Eurostat, the statistical office of the European Union

F5: Education, health and social protection

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Data on causes of death (COD) provide information on mortality patterns and form a major element of public health information.

COD data refer to the underlying cause which - according to the World Health Organisation (WHO) - is "the disease or injury which initiated the train of morbid events leading directly to death, or the circumstances of the accident or violence which produced the fatal injury".

Causes of death are classified by the 86 causes of the "European shortlist" of causes of death. This shortlist is based on the International Statistical Classification of Diseases and Related Health Problems (ICD).

COD data are derived from death certificates. The medical certification of death is an obligation in all Member States. Countries code the information provided in the medical certificate of cause of death into ICD codes according to the rules specified in the ICD.

Data are broken down by sex, 5-year age groups, cause of death and by residency and country of occurrence. For stillbirths and neonatal deaths additional breakdows might include age of mother.

Data are available for EU-28, the former Yugoslav Republic of Macedonia, Albania, Iceland, Norway, Liechtenstein and Switzerland. Regional data (NUTS level 2) are available for most of the countries.

Annual national data are provided in absolute number, crude death rates and standardised death rates. At regional level (NUTS level 2) the same is provided in form of 3 years averages. Annual crude death rates are also available at NUTS level 2.

Eurostat's COD statistics build on standards set out by the World Health Organisation (WHO) in the International Statistical Classification of Diseases and Related Health Problems (ICD). The ICD does not only provide codes for diagnosis but also rules and guidelines for mortality coding; it also recommends an international form of medical certificate of cause of death. All countries follow the ICD, currently in its tenth revision. Causes of death are grouped for dissemination on Eurostat's website by the 86 causes of the "European shortlist 2012" of causes of death. This shortlist was created by Eurostat as an update of the previous one which listed 65 causes of death and was in use from 1998 to November 2013.

The regional breakdown of the EU Member States is based on the Nomenclature of Territorial Units for Statistics (NUTS).

Public Health

Causes of death (COD) statistics are based on information derived from the medical certificate of cause of death. COD target at the underlying cause of death, in accordance with the ICD-10 definition i.e. "the disease or injury which initiated the train of morbid events leading directly to death, or the circumstances of the accident or violence which produced the fatal injury".

Absolute numbers, crude death rates and (age-) standardised death rates are provided for COD.

The crude death rate describes mortality in relation to the total population. Expressed in deaths per 100,000 inhabitants, it is calculated as the number of deaths recorded in the population for a given period divided by population in the same period and then multiplied by 100,000.

Crude death rates are calculated for 5-year age groups. At this level of detail, comparisons between countries and regions are meaningful. The crude death rate for the total population (all ages) however, is a weighted average of the age-specific mortality rates. The weighting factor is the age distribution of the population whose mortality is being observed. Thus, the population structure strongly influences this indicator for broad age classes. In a relatively 'old' population, there will be more deaths than in a 'young' one because mortality is higher for age groups referring to older ages.

For comparisons, the age effect can be taken into account by using a standard population. The (age-) standardised death rate is a weighted average of age-specific mortality rates. The weighting factor is the age distribution of a standard reference population. The standard reference population used is the European standard population (see annex European standard population - revision 2012) as defined by Eurostat in 2012. The new European Standard Population (ESP) is the unweighted average of the individual populations of EU-27 plus EFTA countries in each 5-years age band (with the exception of under 5 and the highest age-group of 95+). The ESP is calculated from on the basis of the 2010-based population projections, averaged over the period 2011-30.

As method for standardisation, the direct method is applied. Standardised death rates are calculated for the age group 0-64 ('premature death') and for the total of ages. As most causes of death vary significantly with people's age and sex, the use of standardised death rates improves comparability over time and between countries.

For calculating crude and standardised death rates, the annual average population available in Eurostat's demography database is used. In case the population data for age groups 85-89 years, 90-94 years and 95+ years was not available for the standardized deaths rate calculation, then the age group 85+ has been used as a proxy. This is denoted in the database by the flag "i". However, the bias is likely to be relatively small.

Indicators on fetal, peri- and neonatal mortality are consistent with definitions used in the Eurostat's demography database:

Infant mortality rate per 1000 live births is calculated as the ratio of number of deaths of children under one year of age to the number of live births. The value is expressed per 1000 live births.

Early neonatal mortality rate per 1000 live births is calculated as the ratio of the number of deaths at age day 0 to (and including) day 6 to the number of live births. The value is expressed per 1000 live births.

Late foetal mortality rate per 1000 births is calculated as the ratio of the number of stillbirths to 1000 births. The value is expressed per 1000 births.

Neonatal mortality rate per 1000 live births is calculated as the ratio of the number of deaths at age day 0 to (and including) day 27 to the number of live births. The value is expressed per 1000 live births.

Perinatal mortality rate per 1000 births is calculated as the the number of stillbirths plus deaths at age day 0 to (and including) day 6 divided by the number of births. The value is expressed per 1000 births.

In addition to the total number of stillbirths, two detailed groups are displayed. The first group (LFD1 - Late Foetal Death - Group 1) records stillbirth with birth weight from 500 to 999 g or (when birth weight does not apply) gestational age from 22 to 27 weeks, or (when neither of the two applies) crown-heel length from 25 to 34 cm. The second group (LFD2 - Late Foetal Death - Group 2) reports stillbirth with birth weight of 1,000 g and more or (when birth weight does not apply) gestational age after 27 completed weeks, or (when neither of the two applies) crown-heel length of 35 cm or more. The sum of the two sub-groups is not necessarily equal to the total number of stillbirths. For example, stillbirths with birth weight below 500 g or gestational age below 22 weeks or crown-heel length below 25 cm are not reported in any of the two sub-groups but might be recorded in the total number of stillbirths.

In addition, data is published on Potential Years of Life Lost (PYLL). Potential Years of Life Lost is a summary measure of premature mortality which provides an explicit way of weighting deaths occurring at younger ages, which might be, a priori, preventable. The calculation for PYLL involves adding up all deaths for all causes (ICD=A-R, V-Y) occurring at each age up to 70 years, multiplying this with the number of remaining years to live until the selected age limit (70 years), and then dividing this by the midterm population. Last, the term is standardized using to the European Standard Population.

For the public health theme tables (hlth_cd_pbt), including amenable and preventable deaths, infant deaths, deaths due to infectous diseases, transport accidents, or dementia including alzheimer's disease, the specific ICD codes to be used were compiled by Eurostat Task Force on Satellite Lists (final report issued in June 2014). Background information on amenable and preventable deaths, as well as the specific ICD codes used for amenable and preventable deaths and for infectous diseases can be found in the annex (Specifications of public theme tables). Data in the public health theme tables are disseminated for absolute numbers (NR) and standardized death rates (RT).

The statistical unit is the deceased person. The reporting unit is the certifier. This is in most cases a physician. In the case of non-natural deaths, the certification could be made by forensic physicians or in some countries by legal professionals, such as coroners in England.

The statistical population is the population of a given country, including both residents and non-residents. For the COD data collection the following definition of 'resident' is used: "'usual resident' in the place where a person normally spends the daily period of rest, regardless of temporary absences for the purposes of recreation, holidays, visits to friends and relatives, business, medical treatment or religious pilgrimage.".

However, national legal requirements as well as national practices concerning the registration of residents dying abroad and domestic deaths of non-residents are not yet fully harmonised across European countries. Therefore, full information about residents dying abroad might not be included in all countries.

The data are published for two different populations: the first one captures deaths by all residents of a country and the second one contains all deaths reported in a country.

The number for "All deaths of residents in or outside their home country (TOT_RESID)" are calculated by taking data for residents dying in their home country (for example, deaths reported by Latvia for Latvian residents dying in Latvia) and adding the number of deaths that were reported by other EU countries to have died in their country (for example deaths of Latvian residents dying in Germany and reported by Germany).

The number for "All deaths reported in the country (TOT_IN)" includes all deaths occurred in the reporting country, i.e. deaths by residents and non-residents in the reporting country.

EU-28, the former Yugoslav Republic of Macedonia, Albania, Iceland, Norway, Liechtenstein and Switzerland

Time series for most EU-28 countries and EFTA are available from 1994 onwards (Belgium, Germany: 1992, Ireland: 1993). For some countries data are only available from 1995 (Bulgaria), 1996 (Latvia and Slovakia), 1999 (Cyprus, Poland and Romania) or 2010 (Liechtenstein) onwards.

Note that due to the fact that 2011 data is the first data collection with a legal basis (and few changes in the requested variables and breakdowns), the data between 1994-2010 and starting from 2011 are not always comparable (In part due to the different groupings of causes of deaths). Moreover time series for data on stillbirths starts in 2011 and no information on previous data is available.

Not applicable

Countries submitted data to Eurostat on the basis of a gentleman's agreement established in the framework Eurostat's Working Group on "Public Health Statistics" until data with reference year 2010. The first data submitted according to the Regulation (EU) No 328/2011 is data with reference year 2011.

A Regulation on Community statistics on public health and health and safety at work (EC) No 1338/2008 was signed by the European Parliament and the Council on 16 December 2008. This Regulation is the framework of the data collection on the domain.

Within the context of this framework Regulation, a Regulation on Community statistics on public health and health and safety at work, as regards statistics on causes of death (EU) No 328/2011 was signed by the European Parliament and the Council on 5 April 2011.

Common specifications with the World Health Organisation (WHO) were used in the data collection up to 2010; in addition, Eurostat asks for NUTS level 2. From 2011 onwards, Eurostat changed the specifications to take into account the data collected through the Regulation No 328/2011.

Regulation (EC) No 223/2009 on European statistics (recital 24 and Article 20(4)) of 11 March 2009 (OJ L 87, p. 164), stipulates the need to establish common principles and guidelines ensuring the confidentiality of data used for the production of European statistics and the access to those confidential data with due account for technical developments and the requirements of users in a democratic society.

All agegroups showing a total mortality of less than 4 cases are considered as confidential. Therefore, any 'confidential' agegroup is grouped with another one to have higher numbers. In practice, this problem mainly occurs for young ages so, either the ages from 0 to 14 years old, or the ages from 0 to 14 and 15 to 24 years old are grouped. The agegroups considered as confidential show then the value ':' and the agegroup '0-14y' (and '15-24y' if needed) shows the sum of all ages before 15 years old (or between 15 and 24 years old). In addition, special measures for ensuring confidentiality may be taken for small countries.

For stillbirth and neonatal figures, no breakdown by parity is displayed to ensure confidentiality.

Not applicable

Not applicable

In line with the Community legal framework and the European Statistics Code of Practice Eurostat disseminates European statistics on Eurostat's website (see item 10 - 'Dissemination format') respecting professional independence and in an objective, professional and transparent manner in which all users are treated equitably. The detailed arrangements are governed by the Eurostat protocol on impartial access to Eurostat data for users.

Not applicable

Health Statistics - Atlas on mortality in the European Union (2009)
Who dies of what in Europe before the age of 65 - Statistics in Focus (Population and Social Conditions - 67/2009)
Circulatory diseases –Main causes of death for persons aged 65 and more in Europe, 2009
Revision of the European Standard Population - Report of Eurostat's task force - 2013 edition
For more information on publications, see also Eurostat website

Please consult free data on-line or refer to contact details.

All causes of death received from countries with ICD codes are stored in several internal GSAST databases on a secured network. A special extraction can be made on request.

http://ec.europa.eu/eurostat

Documents for COD are available in CIRCABC, Causes of Death section.

The quality of COD data is subject to the way in which the information on causes of death is reported and classified in each country (i.e. national certification and coding procedures). In general, all countries follow the standards and rules specified in the ICD, and the overall procedures for the collection of COD data are relatively homogenous between European countries (medical certification of cause of death, use of ICD).

However, national differences in interpretation and use of ICD rules exist and as a result important quality and comparability issues remain. Based on the report "Comparability and Quality Improvement of the European Causes of Death Statistics" countries work towards further improving certification and coding procedures.

Ongoing work is reported to Eurostat's Working Group "Public Health Statistics" (documents available here).

The causes of death data are based on a regulation, which defines scope, definitions of variables and characteristics of the data.

A quality assessment of Eurostat's COD statistics was organised in May and June 2008. In that framework, a questionnaire was sent to Eurostat's partners (data providers) for COD statistics and a user survey was set up on Eurostat's website, for which 25 partners and 34 users answered. A questionnaire was also filled in by responsible people of COD statistics in Eurostat.

Based on the 34 answers received from the web survey, the main users are Research Institutes,  Universities, Public Government agencies, Private, Commission services and Business companies. On these 34 answers, Eurostat data on Causes of Death are "essential", "important", or "used for background information" for 25 respondents.
Asking about the availability of needed data in the Eurostat production, users are divided in two equivalent part: 12 answered that they do not need statistics on the field not currently available from Eurostat and 13 answered that they need, giving information about defects and lacks of the Eurostat data.

Users were asked to assess each of the classical elements that characterise the quality of statistics.

Respondents generally give high scores to the different dimensions of data quality and to the supporting service that is perceived as "Good or Very Good" by the users (14 out of 21 respondents expressing opinions about this). The overall quality, comprising both data quality and supporting service, is perceived as "Good" or "Very good" by 16 out of 24 respondents to those questions.

Among different data quality dimensions, coherence and comparability receive the higher satisfaction. The less appreciated dimension is the completeness.

All data received are disseminated on Eurostat's website if the consistency of the dataset is good. However, a number of countries faces difficulties to deliver data on time.

The accuracy of COD statistics was also assessed by users and partners in the framework of the quality assessment. On 25 respondents, 14 users answered "good or very good" and 7 answered "adequate".

For the same question, on 27 respondents, 19 partners answered "good or very good" and 7 answered "adequate".

In addition, national legal requirements as well as national practices concerning the registration of residents dying abroad and domestic deaths of non-residents are not yet fully harmonised across European countries. Therefore, information about residents dying abroad might not be included in all countries, and deaths of non-residents might be included.

Not applicable

Not available.

From data collection with reference year 2011 onwards, Eurostat asks for the submission of final data for the year N at N+24 months. Some countries are able to transmit data to Eurostat already at N+18 and Eurostat publishes the data as soon as it is validated. In exceptional cases, countries are able to submit data with a delay of only 1 year (N+12), however this is not to be expected from a large number of countries.

Not available

The comparability of the data across different countries is limited by the fact that the revision of classification used to collect information on underlying causes of death may be different. However, only one country (Greece) is currently still using the ninth revision of the ICD. Furthermore, not all countries apply the recommended WHO's updates.
The coverage of residents dying abroad or non-residents dying in the reporting country can also affect the comparability among countries.
On-going work to increase quality, comparability and coverage done by the Technical group on Causes of Death or by ad-hoc Task Forces, or other means (e.g. ad-hoc workshops), is reported to Eurostat's Working Group "Public Health Statistics".

The comparability of the data over time is checked before dissemination. It could be that in few categories of causes of death, for which not all EU Member States reported data, the EU average is not be strictly comparable over time due to different composition of countries.  

Note that due to the fact that 2011 data is the first data collection with a legal basis (and few changes in the requested variables and breakdowns), the data between 1994-2010 and starting from 2011 are not always comparable (In part due to the different groupings of causes of deaths). Moreover time series for data on stillbirths starts in 2011 and no information on previous data is available.

COD data are also available in the database "Regions".

The total number of all deaths by cause (i.e. all causes) should equal the annual number of deaths shown in the database "Demography".

Any data considered as 'non consistent' are not published.

Not applicable.

There is no systematic revision of previous year data. Data are occasionally revised, e.g. if the "NUTS" changes or if a country notifies Eurostat about any changes in the data.

The statistics on causes of death (COD) are based on the information provided on death certificates (administrative data). All deaths of residents and non-residents are counted.

In all EU countries, the medical certification of death is an obligation. Most countries already use WHO's international standard model for all but perinatal deaths (0 to 1 week). For perinatal deaths, WHO recommends a specific form which is less frequently applied. The objective of the medical certificate of cause of death is to allow the certifier to enter as clearly and completely as possible the causes of death, i.e. describing the sequence of diseases and conditions leading to the death, mentioning other contributing conditions etc. In most countries, the medical certificates of cause of death are forwarded to COD statistics offices for centralised coding. COD statistics also require information on sex, age, place of residence etc. of the deceased. Depending on the country, this information is either collected through the death certificate or taken from other sources.

For calculating crude and standardised death rates, the annual average population available in Eurostat's demography database is used.

However, national legal requirements as well as national practices concerning the registration of residents dying abroad and domestic deaths of non-residents are far from being harmonised across European countries. Therefore, information about residents dying abroad might not be included in all countries, while deaths of non-residents are mandatory information.

Annual

The reporting unit is the certifier. This is in most cases a physician. In the case of non-natural deaths, the certification could be made by forensic physicians or in some countries by legal professionals, such as coroners in the UK. The Causes of death certificate is submitted electronically or in paper.

The information provided on the medical certificates of cause of death is to be coded into the International Statistical Classification of Diseases and Related Health Problems (ICD). The purpose of coding is to select the underlying cause of death which is defined as "the disease or injury which initiated the train of morbid events leading directly to death, or the circumstances of the accident or violence which produced the fatal injury". Depending on the country, coding is done manually or using automated coding systems. In most countries, coding is done centrally in the COD statistics office. COD statistics also require information on sex, age, place of residence and occurrence etc. of the deceased. Depending on the country, this information is either collected through the death certificate or taken from other sources.

The data is collected annually by Eurostat from countries via eDamis.

Countries submit data for the underlying causes of death either at the ICD 4-digit level or according to the "European shortlist" for causes of death (86 causes, based on ICD). A number of consistency checks (on age, sex, cause of death) are applied on the data at the level of the European shortlist. After validation of the COD total number data, the derived indicators (crude death rates, standardised death rates) are calculated and stored in Eurostat's database. Countries are encouraged to apply a standard validation tool (i.e. a list of standard checks that each country should perform on their COD data) before submitting data to Eurostat.

The absolute numbers for EU aggregates are the sum of country numbers. Note that when data of a member state are missing, the latest available number for this country is used to compute EU aggregate. Hence, the EU-28 aggregate might not correspond to the sum of the published data of the 28 member states. European aggregates calculated for crude death rates and standardised death rates are weighted averages.

No adjustments are made.