[Skip to Content]
Access to paid content on this site is currently suspended due to excessive activity being detected from your IP address Please contact the publisher to request reinstatement.
[Skip to Content Landing]
Pinner  RW, Teutsch  SM, Simonsen  L,  et al.  Trends in infectious diseases mortality in the United States.  JAMA. 1996;275(3):189-193.PubMedGoogle ScholarCrossref
Armstrong  GL, Conn  LA, Pinner  RW.  Trends in infectious disease mortality in the United States during the 20th century.  JAMA. 1999;281(1):61-66.PubMedGoogle ScholarCrossref
Centers for Disease Control and Prevention (CDC).  Control of infectious diseases.  MMWR Morb Mortal Wkly Rep. 1999;48(29):621-629.PubMedGoogle Scholar
Watson  JT, Gayer  M, Connolly  MA.  Epidemics after natural disasters.  Emerg Infect Dis. 2007;13(1):1-5.PubMedGoogle ScholarCrossref
Lederberg  J, Shope  RE, Oaks  SC  Jr, Institute of Medicine; Committee on Emerging Microbial Threats to Health eds.  Emerging Infections: Microbial Threats to Health in the United States. Washington, DC: National Academy Press; 1992.
Morse  SS.  Factors in the emergence of infectious diseases.  Emerg Infect Dis. 1995;1(1):7-15.PubMedGoogle ScholarCrossref
Dwyer-Lindgren  L, Bertozzi-Villa  A, Stubbs  RW,  et al.  US county-level trends in mortality rates for major causes of death, 1980-2014.  JAMA. 2016;316(22):2385-2401.PubMedGoogle ScholarCrossref
National Vital Statistics System.  Multiple cause of death data file. (1980-2014).https://www.cdc.gov/nchs/nvss/mortality_public_use_data.htm. Accessed February 8, 2018.
United States Census Bureau.  County intercensal estimates by age, sex, race: 1980-1989. Published 2009.https://www.census.gov/data/tables/time-series/demo/popest/1980s-county.html. Accessed January 8, 2018.
National Center for Health Statistics.  Bridged-race intercensal estimates of the resident population of the United States for July 1, 2000-July 1, 2009, by year, county, single-year of age (0, 1, 2, ..., 85 years and over), bridged race, Hispanic origin, and sex. 2012.http://www.cdc.gov/nchs/nvss/bridged_race/data_documentation.htm#july2000-2009. Accessed January 8, 2018.
National Center for Health Statistics.  Vintage 2014 postcensal estimates of the resident population of the United States (April 1, 2010, July 1, 2010-July 1, 2014), by year, county, single-year of age (0, 1, 2, ..., 85 years and over), bridged race, Hispanic origin, and sex. 2015.http://www.cdc.gov/nchs/nvss/bridged_race/data_documentation.htm#Vintage2014. Accessed January 8, 2018.
University of California Berkeley, Max Planck Institute for Demographic Research. Human mortality database. http://www.mortality.org/. Accessed January 8, 2018.
Wang  H, Naghavi  M, Allen  C,  et al; GBD 2015 Mortality and Causes of Death Collaborators.  Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980-2015: a systematic analysis for the Global Burden of Disease Study 2015.  Lancet. 2016;388(10053):1459-1544.PubMedGoogle ScholarCrossref
Naghavi  M, Makela  S, Foreman  K, O’Brien  J, Pourmalek  F, Lozano  R.  Algorithms for enhancing public health utility of national causes-of-death data.  Popul Health Metr. 2010;8:9.PubMedGoogle ScholarCrossref
Leroux  BG, Lei  X, Breslow  N. Estimation of disease rates in small areas: a new mixed model for spatial dependence. In:  Statistical Models in Epidemiology, the Environment, and Clinical Trials. Vol 116. New York, NY: Springer-Verlag; 2000:179-191.Crossref
Knorr-Held  L.  Bayesian modelling of inseparable space-time variation in disease risk.  Stat Med. 2000;19(17-18):2555-2567.PubMedGoogle ScholarCrossref
Kristensen  K, Nielsen  A, Berg  CW, Skaug  H, Bell  BM.  TMB: automatic differentiation and laplace approximation.  J Stat Softw. 2016;70(5). doi:10.18637/jss.v070.i05Google Scholar
R Core Team.  R: a language and environment for statistical computing. Vienna, Austria: R Foundation for Statistical Computing; 2016.http://www.R-project.org/. Accessed January 8, 2018.
University of Washington Institute for Health Metrics and Evaluation.  US health map.https://vizhub.healthdata.org/subnational/usa. Accessed February 27, 2018.
Collins  IJ, Cairns  J, Ngo-Giang-Huong  N,  et al; Programme for HIV Prevention and Treatment Study Team.  Cost-effectiveness of early infant HIV diagnosis of HIV-exposed infants and immediate antiretroviral therapy in HIV-infected children under 24 months in Thailand.  PLoS One. 2014;9(3):e91004.PubMedGoogle ScholarCrossref
Caliendo  AM, Gilbert  DN, Ginocchio  CC,  et al; Infectious Diseases Society of America (IDSA).  Better tests, better care: improved diagnostics for infectious diseases.  Clin Infect Dis. 2013;57(suppl 3):S139-S170.PubMedGoogle ScholarCrossref
May  M, Gompels  M, Delpech  V,  et al.  Impact of late diagnosis and treatment on life expectancy in people with HIV-1: UK Collaborative HIV Cohort (UK CHIC) Study.  BMJ. 2011;Oct 11(343):d6016.PubMedGoogle Scholar
Pouget  ER, Hagan  H, Des Jarlais  DC.  Meta-analysis of hepatitis C seroconversion in relation to shared syringes and drug preparation equipment.  Addiction. 2012;107(6):1057-1065.PubMedGoogle ScholarCrossref
Centers for Disease Control and Prevention.  Today’s heroin epidemic: more people at risk, multiple drugs abused. Published July 7, 2015.https://www.cdc.gov/vitalsigns/heroin/index.html. Accessed January 8, 2018.
Hedden  SL, Kennet  J, Medley  G, Tice  P; Substance Abuse and Mental Health Services Administration.  Behavioral health trends in the United States: results from the 2014 National Survey on Drug Use and Health; 2015:1-64.https://www.samhsa.gov/data/sites/default/files/NSDUH-FRR1-2014/NSDUH-FRR1-2014.pdf. Accessed August 17, 2017.
Dwyer-Lindgren  L, Mackenbach  JP, van Lenthe  FJ, Flaxman  AD, Mokdad  AH.  Diagnosed and undiagnosed diabetes prevalence by county in the US, 1999-2012.  Diabetes Care. 2016;39(9):1556-1562.PubMedGoogle ScholarCrossref
Dwyer-Lindgren  L, Flaxman  AD, Ng  M, Hansen  GM, Murray  CJL, Mokdad  AH.  Drinking patterns in US counties From 2002 to 2012.  Am J Public Health. 2015;105(6):1120-1127.PubMedGoogle ScholarCrossref
Dwyer-Lindgren  L, Mokdad  AH, Srebotnjak  T, Flaxman  AD, Hansen  GM, Murray  CJ.  Cigarette smoking prevalence in US counties: 1996-2012.  Popul Health Metr. 2014;12(1):5.PubMedGoogle ScholarCrossref
US Census Bureau.  Small area income and poverty estimates data.https://www.census.gov/programs-surveys/saipe/data.html. Accessed January 8, 2018.
Riley  ED, Gandhi  M, Hare  C, Cohen  J, Hwang  S.  Poverty, unstable housing, and HIV infection among women living in the United States.  Curr HIV/AIDS Rep. 2007;4(4):181-186.PubMedGoogle ScholarCrossref
Centers for Disease Control and Prevention.  Twenty-five years of HIV/AIDS—United States, 1981–2006.https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5521a1.htm. Accessed January 8, 2018.
Kim  WR.  Epidemiology of hepatitis B in the United States.  Hepatology. 2009;49(5)(suppl):S28-S34.PubMedGoogle ScholarCrossref
Armstrong  GL.  Injection drug users in the United States, 1979-2002: an aging population.  Arch Intern Med. 2007;167(2):166-173.PubMedGoogle ScholarCrossref
Jump  RL.  Clostridium difficile infection in older adults.  Aging Health. 2013;9(4):403-414.PubMedGoogle ScholarCrossref
Montoya  A, Mody  L.  Common infections in nursing homes: a review of current issues and challenges.  Aging Health. 2011;7(6):889-899.PubMedGoogle ScholarCrossref
Lessa  FC, Mu  Y, Bamberg  WM,  et al.  Burden of Clostridium difficile infection in the United States.  N Engl J Med. 2015;372(9):825-834.PubMedGoogle ScholarCrossref
Centers for Disease Control and Prevention.  2014 National and state healthcare-associated infections progress report: 2016.https://www.cdc.gov/hai/surveillance/progress-report/index.html. Accessed January 8, 2018.
Centers for Disease Control and Prevention.  Antibiotic resistance threats in the United States, 2013.; 2013:1-114.https://www.cdc.gov/drugresistance/threat-report-2013/pdf/ar-threats-2013-508.pdf#page=49. Accessed April 14, 2017.
Dieleman  JL, Baral  R, Birger  M,  et al.  US spending on personal health care and public health, 1996-2013.  JAMA. 2016;316(24):2627-2646.PubMedGoogle ScholarCrossref
Caucci  L, Warner  M; Centers for Disease Control and Prevention.  Table 1: selected characteristic of death requiring investigation by state, 2013.https://www.cdc.gov/phlp/docs/coroner/table1-investigation.pdf. Accessed February 8, 2018.
Caucci  L, Warner  M; Centers for Disease Control and Prevention.  Table 2: characteristic of deaths requiring autopsy by state, 2013. https://www.cdc.gov/phlp/docs/coroner/table2-autopsy.pdf. Accessed February 8, 2018.
Original Investigation
March 27, 2018

Trends and Patterns of Differences in Infectious Disease Mortality Among US Counties, 1980-2014

Author Affiliations
  • 1Institute for Health Metrics and Evaluation, University of Washington, Seattle
JAMA. 2018;319(12):1248-1260. doi:10.1001/jama.2018.2089
Key Points

Question  What are the spatial and temporal trends in mortality due to lower respiratory infections, diarrheal diseases, HIV/AIDS, meningitis, hepatitis, and tuberculosis among US counties from 1980 to 2014?

Findings  In this study that applied small-area estimation models to deidentified death records from the National Center for Health Statistics, overall mortality due to infectious diseases decreased from 42.95 to 34.10 deaths per 100 000 persons, but with substantial variation among counties. The only category of infectious diseases to increase over this time was diarrheal diseases (from 0.41 to 2.41 deaths per 100 000 persons).

Meaning  Between 1980 and 2014, there were declines in mortality from most categories of infectious disease, but an increase in mortality for diarrheal diseases; however, there were large differences among US counties.


Importance  Infectious diseases are mostly preventable but still pose a public health threat in the United States, where estimates of infectious diseases mortality are not available at the county level.

Objective  To estimate age-standardized mortality rates and trends by county from 1980 to 2014 from lower respiratory infections, diarrheal diseases, HIV/AIDS, meningitis, hepatitis, and tuberculosis.

Design and Setting  This study used deidentified death records from the National Center for Health Statistics (NCHS) and population counts from the US Census Bureau, NCHS, and the Human Mortality Database. Validated small-area estimation models were applied to these data to estimate county-level infectious disease mortality rates.

Exposures  County of residence.

Main Outcomes and Measures  Age-standardized mortality rates of lower respiratory infections, diarrheal diseases, HIV/AIDS, meningitis, hepatitis, and tuberculosis by county, year, and sex.

Results  Between 1980 and 2014, there were 4 081 546 deaths due to infectious diseases recorded in the United States. In 2014, a total of 113 650 (95% uncertainty interval [UI], 108 764-117 942) deaths or a rate of 34.10 (95% UI, 32.63-35.38) deaths per 100 000 persons were due to infectious diseases in the United States compared to a total of 72 220 (95% UI, 69 887-74 712) deaths or a rate of 41.95 (95% UI, 40.52-43.42) deaths per 100 000 persons in 1980, an overall decrease of 18.73% (95% UI, 14.95%-23.33%). Lower respiratory infections were the leading cause of infectious diseases mortality in 2014 accounting for 26.87 (95% UI, 25.79-28.05) deaths per 100 000 persons (78.80% of total infectious diseases deaths). There were substantial differences among counties in death rates from all infectious diseases. Lower respiratory infection had the largest absolute mortality inequality among counties (difference between the 10th and 90th percentile of the distribution, 24.5 deaths per 100 000 persons). However, HIV/AIDS had the highest relative mortality inequality between counties (10.0 as the ratio of mortality rate in the 90th and 10th percentile of the distribution). Mortality from meningitis and tuberculosis decreased over the study period in all US counties. However, diarrheal diseases were the only cause of infectious diseases mortality to increase from 2000 to 2014, reaching a rate of 2.41 (95% UI, 0.86-2.67) deaths per 100 000 persons, with many counties of high mortality extending from Missouri to the northeastern region of the United States.

Conclusions and Relevance  Between 1980 and 2014, there were declines in mortality from most categories of infectious diseases, with large differences among US counties. However, over this time there was an increase in mortality for diarrheal diseases.