A mortality analysis of Native American in New York State, 1980-86

This investigation examined the mortality experience of Native Americans in New York State, exclusive of New York City, between 1980 and 1986. Compared to the general population of New York State, exclusive of New York City, deaths among Native Americans occurred an average of nine years earlier. Among Native males, elevated risk of death was noted for tuberculosis, diabetes mellitus, pneumonia and cirrhosis. Native females demonstrated an excess of deaths due to diabetes mellitus and cirrhosis. Fewer than expected malignant neoplasm deaths occurred among both Native males and females. A deficit of deaths was observed for colon and lung cancer deaths among Native males and for colon and breast cancer deaths among Native females. While these results are generally in agreement with previous reports, this study did not identify an excess of deaths due to accident-related mortality. Findings from this study, while limited, do serve as crude indicators of the overall health status of Native Americans in New York State and may prove useful in the context of planning and evaluating future health care services among this population.     

Diabetes mellitus mortality among elderly as an underlying or secondary cause of death

OBJECTIVE:To analyze diabetes mellitus-related mortality among elderly and the rate of undereporting of diabetes mellitus as a cause of death when statistical data on diabetes exclusively on the underlying cause of death are considered. METHODS:A total of 2.974 death certificates of elderly people living in a housing project in the city of Rio de Janeiro were revised. The study period was 1994. Of them, 291 deaths were due to diabetes mellitus, 150 as the underlying and 141 as the secondary cause of death. The proportion of deaths where diabetes was stated as the underlying cause in relation to the total of diabetes deaths was calculated globally and categorized by sex and age groups. RESULTS:Of the 291 deaths studied, 138 (47.4%) were men and 153 (52.6%) were women. Mortality rates showed a continuous age increase and were higher among men, though sex difference was smaller when only the underlying cause was considered. It was found a higher proportion of deaths (22%) occurring at home. Overall rate of diabetes deaths as the underlying cause was 51.5%, with higher rates seen in women. CONCLUSIONS:The analysis of mortality statistics based exclusively on the underlying cause of death can yield misleading profiles due to unrandomized underreporting. There is a need of further studies with diabetic elderly cohorts for a more accurate mortality analysis in this population group.     

The cost of diabetes in Latin America and the Caribbean

OBJECTIVE: To measure the economic burden associated with diabetes mellitus in Latin America and the Caribbean. METHODS: Prevalence estimates of diabetes for the year 2000 were used to calculated direct and indirect costs of diabetes mellitus. Direct costs included costs due to drugs, hospitalizations, consultations and management of complications. The human capital approach was used to calculate indirect costs and included calculations of forgone earnings due to premature mortality and disability attributed to diabetes mellitus. Mortality and disability attributed to causes other than diabetes were subtracted from estimates to consider only the excess burden due to diabetes. A 3% discount rate was used to convert future earnings to current value. FINDINGS: The annual number of deaths in 2000 caused by diabetes mellitus was estimated at 339,035. This represented a loss of 757,096 discounted years of productive life among persons younger than 65 years (> billion US dollars). Permanent disability caused a loss of 12,699,087 years and over 50 billion US dollars, and temporary disability caused a loss of 136,701 years in the working population and over 763 million US dollars. Costs associated with insulin and oral medications were 4720 million US dollars, hospitalizations 1012 million US dollars, consultations 2508 million US dollars and care for complications 2,480 million US dollars. The total annual cost associated with diabetes was estimated as 65,216 million US dollars (direct 10,721 US dollars; indirect 54,496 US dollars). CONCLUSION: Despite limitations of the data, diabetes imposes a high economic burden to individuals and society in all countries and to Latin American and the Caribbean as whole.     

An analysis of excess mortality rates for persons with non-insulin-dependent diabetes mellitus in Western Australia using the Cox proportional hazards regression model.

A cohort of 888 rural, nonaboriginal persons with non-insulin-dependent diabetes mellitus identified in Western Australia through surveys in 1978-1982 were followed for death until the end of 1986. A total of 257 deaths were observed. Excess mortality in this cohort as compared with the general Australian population was investigated by calculating standardized mortality ratios and using the Cox proportional hazards regression model with hazard rates for the general population as the baseline. The overall standardized mortality ratio was 1.83 (95% confidence interval 1.51-2.16) for women and 1.43 (95% confidence interval 1.18-1.67) for men. Cause-specific comparisons with the general population showed that the majority of excess deaths could be attributed to diseases of the circulatory system. Factors assessed at the baseline survey that were independently prognostic of shorter survival were early onset of diabetes (for females only), high plasma glucose level, retinopathy, macrovascular disease, albuminuria (for females only), and elevated plasma creatinine level. Reductions in life expectancy at 60 years of age as compared with the general population averaged about 5 years but could be as much as 16 years for female diabetics with early onset of diabetes, high plasma glucose levels, and several complications.     

Indigenous mortality in remote Queensland, Australia

OBJECTIVES: To quantify Indigenous mortality, compare it with non-Indigenous mortality, and identify causes of excess Indigenous mortality by remoteness in Queensland, 1997-2000. DESIGN: Cross-sectional survey of all deaths of Queensland residents registered in Australia during the study period. MAIN OUTCOME MEASURES: Mortality rates were standardised to the concurrent non-Indigenous population and categorised by age and sex. RESULTS: Death rates in Indigenous people were higher in remote areas. The difference between Indigenous and non-Indigenous mortality was also highest in remote areas. The leading causes of deaths were ischaemic heart disease, diabetes mellitus, respiratory diseases, malignant neoplasms, and injury, which accounted for more than 60% of excess deaths. CONCLUSIONS: Despite limitations with Indigenous identification, particularly in urban areas, Indigenous people, compared with the non-Indigenous population, have elevated mortality rates that increase by remoteness. This is in agreement with past work. To the extent that some of the causes of excess mortality can be attributed to lifestyle conditions, the health of Indigenous Australians can be substantially improved.     

Mortality in a large population-based cohort of patients with drug-treated diabetes mellitus.

OBJECTIVES: This paper presents detailed cause-specific data about excess mortality among diabetic persons in Finland, by age and sex. METHODS: Five-year follow-up data on the Finnish population aged 30 through 74 years were analyzed. During these 5 years, 11,215 persons with diabetes and 102,843 persons without diabetes died. The diabetic population was defined as people who were entitled to free medication for diabetes at the beginning of the follow-up period, that is, at the end of 1980. RESULTS: The relative mortality of persons with drug-treated diabetes compared with nondiabetic persons was higher among women (3.4) than among men (2.4). Almost three quarters of the mortality excess was due to circulatory diseases. For most other causes of death, too, diabetic persons had higher than average mortality. The exceptions were lung cancer, chronic obstructive pulmonary disease, and alcohol poisoning. CONCLUSIONS: Diabetes is a general risk factor for untimely death and makes a significant contribution to overall national death rates, particularly for circulatory diseases. Lower than average mortality from smoking-related diseases and alcohol poisoning, however, warrant optimism about the effects of health education among diabetic persons.     

Pregnancy in women with diabetes mellitus type I: maternal and perinatal complications, in spite of good blood glucose control

OBJECTIVE: To examine the maternal and neonatal outcome of pregnancies of women with type I diabetes mellitus. DESIGN: Retrospective. METHODS: The medical records of pregnancies (> or = 16 weeks) in women with type I diabetes mellitus between 1986/'97 were studied in University Medical Center Utrecht, Academic Hospital Groningen and Isala Clinics, location 'De Weezenlanden', Zwolle, the Netherlands. RESULTS: During the study period, 172 women had 220 pregnancies: 212 single and 8 twin pregnancies. The mean age was 29.1 years (SD: 4.1), the mean duration of standing of the diabetes was 12 years (range: 1-32) and the mean concentration of glycosylated haemoglobin (HbA1c) was 6.3% at 10 weeks of pregnancy. The incidence of children with congenital malformations was 4 times higher (n = 19; 9.0%) than that in the Dutch population (2%). Macrosomia occurred in 92 children (43.4%) and perinatal mortality in 7 (3.3%). Maternal hypertensive complications occurred in 39 single pregnancies (18.4%), which is 2-3 times more often than in the Dutch population. CONCLUSION: In type I diabetic women maternal complications, perinatal morbidity and mortality are increased, despite near optimal glycaemic control.     

The investigation of age at onset as a risk factor for mortality in persons with insulin-dependent diabetes mellitus using Cox proportional hazards models

Proportional hazards models measuring the effect of age at onset of insulin-dependent diabetes mellitus on mortality risk are presented. The study population consisted of 924 insulin-dependent diabetic patients who were seen within 1 year of diagnosis at Children's Hospital of Pittsburgh between 1950 and 1981 and were more than 20 years old at follow-up. Age at diabetes onset was categorized as prepubertal or pubertal, defined by age. Individuals with pubertal onset of diabetes had a significantly higher risk of mortality compared with those with prepubertal onset by diabetes duration but not by attained age. It is proposed that age at onset is an independent determinant of mortality in diabetic individuals and may represent either heterogeneity within insulin-dependent diabetes mellitus with respect to long-term prognosis or an interactive effect of diabetes duration and puberty on prognosis.     

The Effects of Diabetes,Hypertension, Asthma,Heart Disease,and Stroke on Quality-Adjusted Life Expectancy

ObjectiveQuality-adjusted life expectancy (QALE) is a summary measure that combines mortality and health-related quality of life across different stages of life. The objective of this study was to estimate QALE loss due to five chronic diseases—diabetes mellitus, hypertension, asthma, heart disease, and stroke.MethodsHealth-related quality of life scores were from the 1993-2009 Behavioral Risk Factor Surveillance System. Using age-specific deaths from the Compressed Mortality File, this study constructed life tables to calculate losses in life expectancy and QALE due to each of the five diseases from 1993 through 2009 and for 50 US states and the District of Columbia.ResultsIn 2009, the individual-level QALE loss for diabetic people, compared with nondiabetic people, was 11.1 years; for those with hypertension, 6.3 years; for those with asthma, 7.0 years; for those with heart disease, 10.3 years; and for those with stroke, 12.4 years. At the population level, diabetes, hypertension, asthma, heart disease, and stroke contributed 1.9, 2.2, 0.8, 1.2, and 0.8 years of population QALE loss at age 18 years, respectively.ConclusionsPersons with each of the five diseases had significantly lower life expectancy and QALE. Because the prevalence of diabetes and hypertension has increased significantly in the United States in the last two decades, the burdens of these two conditions, measured by population QALE losses, had increased 83% and 29% from 1993 to 2009, respectively. Also, by examining changes in population QALE loss at different ages, policymakers can identify age groups most affected by particular diseases and develop the most cost-effective interventions by focusing on these groups.     

Gender equity in health care: the case of Swedish diabetes care

To explore the issue of gender equity in diabetes care in Sweden and to develop strategies for monitoring gender equity in health care, population-based studies and statistics published since 1990 were reviewed that contained gender-specific data on health care utilization, glycemic control, patient satisfaction, health-related quality of life, and mortality from diabetes. The review shows that diabetic women in Sweden report more frequent outpatient contacts, less patient satisfaction, and a lower health-related quality of life than diabetic men. No gender differences were found in the level of glycemic control. Young and middle-aged men with diabetes have a high excess all-cause mortality as compared with nondiabetic men. A trend toward stronger social gradient in mortality among women than men with diabetes was observed in a large nationwide study.     

Insulin treated diabetes mellitus: causes of death determined from record linkage of population based registers in Leicestershire, UK.

STUDY OBJECTIVE--Analyses of causes of mortality in people with diabetes using data form death certificates mentioning diabetes provide unreliable estimates of mortality. Under-recording of diabetes as a cause on death certificates has been widely reported, ranging from 15-60%. Using a population based register on people with diabetes and linking data from another source is a viable alternative. Data from the Office of Population Censuses and Surveys (OPCS) are the most acceptable mortality data available for such an exercise, as direct comparison with other published mortality rates is then possible. DESIGN--A locally maintained population-based mortality register and all insulin-treated diabetes mellitus cases notified to the Leicestershire diabetes register (n = 4680) were linked using record linkage software developed in-house (Lynx). This software has been extensively used in a maintenance and update cycle designed to maximise accuracy and minimise duplication and false registration on the diabetes register. Deaths identified were initially coded locally to the International Classification of Diseases, 9th revision (ICD9), and later a linkage was performed to use official OPCS coding. Mortality data identified by the linkage was indirectly standardised using population data for Leicestershire for 1991. Standardised mortality ratios (SMR) were estimated, with 95% confidence intervals. Insulin dependent diabetes (IDDM) was defined as diabetes diagnosed before age 30 years with insulin therapy begun within one year of diagnosis. All other types were considered non-insulin dependent diabetes (NIDDM). Analyses were performed for the whole sample and then for the NIDDM subgroup. Results from these analyses were similar and therefore only whole group analyses are presented. MAIN RESULTS--A total of 370 deaths were identified for the period of 1990-92 inclusive - 56% were in men and 44% in women, median age (range) 71 years (12-94). Approximately 90% of deaths were subjects with NIDDM. Diabetes was mentioned on 215 (58%) death certificates. The all causes SMRs were significantly raised for men and women for all ages less than 75 years. Ischaemic heart disease (ICD9) rubrics 410-414) accounted for 146 (40%) deaths - 41% of male and 38% of female deaths. Male and female SMRs were significantly raised for the age groups 45-64, 65-74, and 75-84 years. Cerebrovascular disease (ICD9 rubrics 430-438) accounted for 39 (10%) deaths and the SMR for women the external causes of death (ICD9 rubrics E800-E999) were also significantly raised overall and in age groups 15-44 and 45-64 years. This was not true for men, although numbers of deaths in this category were small for both men (4) and women (9). CONCLUSION--Record linkage has been used successfully to link two local, population based registers. This has enabled an analysis of mortality in people with diabetes to be performed which overcomes the problems associated with using as a sample, death certificates where diabetes is mentioned. The mortality rates and SMRs estimated should more accurately reflect the true rates than would be possible using other methods. The persisting excess mortality identified for people with diabetes is of a similar magnitude and attributable to similar causes as has been reported elsewhere in population based studies.     

Systolic blood pressure and cardiovascular mortality among 13,740 Dutch women

Prospective data of cardiovascular mortality in relation to the systolic blood pressure of women are scarce, especially when combined with other risk factors. The association between systolic blood pressure and cardiovascular mortality was therefore studied in a 10-year follow-up of a population of 13,740 Dutch women, born between 1911 and 1925 who participated in a population-based breast cancer screening project (the DOM Project). Age-adjusted mortality rates over the 10-year follow-up period suggest a J-shaped pattern of cardiovascular mortality according to level of systolic blood pressure. Age-adjusted total cardiovascular, coronary, and cerebrovascular mortality rate ratios were significantly greater than 1.0 among women with elevated systolic blood pressure. Within categories of other risk factors (obesity index, diabetes mellitus, current smoking, and use of antihypertensive medicines) the age-adjusted cardiovascular rate ratios did not show confounding by any of these variables. A very high increase in cardiovascular mortality was observed among hypertensive diabetic women. This study shows that elevated systolic blood pressure is associated with increased rates of cardiovascular mortality for women in this age group.     

Lack of improvement of life expectancy at advanced ages in The Netherlands

BACKGROUND: Several countries have reported an increase in life expectancy at advanced ages. This paper analyses recent changes in life expectancy at age 60 and 85 in The Netherlands, a low mortality country with reliable mortality data. METHODS: We used data on the population and the number of deaths by age, sex and underlying cause of death for 1970-1994. Life expectancy at age 60 and 85 was estimated using standard life-table techniques. The contribution of different ages and causes of death to the change in life expectancy during the 1970s (1970/74-1980/84) and the 1980s (1980/84-1990/94) were estimated with a decomposition technique developed by Arriaga. RESULTS: Life expectancy at age 60 increased in the 1970s and 1980s, whereas life expectancy at age 85 decreased (men) and stagnated (women) in the 1980s, and has decreased in both sexes since 1985/89. The decomposition by age showed that constant mortality rates in women aged 85-89, and increasing mortality rates at ages 85+ (men) and 90+ (women) have caused this lack of increase in life expectancy. The decomposition by cause of death showed that smaller mortality reductions from other cardiovascular and cerebrovascular diseases, which contributed most to the increase in life expectancy at age 85 in the 1970s, and mortality increases from, amongst others, chronic obstructive pulmonary disease (COPD), mental disorders and diabetes mellitus produced the decrease (men) and plateau (women) in life expectancy at age 85. CONCLUSIONS: Life expectancy at advanced ages stopped increasing during the 1980s in The Netherlands due to mortality increases at ages 85+ (men) and 90+ (women). Cause-specific trends suggest that, in addition to (past) smoking behaviour in men, changes in the distribution of morbidity and frailty in the population might have contributed to this stagnation.     

1991—2011年上海市宝山区居民糖尿病死亡和潜在寿命损失趋势的分析

目的了解上海市宝山区居民糖尿病死亡情况以及对居民寿命的影响,为采取有针对性的预防和干预措施提供科学依据。方法死因登记资料来源于宝山区生命统计监测。使用时间序列分析的方法,并采用粗死亡率、标化死亡率、占全死因构成比、潜在寿命损失年（YPLL）、平均减寿年数等指标对宝山区1991—2011年居民死因登记资料进行分析。结果1991—2011年间,糖尿病死亡病例3115例,年平均死亡率为19．69／10万（年平均标化死亡率为10．16／10万）。占总死亡人数的2．89％;死亡率从1991年的4．63／10万上升至2011年的32．14／10万,且随时间呈递增趋势（P〈0．01）。女性的年平均粗死亡率（24．26／10万）、占全死因构成比（3．71％）和标化死亡率（11．21／10万）均高于男性（分别为15．29／10万、2．16％和8．80／10万）,两者的粗死亡率、占全死因构成比均呈递增趋势（均P〈0．01）。0～84岁组糖尿病的年龄别死亡率（男／女／总计）均随年龄的增加呈明显的增加趋势（均P〈0．01）。糖尿病总人群的YPLL从1991年的115．31年上升到2011年的2744．63年;期望寿命从1991年的76．03岁上升到2011年的82．11岁。总人群、男性人群以及女性人群的YPLL、期望寿命均随时间呈递增趋势（均P〈0．01）。结论21年间,宝山区糖尿病死亡率、YPLL均随时间呈递增趋势,糖尿病已经成为影响宝山区居民寿命的重要因素。     

上海市宝山区居民20年糖尿病死亡趋势分析

[目的 ]　了解宝山区居民近 2 0年来糖尿病死亡率的变化趋势。　 [方法 ]　采用 1980～ 2 0 0 0年宝山区死因统计资料对糖尿病死亡率进行描述性分析。　 [结果 ]　宝山区糖尿病死亡率由 1980年的 2 .91/10万上升到 2 0 0 0年的17.6 9/10万。 <6 0岁死亡的病人主要死于肾病、酮症酸中毒、周围循环障碍。　 [结论 ]　宝山区糖尿病的危害日益严重 ,尤其是 1990～ 2 0 0 0年。     

Changing mortality patterns in Nauruans: an example of epidemiological transition.

An analysis of mortality data for the years 1982-5 was carried out for the Micronesian population (aged 15 years and over) of the central Pacific Island, Nauru. Among males, the most common causes of death were circulatory system disorders (33.3%), accidents (25.2%), and diabetes mellitus (12.1%). The majority of accidents occurred in the 15-34 year age group and involved motor vehicles. Among females, neoplasms (almost all lung and cervix) (22.4%), circulatory system disorders (20.7%), and diabetes mellitus (17.2%) were the most common causes of death. When accidents are excluded, 59.4% of deaths were in persons with diabetes. Compared with Australia, mortality rates in almost all age groups were at least five times higher for males and females for a comparable period. Nauruan life expectancy (39.5 years for men and 48.5 years for women) is one of the lowest in the world. These data confirm the high mortality associated with diabetes mellitus in Nauruans as evidenced in earlier studies. Modernization of this society through the affluence acquired by the mining of phosphate has led to serious public health problems relating to non-communicable diseases so that the mortality trends now mirror those of developed societies.     

Quality-Adjusted Life-Years Lost Due to COVID-19 Mortality: Methods and Application for The Netherlands

ObjectivesThe COVID-19 pandemic has increased mortality worldwide considerably in 2020. Nevertheless, it is unknown how the increase in mortality translates into a loss in quality-adjusted life-years (QALYs), which is a function of age and the health condition of the deceased patient at time of death. We estimate the QALYs lost in The Netherlands as a result of deaths because of COVID-19 in 2020.MethodsAs a starting point, we use estimates of underlying diseases and the number of COVID-19 deaths in nursing homes as a proxy for underlying health status. In a next step, these are combined with estimates of excess mortality rates and quality of life for different groups to calculate QALYs lost. We compare the results with an alternative scenario, in which COVID-19 deaths occurred randomly across the population regardless of underlying conditions. For this alternative scenario, we use population mortality and average quality of life by age and sex.ResultsAccounting for underlying health status, we estimate that QALYs lost because of COVID-19 mortality are on average 3.9 per death for men and 3.5 for women. This is approximately 3.5 QALYs less than when not taking selective mortality into account. Given 16 308 excess deaths, this translates into 61 032 QALYs lost because of COVID-19.ConclusionsWe conclude that QALYs lost because of COVID-19 mortality are still substantial, even if mortality is strongly concentrated in people with poor health.     

Ethnic differences in mortality from cardiovascular disease in the UK: do they persist in people with diabetes?

STUDY OBJECTIVE: To determine whether ethnic differences in cardiovascular disease mortality persist in people with non-insulin-dependent diabetes mellitus. DESIGN: This was an ecological study in which routine mortality data from 1985-86, which coded all mentioned causes of death, provided the numerator. The UK population derived from 1981 census formed the denominator. SETTING: United Kingdom. PARTICIPANTS: Records of all deaths in people aged 45 years and above were extracted if diabetes was mentioned anywhere on the death certificate. The denominator was aged five years to approximate to the 1986 population. Mortality rates where a cardiovascular underlying cause was given were compared between South Asians, African-Caribbeans, and those born in England and Wales. The latter group formed the standard for directly standardised rate ratios. MAIN RESULTS: Mortality from heart disease was approximately three times higher in diabetic South Asian born men and women than in those with diabetes born in England and Wales. This ethnic difference was greatest in the younger age group. Conversely, stroke mortality rates in African-Caribbeans were 3.5-4 times higher than those in the England and Wales population. Despite this high mortality from stroke, ischaemic heart disease death rates were not high in African-Caribbean men. CONCLUSIONS: Ethnic differences in cardiovascular mortality persisted and were greater in those with diabetes. Thus the high risk of heart disease should be targeted for intervention in South Asians, and the high rates of stroke targeted in African-Caribbeans.     

中国糖尿病死亡率研究进展

朱向东⑤[*基金项目：甘肃中医药大学2016年度引进人才科研启动基金项目(No.2016-YJRC01)；兰州市科技局2019年度兰州市人才创新创业项目(No.2019-RC-100)；2019年省卫健委基层基本公共卫生服务补助(No.31140215)。 ①甘肃中医药大学公共卫生学院 兰州 730000 ②甘肃中医药大学循证医学中心 兰州 730000 ③西北环境与营养相关疾病的中医药防控协同创新中心 兰州 730000 ④甘肃中医药大学研究生院 兰州 730000 ⑤甘肃中医药大学基础医学院 兰州 730000 # 通讯作者]，樊景春①②③[] 摘 要 糖尿病作为主要慢性病已经严重威胁到人类健康，久病可引起身体多系统损害甚至导致死亡。随着社会发展，因糖尿病而死亡的人数在我国乃至全世界范围内呈逐年增加的趋势，严重危害着公众健康和生活质量，已成为全球性的重要公共卫生问题。为了解近年来我国糖尿病死亡率及各个地区糖尿病发生的分布情况，本文通过对国内外糖尿病死亡情况的相关报道进行文献综述，分析糖尿病的发展趋势，为我国糖尿病预防干预、筛查及治疗指南的制定提供科学依据，以实现“健康中国2030”的目标。     

The perils of using annual all-cause mortality data to estimate pandemic influenza burden

Measuring the burden of historic pandemics is not straightforward and often must be based on suboptimal mortality data. For example, the critical 1918 pandemic global burden estimate was based on excess in annual all-cause mortality--calculated as the difference between deaths during 1918-1920 and the surrounding 3-year periods. One intriguing result was a ～ 40-fold between-country variation in pandemic mortality burden: ～ 0.2% of Danes died, compared to ～ 8% of populations in some Indian provinces (Murray et al., 2006 [16]). Using the same methodology and data source we explore the robustness of this methodology for different age-groups. For infants the country estimates varied 100-fold, from 15 to 1500 excess deaths/10,000 population, while for adults ≥ 45 years estimates ranged from -70 to 170/10,000 population. In contrast, estimates for children, 1-14 years, and adults aged 15-44 years, were far more stable. We next used detailed mortality data from Copenhagen to compare such estimates to the more precise estimates obtained from monthly mortality time series data and respiratory deaths. We found that the all-cause annual method substantially underestimated due to an unexplained depression in all-cause mortality in Denmark in 1918 and deaths caused by other epidemic diseases during the baseline periods. We conclude that country estimates for infants and older adults were highly variable by the Murray method due to substantial variability in annual all-cause mortality. A more precise 1918 pandemic burden estimate would be gotten from either focusing analysis on persons age 1-44 who suffered 95% of all pandemic deaths and had a substantial rise over their baseline mortality level, or if possible focus analysis on annual respiratory deaths. For less severe pandemics, including the ongoing 2009 H1N1 pandemic, the use of all-cause mortality data requires careful consideration of excess deaths in defined pandemic periods and a focus on age groups known to be at risk.