In 1989, chronic liver disease,* including cirrhosis, was the ninth mostfrequent cause of death in the United States (1). Periodic analysis of trendsand factors related to preventable death and hospitalization for chronic liverdisease may be used to target prevention and control programs. This reportexamines national trends in death and hospitalization rates and state-specificdeath rates for chronic liver disease using data from CDC's National Center forHealth Statistics' multiple-cause-of-death file and the National HospitalDischarge Survey (NHDS).
From 1980 through 1989, the age-adjusted death rate ** for chronic liverdisease decreased 23%, from 13.5 to 10.4 per 100,000 persons (Figure 1). Duringthis period, rates for men were more than two times higher than for women, andrates for blacks were more than 50% higher than for whites. *** Death rates foreach of these groups declined steadily during this period.
In 1989, chronic liver disease was the underlying cause of death for26,720 persons (Table 1) and a contributing cause of death for an additional14,101 persons. Among deaths for which chronic liver disease was the underlyingcause, 46.1% were diagnostically associated with alcohol (i.e., alcoholic fattyliver, acute alcoholic hepatitis, alcoholic cirrhosis of the liver, andalcoholic liver damage-unspecified); 2.9%, with chronic hepatitis; 1.5%, withbiliary cirrhosis; and 49.5%, with unspecified conditions and no mention ofalcohol (i.e., cirrhosis of the liver without mention of alcohol, other chronicnonalcoholic liver disease, and unspecified chronic liver disease withoutmention of alcohol).
Age-specific death rates increased with age for men in the 35-44-yearthrough 65-74-year age groups (from 15.2 to 49.0 per 100,000 men) and for womenin the 35-44-year through 75-84-year age groups (from 4.8 to 26.7 per 100,000women) (Table 1). State-specific age-adjusted death rates of chronic liverdisease in 1989 varied more than fivefold, from 6.1 per 100,000 population (forIdaho) to 31.5 per 100,000 (for the District of Columbia). The median rate was9.6 per 100,000.
Chronic liver disease was also an important, although diminishing, causeof hospitalizations during 1980-1989. The age-adjusted hospitalization rate ofchronic liver disease decreased 44% during this period (from 50.6 to 28.2 per100,000) (Figure 1). Rates for women were generally one third lower than formen, and for both, declined steadily throughout the decade. For most years,rates for whites were 20%-30% lower than rates for blacks.
Chronic liver disease appeared as the first-listed diagnosis in anestimated 72,232 hospitalizations in 1989 (Table 2). Among thesehospitalizations, 49.3% were diagnostically associated with alcohol, 10.5% withchronic hepatitis, 1.8% with biliary cirrhosis, and 38.3% with unspecifiedconditions and no mention of alcohol. Chronic liver disease was also listed asa diagnosis (other than first-listed) in an additional 218,156hospitalizations.
Age-adjusted hospitalization rates of chronic liver disease in 1989 were38% higher for men than for women (33.1 versus 23.9 per 100,000) and 27% higherfor blacks than for whites (30.1 versus 23.7 per 100,000). Rates weresuccessively higher in each age group from 35-44 years through 55-64 years forboth men and women (from 40.9 to 96.5 per 100,000 and from 30.1 to 88.9 per100,000, respectively) and decreased sharply after this age.
Reported by: Chronic Disease Surveillance Br, Office of Surveillance andAnalysis, National Center for Chronic Disease Prevention and Health Promotion,CDC.
Editorial Note: Most specific types of chronic liver disease in the UnitedStates are preventable (2). The findings in this report indicate a steadydecline in rates of hospitalization and death from chronic liver disease duringthe 1980s. The variation in state-specific age-adjusted death rates suggestsunderlying regional differences in the occurrence of chronic liver disease andrelated risk factors. These findings may be used to target prevention andtreatment programs and in the design of further epidemiologic research.
The findings in this report are subject to at least two limitations.First, because NHDS data do not distinguish initial from recurrenthospitalizations for a given person, these results represent the number ofhospitalizations rather than the number of persons hospitalized for chronicliver disease. Thus, the declines might reflect a decline in the number ofpersons with chronic liver disease or in fewer hospitalizations among thosewith chronic liver disease, or some combination of both. Second, for bothhospitalization and death certificate data, alcohol-related diagnoses may beunder-reported.
Despite these potential limitations, the declining hospitalization anddeath rates reported here may indicate a true decrease in the underlyingoccurrence of chronic liver disease as a result of decreases in the prevalencesof major risk factors (e.g., heavy alcohol use). In the United States, heavyalcohol use is considered the most important risk factor for chronic liverdisease; even among deaths coded as chronic liver disease with unspecifiedconditions and no mention of alcohol, approximately 50% are thought to be dueto alcohol use (3). Thus, decreasing hospitalization and death rates mayreflect, in part, the decline in per capita alcohol consumption from 1977through 1989 (4). These findings also are consistent with data from CDC'sBehavioral Risk Factor Surveillance System that have shown a greater proportionof heavy drinkers among men than women and that alcohol consumption isinversely related to age (5). Strategies for reducing per capita consumption ofalcohol include price controls (e.g., increased taxes on alcohol), control ofthe physical availability of alcohol, changes in legal accessibility,information and education programs, health warning labels,targeted health-promotion programs, and related activities (6).
Hepatitis B and C viruses are also important risk factors for chronicliver disease (7), and their relative contribution to chronic liver disease,alone and in combination with alcohol, requires further study. A comprehensivevaccination strategy for eliminating hepatitis B virus transmission and itssequelae in the United States has been recommended (8). Other potential riskfactors include certain drugs, industrial chemicals, and less common infectiousagents.
An estimated 90% of deaths attributed to cirrhosis is preventable (2). Thenational health objectives for the year 2000 include reducing cirrhosis deathsto no more than six per 100,000 **** (9). The findings in this reportunderscore that efforts to decrease mortality associated with chronic liverdisease will have to be intensified if this objective is to be met.
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National Institute on Alcohol Abuse and Alcoholism. Apparent per capita consumption: national, state, and regional trends, 1977-1989. Rockville, Maryland: US Department of Health and Human Services, Public Health Service, 1991; DHHS publication no. (ADM)281-89-0001.
Anda RF, Waller MN, Wooten KG, et al. Behavioral risk factor surveillance, 1988. In: CDC surveillance summaries (June). MMWR 1990;39(no. SS-2):1-21.
Rankin JG, Ashley MJ. Alcohol-related health problems. In: Last JM, Wallace RB, eds. Maxcy-Rosenau-Last public health and preventive medicine. 13th ed. East Norwalk, Connecticut: Appleton and Lange, 1992.
Hurwitz ES, Neal JJ, Holman RC, et al. Chronic liver disease deaths associated with viral hepatitis in the United States {Abstract}. In: Program and abstracts of the Seventh National Conference on Chronic Disease Prevention and Control. Atlanta: US Department of Health and Human Services, Public Health Service, CDC, 1992:85.
ACIP. Hepatitis B virus: a comprehensive strategy for eliminating transmission in the United States through universal childhood vaccination -- recommendations of the Immunization Practices Advisory Committee (ACIP). MMWR 1991;40(no. RR-13).
Public Health Service. Healthy people 2000: national health promotion and disease prevention objectives -- full report, with commentary. Washington, DC: US Department of Health and Human Services, Public Health Service, 1991; DHHS publication no. (PHS)91-50212.
International Classification of Diseases, Ninth Revision, code 571. ** Based on the underlying cause of death. Intercensal population estimates were used to calculate age-adjusted rates standardized to the 1980 U.S. population. *** Estimates are presented by race to address the national health objectives for the year 2000 to reduce cirrhosis deaths in special populations. Estimates are not presented for races other than black and white because numbers were too small for analysis. **** Age-adjusted to the 1940 U.S. standard population.