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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.

The 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".

The data are derived from the medical certificate of death, which is an obligation in the Member States. The information recorded in the medical certificate is according to the rules specified in the WHO (World health organisation).

Data published in Eurobase 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 breakdowns might include age of mother and parity.

Data are available for Member States, Iceland, Norway, Liechtenstein, Switzerland, United Kingdom, Serbia, Turkey, North  Macedonia and Albania. Regional data (NUTS level 2) are available for all of the countries having NUTS2 regions except Serbia and Albania.

Annual national data are availble in Eurobase in absolute number, crude death rates and standardised death rates. At regional level the same is provided in form of 3 years averages. Annual crude and standardized death rates are also available at NUTS2.

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). Since reference year 2014, all the countries follow the ICD classification in its tenth revision (ICD-10).

The regional breakdown is based on the Nomenclature of Territorial Units for Statistics (NUTS 2).

Causes of death are classified by the 86 groups of the "European shortlist" of causes of death stablished in 2012 (see document in the Annexes concept). This shortlist is based on the ICD classification and is used for the dissemination if the data in Eurobase.

Public Health

The concepts and definitions are described in the Commission regulation (EU) No 328/2011, articles 2 and 3.

All the countries use the concepts and definitions as described in the regulation, however the definitions of stillbirths and usual residence may differ for a few countries. 

There are some additional concepts and definitions which refers to the data published in Eurobase:

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. The new European Standard Population (ESP) is the unweighted average of the individual populations of EU Member States 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 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. 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 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 (see concept 3.4.2). 

In addition, data is published on Potential Years of Life Lost (PYLL). PYLL is an indicator estimating the potential years lost due to premature death, i.e. death before 70. It is calculated by summing the number of years between the age at death and 70 years for each premature death. PYLL rate is expressed per 100 000 age-standardised population under 70.

For the public health theme tables (hlth_cd_pbt), including treatable and preventable mortality, infant deaths, deaths due to infectious 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 treatable and preventable mortality, as well as the specific ICD codes used for preventable and treatable deaths and for infectious 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 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."

Most of the countries applies the definition as in the regulation ((i) those who have lived in their place of usual residence for a continuous period of at least 12 months before the reference date; or (ii) those who arrived in their place of usual residence during the 12 months before the reference date with the intention of staying there for at least 1 year).

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

The number for "All deaths reported in the country (TOT_IN)" includes all deaths occurred in the reporting country, i.e. deaths of residents and non-residents in the reporting 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 countries to have died in their country (for example deaths of Latvian residents dying in Germany and reported by Germany).

The data covers all the deaths of residents and non-residents occurring in the Member States, Iceland, Norway, Liechtenstein, Switzerland,  United Kingdom, Serbia, Turkey. North Macedonia and Albania.

Time series for most Member States and EFTA are available from 1994 onwards (Belgium, Czechia: 1919, Germany: 1992, Ireland: 1993, Estonia: 1989, Greece: 1956, Luxembourg: 1967 and Slovenia: 1985). For some countries data are only available from 1995 (Bulgaria), 1996 (Latvia and Slovakia), 1998 (Serbia), 1999 (Cyprus, Poland, Romania and Liechtenstein) onwards. Data on CoD for North Macedonia and Albania are available until 2010.

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 (partly 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.

Eurostat does not share the data with any other Organisation or Institution, however specific extraction can be made on request by users and other organisations.

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.

Eurostat applies the k-confidentiality with k=4 to the COD data disseminated in Eurobase. It means that the value is replaced by ":" and the flag c is added if there are 1 to 3 deaths for any given combination of the dimensions GEO, YEAR, SEX and AGE_GROUP. In addition, special measures for ensuring confidentiality may be taken for small countries.

Data are published as soon as received by countries by the occurrence concept in the following tables:

Causes of death - deaths by country of residence and occurrence [HLTH_CD_ARO]

Causes of death - infant mortality by country of occurrence [HLTH_CD_AINFO]

Peri-neonatal mortality by age of mother, by residence and occurrence [HLTH_CD_APERRO]

Fetal, peri- and neonatal mortality rates by country of occurrence [HLTH_CD_APERRTO]

Deaths related to transport accidents occurring in the country [HLTH_CD_TRO]

Deaths related to infectious diseases [HLTH_CD_IDO]

When that data from all the countries are available, they are published in Eurobase, including EU aggregates.

Not applicable as the data is published as they are submitted by the countries, after being validated.

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 - 'Accessibility and clarity') 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.

Eurostat news: https://ec.europa.eu/eurostat/web/products-eurostat-news/-/DDN-20190716-1

Press release on avoidable mortality: https://ec.europa.eu/eurostat/documents/portlet_file_entry/2995521/3-05092019-AP-EN.pdf/d51b508a-9a90-47ce-b9f4-eeeda5a5de92

There is not any specific publication for the COD data, however the "Health in the European Union - facts and figures" has several chapters on Causes of death:

https://ec.europa.eu/eurostat/statistics-explained/index.php?title=Health_in_the_European_Union_%E2%80%93_facts_and_figures

Regional COD data is published in the Eurostat Regional book:

https://ec.europa.eu/eurostat/web/products-statistical-books/-/ks-ha-21-001 

Statistics explained:

https://ec.europa.eu/eurostat/statistics-explained/index.php?title=Health

News articles: 

https://ec.europa.eu/eurostat/web/main/news/whats-new

COD data are available on the online database of Eurostat (Erobase).

Please consult free data on-line: https://ec.europa.eu/eurostat/web/health/data/database, or refer to contact details.

Eurostat does not provide access to the COD microdata.

There is not any other dissemination format.

The guidelines for recording and coding the causes of deaths using the ICD-10 classification can be found at:

https://icd.who.int/browse10/Content/statichtml/ICD10Volume2_en_2019.pdf

The submission to Eurostat of the national quality reports shall be done every five year. So far there has been two rounds for reference years 2011 and 2018. Almost all the countries have provided their quality reports.

Those for reference year 2018 are published in Eurobase.

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

There are clear and delailed  guidelines for recording and coding the causes of deaths using the ICD-10 classification published by the WHO. All the countries are following this methodology.

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 the domain manager 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 parts: 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.

Some users as researchers, journalist and professionals working in health institutes or organisations need COD data more disaggregated than published in Eurobase, i.e. deaths for some specific ICD codes and different breakdowns. Eurostat is providing the data anonymised with the same methodology applied to the disseminated data.

In 2008, users were asked to assess each of the classical elements that characterise the quality of statistics.

Respondents generally gave high scores to the different dimensions of data quality and to the supporting service that was 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, was perceived as "Good" or "Very good" by 16 out of 24 respondents to those questions.

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

Additionally, Eurostat carried out a general User Satisfaction Survey (USS) over the period of April - July 2019 and April - June 2020 on the Health domain statistics with the following result (% of respondants):

The Commission Regulation N° 328/2011, of 5 April 2011 implementing Regulation (EC) No 1338/2008 of the European Parliament and of the Council on Community statistics on public health and health and safety at work, as regards statistics on causes of death, describes in addition the data transmission.

Member States shall transmit to the Commission (Eurostat) the list of variables set out in the Annex of this regulation. Member States shall provide aggregated or micro data (finalised and validated) and metadata required by this Regulation. The transmission channels to provide data and metadata are those standards specified by the Commission (Eurostat).

The overall accuracy of the COD data collection is quite good. It is based on the information recorded in the death certificates, which is compulsory in all the countries.

All the compulsory variables requested in the regulation are collected by the countries. However, in some few cases it could be that some information is missing, as the residence of the deceased person, the age or the sex, which are finally reported as “unknown”. 

Not applicable.

Not applicable.

The time needed to process the deaths certificates and to have the data ready for national publication differs quite a lot depending on the countries. Usually it lasts from 6 months to 28 months.

Countries shall provide the data specified in this Regulation to the Commission No 328/2011 (Article 4)  within 24 months (T+24) after the end of the reference year, starting from 2011.

Some countries submitted data to Eurostat within a deadline 18 months (T+18) after the end of the reference year in accordance with the gentleman's agreement established in the framework Eurostat's Working Group on "Public Health Statistics". 

See below the timeliness for data and metadata for reference year 2018.

There is not any problem reported by countries about the comparability between the regions.

There is a break in series in 2011, when the regulation entered into force and some concept were revised (place of occurrence/residence and age groups). Additionally, before 2011 different classification systems for coding the cause of death could be used. 

Some countries have reported some other break in series that are described in the own metadata files.

For most of the countries, based on the reported information in their national SIMS, they have checked with other sources. The total number of deaths by causes is equal to the number of deaths (stillbirths) in the demographic statistics for most of the countries.

The variables requested for neonatal deaths are transmitted in two datasets. Eurostat is validating the consistency of both datasets and only two countries, Norway and Sweden, have some small inconsistencies because two data sources are used or late registered deaths.

The data submitted to Eurostat is final and consequently there is not any data revision policy defined.

Exceptionally, one country can revise its data after it has been published in Eurobase. Eurostat accepts those revision and updates the data in Eurobase.

When there is a change in the NUTS classification at NUTS level 2, the countries must revised their data since 2011 in accordance with the new classification.

Last NUTS revision is applied since reference year 2016. France, Hungary, Ireland, Lithuania, Poland and the United Kingdom have revised their data since 2011.

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 happening in the country are counted. In all the Member States, 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 the statistical office or other institution for centralised coding.

Some countries use secondary data sources in order to capture more detailed information or to check the data registered in the death certificates.

Annual.

The data collection is based on the death certificates, which are filled in by the certifiers. In most of the cases, the certifier is a physician.

The information provided on the medical certificates of cause of death is 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".

The coding is done either manually or with specific IT tools. In most countries, the coding is done centrally in the statistical office or in a health institute or organisation.

Countries are submitting two datasets to Eurostat:

1. general mortality. All deaths occurring in the country (residents and non-residents) broken down by country/region of residence, country/region of occurrence, sex, age, ICD code. For the external causes of death three optional variables are provided (injury code, place of occurrence and activity)
2. stillbirths and neonatal deaths broken down by country/region of residence, country/region of occurrence, sex, age, ICD code, age of the mother and parity. For stillbirths optional variables are provided (birth weight or gestational age or crown-heel length.

There are two transmission formats:

1. microdata. One record per death
2. aggregated data. Tabulated data by age groups of 5 years

Eurostat compiles and validates all the submitted datasets. The data are stored and treated in a secure environment. The COD indicators and the EU aggregates are computed and finally disseminated in Eurobase.

All the datasets transmitted to Eurostat are automatically validated. The validation report is sent back to the countries in order they could check and fixed the inconsistencies detected, if any. Eurostat is also checking the validation reports and only datasets free of errors are treated and published.

The following checks are performed:

- ICD codes that can be used as underlying cause of death

- Countries and regions at NUTS2 level

- Age, sex and age of the deceased person

- For neonatal deaths and stillbirths: age of the mother and parity

- For stillbirths: birth weight, gestational age and crown-heel length

- Combination of cause of death and sex

- Combination of cause of death and age

- Combination of cause of death and injury codes

The absolute numbers for EU aggregates are the sum of country numbers and are computed only when all the countries have submitted the data. Eurostat is not imputing any missing data.

No adjustments are made.