 years</strong></td>
|
||
<td headers="un_9 un_6 un_4">432,093</td>
|
||
<td headers="un_9 un_6 un_5">97,039,882</td>
|
||
</tr>
|
||
<tr>
|
||
<td abbr="25-34" headers="un_3"><strong>25 to 34 years</strong></td>
|
||
<td headers="un_10 un_6 un_4">162,066</td>
|
||
<td headers="un_10 un_6 un_5">37,233,437</td>
|
||
</tr>
|
||
<tr>
|
||
<td abbr="35-44" headers="un_3"><strong>35 to 44 years</strong></td>
|
||
<td headers="un_11 un_6 un_4">139,237</td>
|
||
<td headers="un_11 un_6 un_5">44,659,185</td>
|
||
</tr>
|
||
<tr>
|
||
<td abbr="45-54" headers="un_3"><strong>45 to 54 years</strong></td>
|
||
<td headers="un_12 un_6 un_4">117,811</td>
|
||
<td headers="un_12 un_6 un_5">37,030,152</td>
|
||
</tr>
|
||
<tr>
|
||
<td abbr="55-64" headers="un_3"><strong>55 to 64 years</strong></td>
|
||
<td headers="un_13 un_6 un_4">80,294</td>
|
||
<td headers="un_13 un_6 un_5">23,961,506</td>
|
||
</tr>
|
||
<tr>
|
||
<td abbr="65-74" headers="un_3"><strong>65 to 74 years</strong></td>
|
||
<td headers="un_14 un_6 un_4">48,426</td>
|
||
<td headers="un_14 un_6 un_5">18,135,514</td>
|
||
</tr>
|
||
<tr>
|
||
<td abbr="75-84" headers="un_3"><strong>75 to 84 years</strong></td>
|
||
<td headers="un_15 un_6 un_4">17,303</td>
|
||
<td headers="un_15 un_6 un_5">12,314,793</td>
|
||
</tr>
|
||
<tr>
|
||
<td abbr="85+" headers="un_3"><strong>85+ years</strong></td>
|
||
<td headers="un_16 un_6 un_4">2,770</td>
|
||
<td headers="un_16 un_6 un_5">4,259,173</td>
|
||
</tr>
|
||
<tr>
|
||
<td abbr="all" headers="un_3"><strong>All ages</strong></td>
|
||
<td headers="un_18 un_6 un_4">1,000,000</td>
|
||
<td headers="un_18 un_6 un_5">274,633,642</td>
|
||
</tr>
|
||
</tbody>
|
||
<tfoot>
|
||
<tr>
|
||
<td abbr="all" colspan="3" headers="un_3">Source: Murphy (2000) for 1940 age standard; Miniño et al. (2007) for 2000 age standard.</td>
|
||
</tr>
|
||
</tfoot>
|
||
</table>
|
||
|
||
<p>Age-adjusted death rates presented in this report were computed by using 10-year age intervals of the enumerated population of the United States in 2000 as the standard population. Results from the age adjustment allow for meaningful comparison of similar rates over long periods of time or from different subpopulations. The basic procedure involves finding the expected number of deaths that would have existed if the age-specific rates for a particular year prevailed in a population whose age distribution was like that of the United States in 2000. This was accomplished by multiplying the specific rates for each age group by the population estimate for the corresponding age group in the standard population. The age-adjusted death rate was then calculated by adding the expected number of deaths for each age group and dividing this sum by the total population estimate taken as the standard.</p>
|
||
|
||
<p>Rates for Hispanic subgroups are based on 5-year annual moving averages to increase the reliability of these estimates. Readers are cautioned that the rates are subject to sampling variability of the population data (denominator) drawn from either the Current Population Survey or the American Community Survey as well as random variations of the death counts (numerator) drawn from the mortality data.</p>
|
||
|
||
<p>Rates for States and Census Regions are based on 3-year annual moving averages to increase the reliability of these estimates.</p>
|
||
|
||
<h3>Limitations</h3>
|
||
|
||
<p>There is no standard definition of liver cirrhosis deaths. This report is based on the NIAAA definition (Stinson et al. 2001), which includes more ICD codes than the NCHS definition but fewer than the WHO Global Burden of Disease definition (Mokdad et al. 2014). The NIAAA definition does not include those deaths with an underlying cause of viral hepatitis, other liver diseases, and some other complications of liver diseases. Death numbers and the corresponding mortality trends over time can differ when estimated using different definitions (Asrani et al. 2013; Manos et al. 2008; Vong and Bell 2004).</p>
|
||
|
||
<p>The introduction of ICD-10 for 1999 data brought changes in rules for selecting the underlying cause of death and new categories. These new rules and categories may contribute to observed changes in the number of deaths from liver cirrhosis. Anderson and colleagues (2001) conducted a comparability study that estimated that the use of ICD-10 would classify an additional 3.67 percent of deaths as due to cirrhosis when compared with ICD-9. Readers should keep this in mind when examining trends involving data from 1999 and later years. In addition, NCHS implemented coding changes in 2007 that resulted in more deaths being assigned to alcoholic liver disease (ICD-10 code K70). Therefore, the unusually big increase in cirrhosis deaths observed from 2006 to 2007 may be largely due to these coding changes (Xu et al. 2010).</p>
|
||
|
||
<h2>REFERENCES</h2>
|
||
|
||
<p>Anderson, R.N.; Miniño, A.M.; Hoyert, D.L.; and Rosenberg, H.M. Comparability of Cause of Death between ICD-9 and ICD-10: Preliminary Estimates. <em>National Vital Statistics Reports</em>, Vol. 49, No. 2. Hyattsville, MD: National Center for Health Statistics, 2001.</p>
|
||
|
||
<p>Arias, E.; Anderson, R.N.; Kung, H.C.; Murphy, S.L.; and Kochanek, K.D. Deaths: Final Data for 2001. <em>National Vital Statistics Reports</em>, Vol. 52, No. 3. Hyattsville, MD: National Center for Health Statistics, 2003.</p>
|
||
|
||
<p>Asrani, S.K.; Larson, J.J.; Yawn, B.; Therneau, T.M.; and Kim, W.R. Underestimation of liver-related mortality in the United States. <em>Gastroenterology </em>145(2):375–382, 2013.</p>
|
||
|
||
<p>Bajaj, J.S.; Kamath, P.S.; and Reddy, K.R. The Evolving Challenge of Infections in Cirrhosis. <em>New England Journal of Medicine</em> 384(24): 2317–2330, 2021.</p>
|
||
|
||
<p>Bureau of the Census. <em>Mortality Statistics (Data for Years 1920–1936). </em>Washington, DC: Department of Commerce, 1922–1938. Available at: <a href="https://www.cdc.gov/nchs/products/vsus.htm">https://www.cdc.gov/nchs/products/vsus.htm</a>. Accessed November 22, 2021.</p>
|
||
|
||
<p>Bureau of the Census. <em>Vital Statistics of the United States</em> <em>(Data for Years 1937–1944). </em>Washington, DC: Department of Commerce, 1939–1946. Available at:. <a href="https://www.cdc.gov/nchs/products/vsus.htm">https://www.cdc.gov/nchs/products/vsus.htm</a>. Accessed November 22, 2021.</p>
|
||
|
||
<p>Department of Health and Human Services. <em>HHS Policy for Changing the Population Standard for Age Adjusting Death Rates</em>. Memorandum from the Secretary. Washington, DC: DHHS, August 26, 1998. Available at: <a href="https://aspe.hhs.gov/datacncl/ageadj.htm">https://aspe.hhs.gov/datacncl/ageadj.htm</a>. Accessed November 22, 2021.</p>
|
||
|
||
<p>Dufour, M.C.; Stinson, F.S.; and Caces, M.F. Trends in cirrhosis morbidity and mortality: United States, 1979–1988. <em>Seminars in Liver Disease </em>13(2):109–125, 1993.</p>
|
||
|
||
<p>Ginès, P.; Castera, L.; Lammert, F.; Graupera, I.; Serra-Burriel, M.; Allen, A.M.; Wong, V.W.-S.; Hartmann, P.; Thiele, M.; Caballeria, L.; de Knegt, R.J.; Grgurevic, I.; Augustin, S.; Tsochatzis, E.A.; Schattenberg, J.M.; Guha, I.N.; Martini, A.; Morillas, R.M.; Garcia-Retortillo, M.; de Koning, H.J.; Fabrellas, N.; Pich, J.; Ma, A.T.; Diaz, M.A.; Roulot, D.; Newsome, P.N.; Manns, M.; Kamath, P.S.; Krag, A.; and LiverScreen Consortium Investigators. Population screening for liver fibrosis: Towards early diagnosis and intervention for chronic liver diseases. <em>Hepatology</em>, 2021 (Epub ahead of print doi: 10.1002/hep.32163).</p>
|
||
|
||
<p>Goldberg, E.; and Chopra, S. Cirrhosis in adults: Etiologies, clinical manifestations, and diagnosis. In: <em>UpToDate</em>, Post, T.W. (ed), Waltham, MA: UpToDate, 2021a.</p>
|
||
|
||
<p>Goldberg, E.; and Chopra, S. Cirrhosis in adults: Overview of complications, general management, and prognosis. In: <em>UpToDate</em>, Post, T.W. (ed.), Waltham, MA: UpToDate, 2021b.</p>
|
||
|
||
<p>Grove, R.D.; and Hetzel, A.M. <em>Vital Statistics Rates in the United States, 1940–1960.</em> Public Health Service Publication No. 1677. Washington, DC: Department of Health, Education, and Welfare, Public Health Service, National Center for Health Statistics, 1968.</p>
|
||
|
||
<p>Haberman, P.W.; and Weinbaum, D.F. Liver cirrhosis with and without mention of alcohol as cause of death. <em>British Journal of Addiction </em>85(2):217–222, 1990.</p>
|
||
|
||
<p>Heron, M.; Hoyert, D.L.; Murphy, S.L.; Xu, J.; Kochanek, K.D.; and Tejada-Vera, B. Deaths: Final Data for 2006. <em>National Vital Statistics Reports,</em> Vol. 57, No. 14. Hyattsville, MD: National Center for Health Statistics, 2009.</p>
|
||
|
||
<p>Hoyert, D.L.; Heron, M.P.; Murphy, S.L.; and Kung, H.C. Deaths: Final Data for 2003. <em>National Vital Statistics Reports</em>, Vol. 54, No. 13. Hyattsville, MD: National Center for Health Statistics, 2006.</p>
|
||
|
||
<p>Kim, D.; Li, A.A.; Gadiparthi, C.; Khan, M.A.; Cholankeril, G.; Glenn, J.S.; and Ahmed, A. Changing trends in etiology-based annual mortality from chronic liver disease, from 2007 through 2016. <em>Gastroenterology</em> 155(4):1154–1163, 2018.</p>
|
||
|
||
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<p>Miniño, A.M.; Murphy, S.L.; Xu, J.; and Kochanek, K.D. Deaths: Final Data for 2008. <em>National Vital Statistics Reports, </em>Vol. 59, No. 10. Hyattsville, MD: National Center for Health Statistics, 2011.</p>
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<p>Mokdad, A.A.; Lopez, A.D.; Shahraz, S.; Lozano, R.; Mokdad, A.H.; Stanaway, J.; Murray, C.J.; and Naghavi, M. Liver cirrhosis mortality in 187 countries between 1980 and 2010: A systematic analysis. <em>BMC Medicine</em> 12:145, 2014.</p>
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<p>Murphy, S.L.; Kochanek, K.D.; Xu, J.; and Heron, M. Deaths: Final Data for 2012. <em>National Vital Statistics Reports</em>, Vol. 63, No. 9. Hyattsville, MD: National Center for Health Statistics, 2015.</p>
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<p>Murphy, S.L.; Xu, J.; and Kochanek, K.D. Deaths: Final Data for 2010. <em>National Vital Statistics Reports,</em> Vol. 61, No. 4. Hyattsville, MD: National Center for Health Statistics, 2013.</p>
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<p>Murphy, S.L.; Xu, J.; Kochanek, K.D.; Arias, E.; and Tejada-Vera, B. Deaths: Final Data for 2018. <em>National Vital Statistics Reports</em>, Vol. 69, No. 13. Hyattsville, MD: National Center for Health Statistics, 2021.</p>
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<p>National Center for Health Statistics. Bridged-race Intercensal Estimates of the July 1, 1990–July 1, 1999, United States Resident Population by State, County, Age Group, Sex, Race, and Hispanic Origin. Washington, DC: U.S. Census Bureau and National Cancer Institute, April 15, 2003. Available at: <a href="https://www.cdc.gov/nchs/nvss/bridged_race/data_documentation.htm">https://www.cdc.gov/nchs/nvss/bridged_race/<br>
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data_documentation.htm</a>. Accessed November 22, 2021.</p>
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<p>National Center for Health Statistics. Intercensal Estimates of the Resident Population of the United States for July 1, 2000–July 1, 2009, by Year, County, Single-year of Age (0, 1, 2, . . . , 85 Years and Over), Bridged Race, Hispanic Origin, and Sex. Washington, DC: NCHS and U.S. Census Bureau, October 26, 2012. Available at: <a href="https://www.cdc.gov/nchs/nvss/bridged_race.htm">https://www.cdc.gov/nchs/nvss/bridged_race.htm</a>. Accessed November 22, 2021.</p>
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<p>National Center for Health Statistics. Vintage 2020 Postcensal Estimates of the Resident Population of the United States (April 1, 2010, July 1, 2010–July 1, 2020), by Year, County, Single-year of Age (0, 1, 2, . . ., 85 years and over), Bridged Race, Hispanic Origin, and Sex. Washington, DC: NCHS and U.S. Census Bureau, September 22, 2021. Available at <a href="https://www.cdc.gov/nchs/nvss/bridged_race.htm">https://www.cdc.gov/nchs/nvss/bridged_race.htm</a>. Accessed November 22, 2021.</p>
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||
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||
<p>Powell, W.J.; and Klatskin, G. Duration of survival in patients with Laennec's cirrhosis: Influence of alcohol withdrawal, and possible effects of recent changes in general management of the disease. <em>American Journal of Medicine </em>44(3):406–420, 1968.</p>
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<p>Ramstedt, M. Alcohol consumption and liver cirrhosis mortality with and without mention of alcohol-The case of Canada. <em>Addiction</em> 98(9):1267–1276, 2003.</p>
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<p>Rehm, J.; Samokhvalov, A.V.; and Shield, K.D. Global burden of alcoholic liver diseases. <em>Journal of Hepatology</em> 59:160–168, 2013.</p>
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<p>Scaglione, S.; Kliethermes, S.; Cao, G.; Shoham, D.; Durazo, R.; Luke, A.; and Volk, M.L. The epidemiology of cirrhosis in the United States: A population-based study. <em>Journal of Clinical Gastroenterology</em> 49(8):690–696, 2015.</p>
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<p>Singh, S.; Osna, N.A.; and Kharbanda, K.K. Treatment options for alcoholic and non-alcoholic fatty liver disease: A review. <em>World Journal of</em> <em>Gastroenterology</em> 23(36):6549–6570, 2017.</p>
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<p>Stein, E.; Cruz-Lemini, M.; Altamirano, J.; Ndugga, N.; Couper, D.; Abraldes, J.G.; and Bataller, R. Heavy daily alcohol intake at the population level predicts the weight of alcohol in cirrhosis burden worldwide. <em>Journal of Hepatology</em> pii:S0168–8278(16):30307–30315, 2016.</p>
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<p>Xu, J.; Murphy, S.L.; Kochanek, K.D.; and Arias, E. Deaths: Final Data for 2019. <em>National Vital Statistics Reports,</em> Vol. 70, No. 8. Hyattsville, MD: National Center for Health Statistics, 2021.</p>
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<p>Zakhari, S. Bermuda Triangle for the liver: Alcohol, obesity, and viral hepatitis. <em>Journal of</em> <em>Gastroenterology and Hepatology </em>28(Suppl. 1):18–25, 2013.</p>
|
||
|
||
<h2>List of Figures</h2>
|
||
|
||
<p><a href="#fig1">Figure 1.</a> Age-adjusted death rates from liver cirrhosis by sex (death registration States, 1910–1932, and United States, 1933–2019).</p>
|
||
|
||
<p><a href="#fig2">Figure 2.</a> Age-specific death rates from liver cirrhosis, United States, 2000–2019.</p>
|
||
|
||
<p><a href="#fig3">Figure 3.</a> Age-specific death rates from liver cirrhosis by race and sex, United States, 2000–2019.</p>
|
||
|
||
<p><a href="#fig4">Figure 4.</a> Age-adjusted death rates from liver cirrhosis by sex, race, and Hispanic origin, United States, 2000–2019.</p>
|
||
|
||
<p><a href="#fig5">Figure 5.</a> Age-adjusted death rates from liver cirrhosis reported with and without mention of alcohol, United States, 2000–2019.</p>
|
||
|
||
<p><a href="#fig6">Figure 6.</a> Percentage of all cirrhosis deaths coded as alcohol related by age, United States, 2000–2019.</p>
|
||
|
||
<p><a href="#fig7">Figure 7.</a> Percentage of all cirrhosis deaths coded as alcohol related by sex and age, United States, 2000–2019.</p>
|
||
|
||
<p><a href="#fig8">Figure 8.</a> Age-specific death rates from alcohol-related liver cirrhosis by sex, United States, 2000–2019.</p>
|
||
|
||
<p><a href="#fig9">Figure 9.</a> Age-adjusted death rates from alcohol-related liver cirrhosis by sex, race, and Hispanic origin, United States, 2000–2019.</p>
|
||
|
||
<p><a href="#fig10">Figure 10.</a> Age-adjusted death rates from specified liver cirrhosis without mention of alcohol by sex, race, and Hispanic origin, United States, 2000–2019.</p>
|
||
|
||
<p><a href="#fig11">Figure 11.</a> Age-adjusted death rates from unspecified liver cirrhosis without mention of alcohol by sex, race, and Hispanic origin, United States, 2000–2019.</p>
|
||
|
||
<p><a href="#fig12">Figure 12.</a> Five-year annual average of age-adjusted death rates from liver cirrhosis with and without mention of alcohol by Hispanic subgroup and sex, United States, 2015–2019.</p>
|
||
|
||
<p><a href="#fig13">Figure 13.</a> Three-year annual average of age-adjusted death rates from all liver cirrhosis by State, 2017–2019.</p>
|
||
|
||
<p><a href="#fig14">Figure 14.</a> Three-year annual average of age-adjusted death rates from alcohol-related liver cirrhosis by State, 2017–2019.</p>
|
||
|
||
<p><a href="#fig15">Figure 15.</a> Three-year annual average of age-adjusted death rates from all other liver cirrhosis without mention of alcohol by State, 2017–2019.</p>
|
||
|
||
<h2><a name="list"></a>List of Tables</h2>
|
||
|
||
<p><a href="/sites/default/files/surveillance-report118.pdf#page=33">Table 1.</a> Age-adjusted death rates from liver cirrhosis by sex (death registration States, 1910–1932, and United States, 1933–2019).</p>
|
||
|
||
<p><a href="/sites/default/files/surveillance-report118.pdf#page=34">Table 2.</a> Age-specific number of deaths, age-specific death rates, and age-adjusted death rates from all liver cirrhosis by race, Hispanic origin, and sex, United States, 2000–2019.</p>
|
||
|
||
<p><a href="/sites/default/files/surveillance-report118.pdf#page=43">Table 3.</a> Age-specific number of deaths, age-specific death rates, and age-adjusted death rates from liver cirrhosis with and without mention of alcohol by sex, United States, 2000–2019.</p>
|
||
|
||
<p><a href="/sites/default/files/surveillance-report118.pdf#page=43">Table 4.</a> Age-adjusted death rates from liver cirrhosis with and without mention of alcohol by sex, race, and Hispanic origin, United States, 2000–2019.</p>
|
||
|
||
<p><a href="/sites/default/files/surveillance-report118.pdf#page=51">Table 5.</a> Age-specific number of deaths, 5-year annual moving average of age-specific death rates, and age-adjusted death rates from all liver cirrhosis by Hispanic subgroup and sex, United States, 2000–2019.</p>
|
||
|
||
<p><a href="/sites/default/files/surveillance-report118.pdf#page=57">Table 6.</a> Age-specific number of deaths, 5-year annual moving average of age-specific death rates, and age-adjusted death rates from liver cirrhosis with and without mention of alcohol by Hispanic subgroup and sex, United States, 2000–2019.</p>
|
||
|
||
<p><a href="/sites/default/files/surveillance-report118.pdf#page=70">Table 7.</a> Number of deaths and 3-year annual moving average of age-adjusted death rates from liver cirrhosis with and without mention of alcohol, States, Census Regions, and the United States, 2000–2019.</p>
|
||
|
||
<p><a href="/sites/default/files/surveillance-report118.pdf#page=92">Appendix A.</a> Data sources of population estimates at the national and State levels and for Hispanic subgroups.<br>
|
||
</p>
|
||
|
||
<p class="text-align-center"><a id="fig1" name="fig1"></a><strong>Figure 1.</strong> Age-adjusted death rates from liver cirrhosis by sex (death registration States, 1910–1932, and United States, 1933–2019)</p>
|
||
|
||
<div class="align-center max-w-900"><img alt="figure 1" src="/sites/default/files/Picture118-1.svg" width="900"></div>
|
||
|
||
<p class="text-align-center"><a id="fig2" name="fig2"></a><strong>Figure 2.</strong> Age-specific death rates from liver cirrhosis, United States, 2000–2019.</p>
|
||
|
||
<div class="align-center max-w-900"><img alt="figure 2" src="/sites/default/files/Picture118-2.svg" width="900"></div>
|
||
|
||
<p class="text-align-center"><strong>Figure 3.</strong> Age-specific death rates from liver cirrhosis by race and sex, United States, 2000–2019.<br>
|
||
<em>Note: Different age groups may have different scales.</em></p>
|
||
|
||
<div class="align-center max-w-900"><img alt="figure 3" src="/sites/default/files/Picture118-3.svg" width="900"></div>
|
||
|
||
<div class="align-center max-w-900"><img alt="figure 4" src="/sites/default/files/Picture118-4.svg" width="900"></div>
|
||
|
||
<p class="text-align-center"><a id="fig4" name="fig4"></a><strong>Figure 4.</strong> Age-adjusted death rates from liver cirrhosis by sex, race, and Hispanic origin, United States, 2000–2019.</p>
|
||
|
||
<div class="align-center max-w-900"><img alt="figure 4" src="/sites/default/files/Picture118-5.svg" width="900"></div>
|
||
|
||
<p class="text-align-center"><a id="fig5" name="fig5"></a><strong>Figure 5.</strong> Age-adjusted death rates from liver cirrhosis reported with and without mention of alcohol, United States, 2000–2019.</p>
|
||
|
||
<div class="align-center max-w-900"><img alt="figure 5" src="/sites/default/files/Picture118-6.svg" width="900"></div>
|
||
|
||
<p class="text-align-center"><a id="fig6" name="fig6"></a><strong>Figure 6.</strong> Percentage of all cirrhosis deaths coded as alcohol related by age, United States, 2000–2019.</p>
|
||
|
||
<div class="align-center max-w-900"><img alt="figure 6" src="/sites/default/files/Picture118-7.svg" width="900"></div>
|
||
|
||
<p class="text-align-center"><a id="fig7" name="fig7"></a><strong>Figure 7.</strong> Percentage of all cirrhosis deaths coded as alcohol related by sex and age, United States, 2000–2019.</p>
|
||
|
||
<div class="align-center max-w-900"><img alt="figure 7" src="/sites/default/files/Picture118-8.svg" width="900"></div>
|
||
|
||
<div class="align-center max-w-900"><img alt="figure 8" src="/sites/default/files/Picture118-9.svg" width="900"></div>
|
||
|
||
<p class="text-align-center"><a id="fig8" name="fig8"></a><strong>Figure 8.</strong> Age-specific death rates from alcohol-related liver cirrhosis by sex, United States, 2000–2019.<br>
|
||
<em>Note: Different age groups may have different scales.</em></p>
|
||
|
||
<div class="align-center max-w-900"><img alt="figure 8" src="/sites/default/files/Picture118-10.svg" width="900"></div>
|
||
|
||
<div class="align-center max-w-900"><img alt="figure 9" src="/sites/default/files/Picture118-11.svg" width="900"></div>
|
||
|
||
<p class="text-align-center"><a id="fig9" name="fig9"></a><strong>Figure 9.</strong> Age-adjusted death rates from alcohol-related liver cirrhosis by sex, race, and Hispanic origin, United States, 2000–2019.</p>
|
||
|
||
<div class="align-center max-w-900"><img alt="figure 9" src="/sites/default/files/Picture118-12.svg" width="900"></div>
|
||
|
||
<p class="text-align-center"><a id="fig10" name="fig10"></a><strong>Figure 10.</strong> Age-adjusted death rates from specified liver cirrhosis without mention of alcohol by sex, race, and Hispanic origin, United States, 2000–2019.</p>
|
||
|
||
<div class="align-center max-w-900"><img alt="figure 10" src="/sites/default/files/Picture118-13.svg" width="900"></div>
|
||
|
||
<p class="text-align-center"><a id="fig11" name="fig11"></a><strong>Figure 11.</strong> Age-adjusted death rates from unspecified liver cirrhosis without mention of alcohol by sex, race, and Hispanic origin, United States, 2000–2019.</p>
|
||
|
||
<div class="align-center max-w-900"><img alt="figure 11" src="/sites/default/files/Picture118-14.svg" width="900"></div>
|
||
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<p class="text-align-center"><a id="fig12" name="fig12"></a><strong>Figure 12.</strong> Five-year annual average of age-adjusted death rates from liver cirrhosis with and without mention of alcohol by Hispanic subgroup and sex, United States, 2015–2019.</p>
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<p class="text-align-center"><a id="fig13" name="fig13"></a><strong>Figure 13.</strong> Three-year annual average of age-adjusted death rates from all liver cirrhosis by State, 2017–2019.</p>
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<p class="text-align-center"><a id="fig14" name="fig14"></a><strong>Figure 14.</strong> Three-year annual average of age-adjusted death rates from alcohol-related liver cirrhosis by State, 2017–2019.</p>
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<p class="text-align-center"><a id="fig15" name="fig15"></a><strong>Figure 15.</strong> Three-year annual average of age-adjusted death rates from all other liver cirrhosis without mention of alcohol by State, 2017–2019.</p>
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