Trends in Cause-Specific Mortality by Race and Hispanic Origin, 1999–2019

Diseases of the Respiratory System

Deaths associated with respiratory system diseases in 2019 accounted for 10.3 percent of all deaths among WNH individuals, 7.3 percent of those among the API population, and 6.6 percent of deaths in the Black and Hispanic communities. This section discusses the five subcategories of respiratory system diseases listed in Box 4.

Chart 17 shows the number and percentage distribution of respiratory system disease–related deaths by subcategory for 1999 and 2019, with detail by RE group and age. The leading cause of death among respiratory disorders is chronic lower respiratory diseases, a category that is dominated by chronic obstructive pulmonary disease (COPD). Although this subcategory also includes emphysema and asthma, it is labeled COPD hereafter for brevity. COPD accounts for disproportionately high shares of deaths among the WNH and Black populations. In 2019, it constituted 35.8 percent of respiratory system disease–related deaths in the API community and 40.3 percent of those among Hispanic individuals, compared with 49.5 percent of such deaths in the Black population and 60.5 percent of those among WNH people. The share of respiratory system–related deaths caused by diseases in this subcategory peaked at ages 65 or older, where it was the leading cause of death for all RE groups. In the midlife years, however, influenza and pneumonia accounted for a higher share of deaths among the Hispanic and API populations. At ages 0–24, COPD was the leading cause of respiratory system disease–related death for only the Black population.

Chart 18 shows age-adjusted death rates for 1999–2019 by RE group, sex, and age group. Panel A shows the rates for respiratory system diseases overall.

Chart 18, Panel B shows that in 2019, WNH males had the highest all-ages COPD mortality rate, followed by WNH females, Black males, and Black females. The all-ages death rate for WNH females surpassed that of Black males in 2007, and the rate for Black females first exceeded the rate for Hispanic males in 2014. All-ages COPD mortality rates improved during the 1999–2019 period for every RE/sex group except WNH females. API men had the highest all-ages mortality rate improvement, with the rate declining by half, from 29.6 to 14.7. At ages 65 or older, the COPD mortality rate for Black women was lower than that of API men until 2014 and was lower than that of Hispanic men every year except 2018. At ages 25–64, however, Black women had higher COPD mortality rates than Hispanic and API men throughout the period.

Taken together, influenza and pneumonia cause the second most respiratory system disorder–related deaths. In 2019, the shares of respiratory system–related deaths caused by influenza/pneumonia at all ages ranged from 16.9 percent among WNH individuals to 33.2 percent in the API population. Those shares tended to peak among the very young and very old, although they declined substantially over the observation period for the aged. For instance, in 1999, influenza/pneumonia was the leading cause of respiratory disease death for individuals older than 84 in every RE group. By 2019, COPD accounted for a greater share of respiratory disease deaths in that age group. Among people aged 0–24, influenza/pneumonia was the main cause of respiratory system–related death for the API, Hispanic, and WNH populations.

From year to year, influenza/pneumonia mortality varies with several factors, including the strain of the seasonal flu virus, vaccination rates, and the effectiveness of the vaccines. Nevertheless, the influenza/pneumonia mortality rate declined significantly over the 1999–2019 period, driven by mortality rate improvement among the aged (Chart 18, Panel C). The death rate for individuals aged 65 or older declined by more than half among WNH, Black, and Hispanic men and women. For instance, among aged Black men, the mortality rate dropped from 214.6 to 93.8 over the period. In 2019, Black males had the highest all-ages influenza/pneumonia mortality rate, followed in rank order by WNH males, Hispanic males, and API males. Among females, the RE group with the highest all-ages death rate was Black (11.4), followed closely by WNH (11.0). Hispanic and API females had the lowest all-ages influenza/pneumonia mortality rates (8.3 and 8.2, respectively). One notable feature of the graphs in Panel C is the spike in mortality in 2009 for the two age groups younger than 65. Influenza/pneumonia mortality at ages 25–64 was higher in 2009 than in any other year in the 1999–2019 period for Black, Hispanic, and API women and for Hispanic and API men. Similarly, the death rate at ages 0–24 peaked in 2009 among WNH and Hispanic males and in all RE groups for females. On June 11, 2009, the World Health Organization declared a global pandemic of the H1N1 virus, or the “swine flu” (CDC 2010). Although many young people have some immunity to seasonal influenza, very few had any immunity to the H1N1 virus and were especially vulnerable to it.

The third most common cause of respiratory system–related death is interstitial respiratory disease—a subcategory formally titled “other respiratory diseases principally affecting the interstitium.” This term generally refers to the fluid-filled space existing between structural barriers, such as between a cell wall and an organ. For example, the pulmonary interstitium is the tissue that surrounds the lung's air sacs, blood vessels, and airways, and interstitial respiratory disease involves scarring and inflammation of the interstitium (as in pulmonary fibrosis). The share of respiratory system–related deaths attributed to this subcategory of disorders is disproportionately high for Hispanic people. For example, in 2019, interstitial respiratory disease caused 16.8 percent of all respiratory system–related deaths at all ages among the Hispanic population, in contrast with 6.8 percent of those in the Black community.²²

Chart 18, Panel D shows that in 2019, WNH males had the highest all-ages interstitial respiratory disease mortality rate (7.8), followed by Hispanic males (7.6) and Hispanic females (5.7). API females, Black females, and Black males had the lowest mortality rates. At ages 25–64, Black men and women had the highest interstitial respiratory disease death rates; yet at ages 65 or older, death rates were lower for Black people than for individuals of the same sex in the other RE groups. For instance, the interstitial respiratory disease mortality rate at ages 65 or older was 17.6 for Black women and 21.5 for API women in 2019. Similarly, the death rate at ages 65 or older from this cause was 26.0 for Black men, 36.7 for API men, and 52.9 for Hispanic men. All-ages interstitial respiratory disease mortality was higher in 2019 than in 1999 for all RE/sex groups other than Black males and females.

Lung diseases caused by external agents include pneumoconiosis from the inhalation of coal dust, asbestos and other mineral fibers, dust containing silica, or other inorganic dusts; and respiratory conditions caused by inhalation of chemicals, gases, fumes, and vapors. In 2019, diseases in this subcategory constituted about 7 percent of respiratory system–related deaths among WNH people, 8.5 percent of those deaths among the Hispanic and Black populations, and 11.0 percent of those among API individuals. The subcategory's share of respiratory system–related deaths typically increases at older ages, in 2019 being more than 10 percent in every RE group at ages 85 or older.

Chart 18, Panel E shows that, for either sex, external-agent lung disease mortality was substantially higher for the WNH and Black populations than the other two RE groups. In 2019, WNH and Black males had all-ages mortality rates of 7.2 and 7.0, respectively, while the rates for API and Hispanic males both were 4.6. In every RE group, the all-ages mortality rates in this subcategory were lower for females than for males. Over the 1999–2019 period, all-ages mortality rates from external-agent lung diseases declined for all RE/sex groups except API males and females. Among people aged 25–64, however, mortality rates increased during the second half of the period in all RE/sex groups.

The residual subcategory “all other respiratory system diseases” includes acute upper respiratory infections, other acute lower respiratory infections (such as bronchitis and bronchiolitis), other diseases of the upper respiratory tract (for example, chronic sinusitis, laryngitis, and laryngotracheitis; and disorders of the nose and nasal sinuses, tonsils, adenoids, vocal cords, and larynx), suppurative and necrotic conditions of the lower respiratory tract, other diseases of the pleura, and other diseases of the respiratory system (that is, respiratory failure not elsewhere classified). In 2019, disorders in this subcategory accounted for 6.5 percent of respiratory system–related deaths among API people, less than 8 percent of those deaths among WNH and Hispanic individuals, and 11.5 percent of respiratory system–related deaths in the Black community.

Chart 18, Panel F shows that in 2019, all-ages mortality from other respiratory diseases was highest among Black males (7.3), followed by WNH males and Black females (each with 5.8). API females had the lowest mortality rate from other respiratory diseases at 1.7.

Chart 19 shows all-ages respiratory system disease mortality rates by cause-of-death subcategory, RE group, and sex in 1999 and 2019. WNH males and females experienced higher mortality rates than their Black counterparts. Although Black males in 1999 had higher mortality rates associated with influenza/pneumonia, lung diseases caused by external agents, and the residual “all other respiratory system diseases” subcategory, these were more than offset by the higher COPD death rate among WNH males, accounting for the latter group's higher overall respiratory system disease death rate. From 1999 to 2019, the ratio of all-ages respiratory system disease mortality rates between WNH males and Black males rose from 1.0 to 1.2. The pattern was similar among females, but with greater mortality differentials by race. For instance, by 2019, the all-ages respiratory system disease mortality-rate ratio between WNH and Black females was 1.4. The combined all-ages mortality rate for COPD and influenza/pneumonia among WNH females (52.7) exceeded the overall respiratory disorders mortality rate among Black females (47.7). Moreover, the all-ages COPD mortality rate for WNH females in 2019 (41.7) was significantly higher than the all-ages mortality rate from all respiratory diseases among Hispanic females (32.2) and API females (23.0).