Cause-specific mortality trends in The Netherlands, 1875-1992: a formal analysis of the epidemiologic transition

BACKGROUND: The objective of this study is to produce a detailed yet robust description of the epidemiologic transition in The Netherlands. METHODS: National mortality data on sex, age, cause of death and calendar year (1875-1992) were extracted from official publications. For the entire period, 27 causes of death could be distinguished, while 65 causes (nested within the 27) could be studied from 1901 onwards. Cluster analysis was used to determine groups of causes of death with similar trend curves over a period of time with respect to age- and sex-standardized mortality rates. RESULTS: With respect to the 27 causes, three important clusters were found: (1) infectious diseases which declined rapidly in the late 19th century (e.g. typhoid fever), (2) infectious diseases which showed a less precipitous decline (e.g. respiratory tuberculosis), and (3) non-infectious diseases which showed an increasing trend during most of the period 1875-1992 (e.g. cancer). The 65 causes provided more detail. Seven important clusters were found: four consisted mainly of infectious diseases, including a new cluster that declined rapidly after the Second World War (WW2) (e.g. acute bronchitis/influenza) and a new cluster showing an increasing trend in the 1920s and 1930s before declining in the years thereafter (e.g. appendicitis). Three clusters mainly contained non-infectious diseases, including a new one that declined from 1900 onwards (e.g. cancer of the stomach) and a new one that increased until WW2 but declined thereafter (e.g. chronic rheumatic heart disease). CONCLUSIONS: The results suggest that the conventional interpretation of the epidemiologic transition, which assumes a uniform decline of infectious diseases and a uniform increase of non-infectious diseases, needs to be modified.