摘要：Objectives. We described death rates and leading causes of death caused by infectious diseases (IDs) in American Indian/Alaska Native (AI/AN) persons. Methods. We analyzed national mortality data, adjusted for AI/AN race by linkage with Indian Health Service registration records, for all US counties and Contract Health Service Delivery Area (CHSDA) counties. The average annual 1999 to 2009 ID death rates per 100 000 persons for AI/AN persons were compared with corresponding rates for Whites. Results. The ID death rate in AI/AN populations was significantly higher than that of Whites. A reported 8429 ID deaths (rate 86.2) in CHSDA counties occurred among AI/AN persons; the rate was significantly higher than the rate in Whites (44.0; rate ratio [RR] = 1.96; 95% confidence interval [CI] = 1.91, 2.00). The rates for the top 10 ID underlying causes of death were significantly higher for AI/AN persons than those for Whites. Lower respiratory tract infection and septicemia were the top-ranked causes. The greatest relative rate disparity was for tuberculosis (RR = 13.51; 95% CI = 11.36, 15.93). Conclusions. Health equity might be furthered by expansion of interventions to reduce IDs among AI/AN communities. Infectious diseases (IDs) continue to be an important health issue in the United States despite predictions made in the 1970s that by the year 2000 their impact would be minimal. 1 Armstrong et al. 2 demonstrated that although ID mortality among all races in the United States declined dramatically between 1900 and 1980, ID death rates slowly began to increase in the 1980s, driven primarily by the emergence of HIV and increases in pneumonia and influenza. Furthermore, rates of hospitalization because of IDs were reported to increase from 1998 to 2006. 3 Despite overall ID mortality rate declines since 1900, the sudden appearance in 1918 and again in 2009 of the pandemic H1N1 influenza provided a stark reminder of how quickly an infectious agent can affect mortality and morbidity, especially among susceptible populations such as American Indians and Alaska Natives (AI/ANs). 4 Among the many disparities affecting AI/AN communities, IDs remain some of the most enduring. A seminal report on the status of AI/AN health in the 1950s noted that the health status of people on many reservations was similar to areas off reservations half a century earlier in 1900. 5 This and another early report focusing on Alaska Native health highlighted the tremendous effect of IDs such as tuberculosis, measles, and smallpox on AI/AN morbidity and mortality. 5,6 Subsequent studies showed that IDs continued to be significant causes of morbidity among AI/AN persons, with rates typically higher than those for other racial or ethnic groups in the United States. 7–11 For example, a recent study found that although the ID hospitalization rate for AI/AN persons declined from 1998 to 2006, the rate among AI/ANs remained higher than the rate for the general US population, especially for the Alaska, Southwest, and Northern Plains West regions. 9 Although a study by Pinner et al. 12 served to renew interest in overall ID mortality in the United States, to date there have been no similar national studies of ID mortality among AI/AN populations. Despite the ongoing health disparity associated with IDs among AI/AN persons, accurate ID death rates for this group have been difficult to estimate. This difficulty stems, in part, from the use of International Classification of Diseases ( ICD ) codes, which are not easily related to many infectious causes of mortality. 12 An additional complication in determining mortality rates for AI/AN persons is the lack of accuracy in classifying AI/AN race on death certificates. 13,14 The accompanying study by Jim et al. 14 in this supplement describes, in detail, the effects of misclassification on death rates in the AI/AN population. Studies of ID surveillance data have shown that some reportable ID rates in AI/AN persons may double upon correction for racial misclassification. 15 We used national mortality data that, for the first time, were linked with Indian Health Service (IHS) patient registry data, a source of verified AI/AN status with stringent federal rules defining eligibility for health care service. 16 This methodology decreased the amount of racial misclassification of AI/AN persons in the national mortality data, and allowed the most complete and accurate view to date of ID mortality among AI/AN populations.
