Atlas of Respiratory Disease Mortality,

United States: 1982-1993

Jay H. Kim, Ph.D.

Division of Respiratory Disease Studies

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Public Health Service

Centers for Disease Control and Prevention

National Institute for Occupational Safety and Health

August, 1998
ii

Disclaimer

Mention of company name or product does not constitute endorsement by the National Institute for Occupational Safety 

Copies of this and other NIOSH documents are available from:

Publications Dissemination, EID

National Institute for Occupational Safety and Health

4676 Columbia Parkway

Cincinnati, OH 45226-1998

FAX (513) 533-8573

DHHS (NIOSH) Number 98-157

For further information about occupational safety and health, call 1-800-35-NIOSH

or visit http://www.cdc.gov/niosh
*National Institute for Occupational Safety and Health. Work-Related Lung Disease Surveillance Report, 1996. DHHS (NIOSH) Pub

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PREFACEThis Atlas of Respiratory Disease Mortality, United States: 1982-1993 presents maps showing geographic distribservice area) of mortality associated with selected respiratory conditions that together represent nearly all respiratcategories of traditional occupational lung diseases mapped in this atlas (i.e., the pneumoconioses, including coal wpneumoconiosis, asbestosis, silicosis, byssinosis, and other and unspecified pneumoconioses), nearly all cases are ahazardous occupational exposure. NIOSH has previously published maps showing geographic distributions (by cpneumoconiosis mortality in the United States [NIOSH 1996]. For other respiratory disease categories mapped i

*

frequently occur in the absence of hazardous occupational exposure, and smaller proportions of cases--much smalcategories--are therefore considered attributable to occupational exposure. Nevertheless, for each of the disease cthis atlas, occupational causes have been documented. The author hopes that the geographic patterns of respiratoin this atlas will stimulate and aid further study of occupational etiologies of a variety of respiratory diseases, not jreferred to as occupational lung diseases.
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ACKNOWLEDGMENTSThe author thanks Dr. Kathleen Kreiss for encouragement and for her decision to produce this atlas; Dr. John E. Psupport from conception to completion; Dr. Ki Moon Bang for advice; Ms. Helen Montagliani for formatting the for verifying the endless numbers that configured the maps; and Ms. Molly Pickett-Harner for editorial assistance. The author also wishes thank the following individuals who reviewed and provided critical comments on draft comDrs. Ki Moon Bang, Robert M. Castellan, William L. Eschenbacher, Kathleen Kreiss, John E. Parker, Edward L. Weissman, and Linda Williams Pickle. Finally, the author expresses gratitude to colleagues at the National Center for Health Statistics, including Drs. MCharles Croner, for providing advice, the HSA boundary file for the mapping program, and other pertinent inform
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CONTENTSPreface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Data and Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Respiratory Disease Categories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Mortality Maps and Disease Categories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1. Tuberculosis (ICD-9 Codes 011, 012)

Age-Adjusted Death Rates by HSA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Death Rates of HSA Compared with U.S. Rate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Description . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

2. Sarcoidosis (ICD-9 Code 135)

Description . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Age-Adjusted Death Rates by HSA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Death Rates of HSA Compared with U.S. Rate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

3. Lung Cancer (ICD-9 Code 162)

Age-Adjusted Death Rates by HSA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Death Rates of HSA Compared with U.S. Rate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Description . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

4. Pleural Malignancy (ICD-9 Code 163)

Description . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Age-Adjusted Death Rates by HSA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Death Rates of HSA Compared with U.S. Rate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

5. Pneumonia (ICD-9 Codes 480-486)

Age-Adjusted Death Rates by HSA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Death Rates of HSA Compared with U.S. Rate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 
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Description . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

6. Chronic Obstructive Pulmonary Disease (ICD-9 Codes 490-492, 494, 496)

Description . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Age-Adjusted Death Rates by HSA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Death Rates of HSA Compared with U.S. Rate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

7. Asthma (ICD-9 Code 493)

Age-Adjusted Death Rates by HSA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Death Rates of HSA Compared with U.S. Rate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Description . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

8. Hypersensitivity Pneumonitis (ICD-9 Code 495)

Description . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Age-Adjusted Death Rates by HSA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Death Rates of HSA Compared with U.S. Rate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

9. Coal Workers’ Pneumoconiosis (ICD-9 Code 500)

Age-Adjusted Death Rates by HSA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Death Rates of HSA Compared with U.S. Rate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Description . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

10. Asbestosis (ICD-9 Code 501)

Description . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Age-Adjusted Death Rates by HSA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Death Rates of HSA Compared with U.S. Rate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

11. Silicosis (ICD-9 Code 502)

Age-Adjusted Death Rates by HSA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

 Death Rates of HSA Compared with U.S. Rate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 
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Description . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

12. Other/Unspecified Pneumoconioses (ICD-9 Codes 503, 505)

Description . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Age-Adjusted Death Rates by HSA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Death Rates of HSA Compared with U.S. Rate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

13. Byssinosis (ICD-9 Code 504)

Age-Adjusted Death Rates by HSA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Death Rates of HSA Compared with U.S. Rate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Description . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

14. Toxic Inhalation Injury (ICD-9 Code 506)

Description . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Age-Adjusted Death Rates by HSA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Death Rates of HSA Compared with U.S. Rate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

15. Pulmonary Fibrosis (ICD-9 Code 515)

Age-Adjusted Death Rates by HSA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Death Rates of HSA Compared with U.S. Rate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Description . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

16. Other Alveolar/Interstitial Diseases (ICD-9 Code 516)

Description . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Age-Adjusted Death Rates by HSA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Death Rates of HSA Compared with U.S. Rate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

17. Pulmonary Eosinophilia (ICD-9 Code 518.3)

Age-Adjusted Death Rates by HSA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Death Rates of HSA Compared with U.S. Rate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Description . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 
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Appendix I. Health Service Area Boundary Map . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Appendix II. List of Health Service Areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 
1

DATA AND METHODSMortality DataMultiple cause of death tapes with Federal Information Processing Standard codes that identify minor civil divisioto the public since 1982 from the National Center for Health Statistics (NCHS). While each tape holds all death rUnited States for a given year, each death record contains International Classification of Diseases 9 Revision (IC

th

20 diseases listed on the death certificate, along with place of residence and demographic characteristics. Beginning in 1987, the public use tapes do not contain geographic identifiers for decedents who were one of less twith any specified cause of death in a geographic area smaller than a state. Therefore, customized tapes with coundeath were obtained from NCHS for 1987 and subsequent years.For this atlas, data for 1982 through 1993 were used, restricting decedents to U.S. residents 15 years of age and odisease categories were selected for mapping (Table 1). For each condition of interest, the number of deaths (with either underlying or contributing cause) was tabulated by four age groups: 15-34; 35-54; 55-74; and 75 years and conditions (e.g., COPD), a death with codes for two or more diagnoses (e.g., bronchitis and emphysema) was couPopulation DataThe U.S. population by county as of January 1, 1988 (the midpoint of the study period) was calculated using 1987 from the Bureau of the Census. Health service area (HSA) populations were aggregated from these county populused as denominators for death rates.Geographic UnitThe basic geographic unit in this atlas is the HSA as defined based on travel patterns between counties by Medicar
Makuc DM, Haglund B, Ingram DD, et al. [1991]. Health service areas for the United States. National Center for Health Statistics. 

**(112).

Bureau of the Census [1981]. Census of population and housing, 1980: county population by age, sex, race, and Spanish origin. (Pr

***consistent modified race), Washington, D.C.

2

routine hospital care (Makuc, 1991). A total of 3,141 counties configure 805 HSAs (Appendices I and II). To p

**

mortality data for this atlas, the county of residence for each decedent was converted to one of the 805 HSAs.Age-Adjusted Death RatesAn age-adjusted death rate for each HSA from each condition of interest was calculated using the 1980 U.S. popu[Bureau of the Census]. The age-specific rates by HSA were computed by dividing the average annual numbe

***

age group by the corresponding population as of January 1, 1988. Then those rates were applied to the standard pthe expected number of deaths. The sum of expected deaths for each HSA was divided by the total standard popresulting quotient was multiplied by 1,000,000 to produce the age-adjusted rates. Therefore, the rates are per yeaperiod. Mortality Rate RatioTo compare the age-adjusted death rates of HSAs to the U.S. rate, a mortality rate ratio method was used: for eacategories, the age-adjusted death rate for each HSA was divided by the U.S. rate.Graphical DisplayTo define ranges for mapping age-adjusted death rates, the rates were ordered and then categorized to five groups the lowest according to the following distribution: 10 per cent, 20 per cent, 40 per cent, 20 per cent, and 10 per cesome conditions, there were considerable numbers of HSAs without any deaths recorded for the study period. 
Vital Statistics of the United States, 1992. Volume II - Mortality, Part A. DHHS PHS, 1992.  

A product of Strategic Mapping, Inc., Santa Clara, CA, 1995. ** ***

3

On rate ratio maps, HSAs with lower than or equal to the U.S. age-adjusted death rate have been assigned to the HSAs with higher than U.S. rate were categorized into quartiles of the mortality distribution. Double-hatched marks indicate that there were less than 20 deaths for the study period in that HSA. Rates and raHSAs should be interpreted with caution. 

For a better visibility, a second New York City HSA map has been scaled as a larger than actual polygon outside oAtlas GIS version 3 has been used with HSA boundary layers and maps developed by NCHS to generate all m

** ***
4

RESPIRATORY DISEASE CATEGORIESTable 1 shows the respiratory disease categories selected for mapping in this atlas, corresponding ICD-9 rubrics aaverage number of deaths and U.S. rates for 1982-1993. 

Table 1. Respiratory Disease Categories: Average Annual Number of Deaths and Age-Adjusted D

U.S. Residents 15 Years of Age and Older, 1982-1993.

Cause of Death ICD-9

Category Code(s) ICD-9 Rubric(s) Annual Number 

of Deaths 

Tuberculosis Pulmonary tuberculosis 011

Other respiratory tuberculosis 012 3,256 

Sarcoidosis Sarcoidosis 135 770 Lung cancer Malignant neoplasm of trachea, bronchus, and lung 162 142,945 Pleural malignancy Malignant neoplasm of pleura 163 513 Pneumonia Pneumonia due to other specified organisms 483 184,670 

Viral pneumonia 480Pneumococcal pneumonia 481Other bacterial pneumonia 482Pneumonia in infectious diseases classified elsewhere 484Bronchopneumonia 485Pneumonia, organism unspecified 486

Chronic obstructivepulmonary disease

Bronchitis, not specified as acute or chronic 490Chronic bronchitis 491Emphysema 492 175,822 Bronchiectasis 494Chronic airway obstruction, not elsewhere classified 496
5

Table 1. Respiratory Disease Categories: Average Annual Number of Deaths and Age-Adjusted D

U.S. Residents 15 Years of Age and Older, 1982 - 1993 (continued).

Cause of Death ICD-9

Category Code(s) ICD-9 Rubric(s) Annual Number 

of Deaths 

Asthma Asthma 493 9,394 Hypersensitivitypneumonitis Extrinsic allergic pneumonitis 495 29 Coal workers'pneumoconiosis Coal workers' pneumoconiosis 500 2,261 Asbestosis Asbestosis 501 733 Silicosis Pneumoconiosis due to other silica or silicates 502 323 Other/unspecified Pneumoconiosis due to other inorganic dust 503pneumoconioses Pneumoconiosis, unspecified 505 315 Byssinosis Pneumonopathy due to inhalation of other dust 504 14 Toxic inhalation injury vapors

Respiratory conditions due to chemical fumes and 506 34 

Pulmonary fibrosis Postinflammatory pulmonary fibrosis 515 9,108 Other alveolar/interstitial diseases Other alveolar and parietoalveolar pneumonopathy 516 1,136 Pulmonaryeosinophilia Pulmonary eosinophilia 518.3 651 
6
7

Mortality Maps

and

Disease Descriptions
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10

Tuberculosis (ICD-9 Codes 011-012)Pulmonary (ICD-9 code 011) and other respiratory (ICD-9 code 012) tuberculosis is caused by infection with Mytuberculosis. Infected individuals produce airborne particles that contain tubercle bacilli when coughing, sneezingPrimary tuberculosis infection, acquired by inhalation of infectious particles small enough (approximately 1-5 diamdeposited in an alveolus [Hopewell 1988], usually requires prolonged exposure in proximity to an individual with tuberculosis. In the United States, most active cases of pulmonary tuberculosis are the result of reactivation of prinfection, sometimes many years after primary infection has occurred.Various risk factors for tuberculosis have been identified that either influence the likelihood of tuberculosis or servincreased risk: HIV infection and other forms of immunosuppression, malnutrition, gastrectomy, lower socioeconhomelessness, and imprisonment [Markowitz 1994]. The relative risk of tuberculosis for nonwhites compared to wfrom 2.9 in 1953 to over 5.0 in 1992. From 1985 to 1992, the tuberculosis incidence rate increased 37.8 in black whereas it decreased by 11 percent among whites. In 1992, the minority population with the highest incidence of tAsian/Pacific Islanders with 46.6 cases per 100,000 population [Braden et al. 1996].Tuberculosis has been recognized as an occupational hazard. Occupations identified at increased risk of tuberculoclassified as: 1) occupations (e.g., migrant farm work) that attract workers otherwise at high risk of tuberculosis; associated with silicosis (e.g., mining, sandblasting, and foundry work) that increases susceptibility to organisms; athat increase the chance of exposure (e.g., health care workers)[Bowden and McDiarmid 1994]. Among health cahave the highest risk, 2 to 3 times that of physicians [Sepkowitz and Schluger 1996]. The increased risk of tubercworkers has been well documented [Markowitz, 1994]. Proportionate mortality analyses have further confirmed risk of occupational exposure among health care workers and silica-exposed workers [NIOSH 1995]. ReferencesBowden KM, McDiarmid MA [1994]. Occupationally acquired tuberculosis: what’s known. J Occup Med 36(3):320-325.Braden CR, Onorato IM, Kent JH [1996]. Tuberculosis epidemiology—United States. In: Rom WN, Garay SM, eds. Tuberculosis. NeBrown and Company, pp. 85-97.Hopewell PC [1988]. Mycobacterial diseases. In: Murray JF, Nadel JA, eds. Textbook of respiratory medicine. Philadelphia, PA: W.B

pp. 856-915.NIOSH (National Institute for Occupational Safety and Health) [1995]. Proportionate mortality from pulmonary tuberculosis associateStates, 1979-1990. MMWR 44:14-19.Markowitz SB [1994]. Epidemiology of tuberculosis among health care workers. Occup Med 9:589-609.Sepkowitz KA, Schluger NW [1996]. Tuberculosis and the health care worker. In: Rom WN, Garay SM, eds. Tuberculosis. New YoCompany, pp. 935-943.