Unrecognised COVID-19 deaths in central Europe: The importance of cause-of-death certification for the COVID-19 burden assessment.

OBJECTIVE: In Central Europe, the increase in mortality during the COVID-19 pandemic exceeded the number of deaths registered due to coronavirus disease. Excess deaths reported to causes other than COVID-19 may have been due to unrecognised coronavirus disease, the interruptions in care in the overwhelmed health care facilities, or socioeconomic effects of the pandemic and lockdowns. Death certificates provide exhaustive medical information, allowing us to assess the extent of unrecognised COVID-19 deaths. MATERIALS AND METHODS: Data from 187,300 death certificates with a COVID-19 mention from Austria, Bavaria (Germany), Czechia, Lithuania and Poland, 2020-2021, was used. The two step analysis uses Cause of Death Association Indicators (CDAIs) and Contributing CDAIs to identify and measure the statistical strength of associations between COVID-19 and all other medical mentions. RESULTS: 15,700 deaths were reported with COVID-19 only as a contributing condition (comorbidity). In three cases out of four, a typical, statistically significant coronavirus complication or pre-existing condition was registered as the underlying causes of death. In Austria, Bavaria, Czechia and Lithuania the scale of COVID-19 mortality would have been up to 18-27% higher had COVID-19 been coded as the underlying cause of death. Unrecognised coronavirus deaths were equivalent to the entire surplus of excess mortality beyond registered COVID-19 deaths in Austria and the Czech Republic, and its large proportion (25-31%) in Lithuania and Bavaria. CONCLUSIONS: Death certificates with typical coronavirus complications or comorbidities as the underlying causes of death and contributing COVID-19 mentions were plausibly unrecognized coronavirus deaths.

Alcohol-related mortality in four European countries: A multiple-cause-of-death study.

INTRODUCTION: The impact of conditions that partly or indirectly contribute to drinking-related mortality is usually underestimated. We investigate all alcohol-related multiple (underlying and contributory) causes of death and compare mortality distributions in countries with different levels and patterns of drinking. METHOD: Analysis of population-level mortality data for persons aged 20 and over in Austria, Czechia, Poland and Spain. Age-standardised death rates and standardised ratios of multiple to underlying cause were calculated for alcohol-related causes of death. RESULTS: Multiple-cause mortality ranged from 20 to 58 deaths per 100,000 for men and from 5 to 16 per 100,000 for women. Liver diseases were the most common underlying and multiple causes, but mental and behavioural disorders were the second or third, depending on country and sex, most prevalent multiple mentions. Two distinct age patterns of alcohol-related mortality were observed: in Czechia and Poland an inverted-U distribution with a peak at the age of 60-64, in Austria and Spain a distribution increasing with age and then levelling off for older age groups. DISCUSSION AND CONCLUSION: The importance of alcohol-related conditions that indirectly impact mortality can be re-assessed with the use of contributory mentions. The multiple-cause-of-death approach provides convergent results for countries characterised by similar patterns of alcohol consumption. Multiple-cause mortality was almost double the level of mortality with alcohol as the underlying cause, except in Poland. Mental and behavioural disorders were mostly certified as contributory to other, non-alcohol-related underlying causes of death.

Between 'Pioneers' of the Cardiovascular Revolution and Its 'Late Followers': Mortality Changes in the Czech Republic and Poland Since 1968.

After several decades of stagnation, mortality in most Central European countries started to decrease after 1989. The Czech Republic and Poland were the first former Communist countries in this region to experience a rapid and sustained increase in life expectancy. This study focuses on the trends in cause-of-death mortality that have contributed to the recent progress in these two countries. The analysis is based on the cause-of-death time series (1968-2013) reconstructed in accordance with the 10th ICD revision, which makes the data fully comparable over the full period under study. Actual trends in cause-specific mortality are presented, and age, sex and causes of death components of life expectancy changes are disentangled. In both countries, the reduction in cardiovascular mortality at adult and old ages was crucial for the increase in life expectancy after 1991. Results are discussed in the context of institutional changes that occurred after the fall of Communism, such as the reorientation of health policies and the emergence of non-governmental organizations. Changes in health-related attitudes and behaviours as well as structural changes in societies, notably the rising share of persons with tertiary education, are also discussed.

The regional variation in tobacco smoking - attributable mortality in Poland, 2006-2010.

STUDY OBJECTIVE: To explain the regional variation in smoking-attributable mortality in Poland by selected environmental characteristics. MATERIAL AND METHODS: On the basis of the simplified Peto method, standardized smoking-attributable death rates were estimated by applying data on overall mortality and mortality due to malignant neoplasms of trachea, bronchus and lung for the years 2006-2010 obtained from the Central Statistical Office. The correlation between smoking-attributable mortality (SAM) and selected regional characteristics was estimated in two models of linear regression (for men and women). The characteristics of 379 NUTS-4 regions for the years 2006-2010 were derived from the CSO and other public data sources. RESULTS: In both absolute and relative terms, the male and female SAM appeared to be higher in the northern and western regions of Poland. For both men and women, the linear regression confirmed the significant positive correlation between the level of SAM and poverty, hazardous working conditions, crime level, low level of settlement, low proportion of persons in agriculture and of University graduates. Additional variables correlating with the male SAM pointed to unemployment, proportion employed in services, mortality due to intentional self-harm and electoral turnout. CONCLUSION: At the NUTS-4 level, the territorial variation in male and female SAM can be partially explained by the variation in regional characteristics indicating unfavourable economic and social conditions.

Role of smoking in regional variation in mortality in Poland.

AIMS: We assess the effect of smoking on regional disparities in mortality in Poland and its contribution to the change in regional disparities during the last two decades. DESIGN, SETTING AND PARTICIPANTS: We used population-level mortality data from the population registry for 379 Nomenclature of Territorial Units for Statistics (NUTS)-4 Polish regions for 1991-93 and 2008-10. MEASUREMENTS: The importance of smoking was assessed by smoking-attributable mortality (SAM) derived using a simplified indirect Peto-Lopez method. Regional differences in age-standardized all-cause, smoking- and non-smoking-attributable mortality (NSAM) rates at ages 35 years and over were mapped, and spatial clustering (Moran's I) and coefficients of variation (CV) were estimated. The contribution of SAM to variation in all-cause mortality was assessed by variance decomposition and compared over time. FINDINGS: In 2008-10, all-cause and SAM rates were characterized by a similar pattern of spatial clustering (Moran's I > 0.44, P < 0.0001). For NSAM, a more random pattern with less regional clustering showed (Moran's I = 0.34, P < 0.0001). The contribution of smoking to regional variation was substantial [54%, 95% confidence interval (CI) = 44.9, 62.5 among men; 24.9%, 95% CI = 20.9, 29.1 among women], and compared with 1991-93, 27.5 percentage points lower for men and 6.3 percentage points higher for women. Smoking contributed to the divergence between the regions in all-cause mortality between 1991-93 and 2008-10 for men [increase in CV of SAM by 2% (0, 4%)], but not for women [decrease in CV of SAM by 15% (22, 10%)]. CONCLUSIONS: Differences in past smoking behaviour may largely explain the regional differences in all-cause mortality existing in 2008-10 in Poland, and its trends since 1991-1993.