Epidemiological Transition in Urban Maharashtra: A Revisit ... IUSSP.pdf · epidemiological transition is the “shift from the predominance of infectious and parasitic diseases to

Note: This is an extended abstract only. We have presented some of entire analyses carried out for

this study. We will full interpretation of results and analyses tables and figures in full paper

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Epidemiological Transition in Urban Maharashtra: A Revisit

Abstract

Like other developing countries, India is undergoing rapid epidemiological transition as a

result of its demographic, economic and social changes. India is moving from second to

third stage of epidemiological transition. However, India is facing both double burdens of

diseases that burden of communicable and non-communicable. Lack of accurate data on

cause of deaths is a major hindrance to comprehensive assessment of epidemiological

transition. The urban Maharashtra known to be the only state where the vital events

registration is above 90%. The results are evident that Maharashtra is at third stage of

epidemiological transition. Among all causes of death “Diseases of the Circulatory System”

is ranked first from 1990 to 2006. For youth, the leading cause of death is “Injury and

poisoning” for both males and females. In the adult groups, leading cause of death is”

Infectious and parasitic disease”. Among adult males the leading cause of death is”

Infectious and parasitic disease” and among adult female it is “disease of circulatory

system”. For the old age group, “Disease of circulatory system is the leading cause of death

in Urban Maharashtra for both males and females. This indicates that state is non-

communicable diseases but the state is facing double burden of diseases.

Introduction

Omran (1971) laid the foundation for ‘Epidemiological Transition Theory’, which “builds

on the demographic transition theory but also includes the changing patterns in diseases and

the causes of death” (Huynen, 2005, p-51). Epidemiological transition is marked by shift in

the cause of death profile with increasing dominance of Non-communicable disease

(Omran 1971; Olshansky and Ault 1986). However, at theoretical perspective,

demographic transition, health transition, nutritional transition and epidemiological

transition overlap and it is difficult to affirm which one precedes the other (Karar, 2009).

Moreover, all these transitions are the product of socio-economic development and

modernisation (Omran, 1971, 1998). Nevertheless a generally accepted of the notion of

epidemiological transition is the “shift from the predominance of infectious and parasitic

diseases to that of chronic and degenerative diseases of adulthood as the main cause of

death” (United Nations, 1998). Epidemiological transition typically takes place first, in

Urban and industrialised areas to be followed by rural areas. Urbanisation brings wealth,



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improved sanitation, nutrition, and health systems which reduces child mortality (Gulliford,

2003, WHO, 2006).

The rate of epidemiological transition in developing countries is very rapid, which has

made it difficult particularly for the policymakers of these countries to address the rapid

change in transition (Reddy et al., 1998; WHO, 2003; Huynen, 2005; Karar, 2009;

WHO, 2004, 2010). About 60 million deaths occur worldwide, out of which 46 million

deaths occur in developing countries (WHO, 2008). The World Health Organization

(WHO) forecasts that in the next two decades there will be dramatic changes and transitions

in the world's health needs, as a result of epidemiological transition. At present, lifestyle and

behaviour are linked to 20–25% of the global burden of disease, which would be increasing

rapidly in poorer countries. Moreover, NCDs are expected to account for seven out of every

10 deaths in the developing regions by 2020, compared with less than half today. Injuries,

both unintentional and intentional, are also growing in importance and by 2020 could rival

infectious diseases as a source of ill-health (WHO, 2010).

However, there is a dearth of reliable and accurate information on the causes and

distribution of mortality in these countries (Reddy 2003). With a growing proportion of the

adult and elderly population, the epidemiological profile of low and middle income

countries reflects the diseases of adults rather than child; however retain high exposure to

risk factors associated with infectious diseases leaving poor rural areas and urban slums

with persisting high rates of infections and childhood deaths alongside richer urban areas

where adults die prematurely of non‐communicable diseases which, health systems are not

yet able to address. And thus most of low and middle income countries are dealing with a

dual burden of infectious diseases among children, and premature chronic and degenerative

diseases among adults (Barrett et al., 1998; WHO, 2004).

The Human Immunodeficiency Virus (HIV) epidemic has added another level of

complexity to the epidemiological transition by reversing the gains made in life expectancy

in regions such as Sub‐Saharan Africa (Moser et al., 2004; WHO, 2003). Violence, injury

and breakdown in society have further complicated the epidemiological transition by

reducing life expectancy in some countries such as the Russian Federation, and Kazakhstan

(WHO, 2003). The main difference in the pattern of mortality in these regions compared to

other countries is the high proportion of premature deaths due to external causes of death,

primarily homicides, suicides, road traffic crashes, and poisoning. Moreover, there are

multiple causes associated with every disease and death is the result of not only one event

rather chain of events (WHO, 2003, 2010).



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Like other developing countries, India is undergoing rapid epidemiological transition

as a result of its demographic, economic and social changes. Further, the pattern of

mortality has been changing very fast. The crude death rate for India was 12.5 (per 1000

deaths) in the year 1981which had declined to 8.5 (per 1000 deaths) in the year 2000.

During the same period, the crude birth rate fell from 34 to 25. Over the last century life

expectancy in India has increased by almost threefold, rising from 22.9 years in 1901 to 61

years in 2000. As might be anticipated for such a huge and diverse country there are

substantial interstate variations with life expectancy ranging from 49.6 years in Uttar

Pradesh to 71.1 years in Kerala, along with interstate variations there are huge urban-rural

differentials in India (Visaria, 2004a; Kanitkar et al., 2010).

Rationale and objectives

Though, “India accounts for about 9.5 million deaths a year, or in other words, about

one in six out of total deaths worldwide. However, more than half of deaths in India lack a

certified cause of death” (Jha et al., 2006). In India, only the state of Maharashtra has been

consistently implemented the medical certification of causes of death (MCCD) in all the

urban areas of Maharashtra from 1969, for obtaining reliable and accurate causes of death

statistics. Among the bigger states Maharashtra has the maximum share of MCCD. Under

the World Bank’s Maharashtra Health System Development Project (MHSDP), the MCCD

data is available for about two lakh deaths out of seven lakh deaths occurred in

Maharashtra. These data are quite useful in understanding the pattern and trend of causes of

deaths share of deaths due to communicable diseases and non-communicable diseases

(Kanitkar et. al. 2010).

Over the years, urbanization in India has also increased rapidly in many states,

particularly in state like Maharashtra. Moreover, urbanization has brought about changes in

disease pattern, poor sanitation and changes in cause of death. Changes in the population

age structure, improvements in the economy of Maharashtra, altered lifestyles of people.

Currently, the state is experiencing currently rapid development, demographic and health

transition. The change in disease pattern is one of the foremost consequences of these

changes (Human Development Report Maharashtra, 2008). To monitor and guard

against the rapid changing disease pattern and the state needs continuous and regularly

updated information on major cause of deaths. Therefore, there is need to analyse the

epidemiological profile of Maharashtra in order to assess the successes achieved as well



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caution against the alarming challenges awaiting the state. On this perspective, this study

investigated the progress in three objectives first, to study the trend in mortality by different

causes of death; Second, to analyse the leading causes of deaths among different age groups

and sex; Third, to examine the changes in the main causes of death by sex and age groups

over the years.

Data source

The state of Maharashtra has been selected based on various reasons expressed in

background and rationale of the paper. In this section, we briefly discussed about the

morphology of the data source and its system and data collection procedure. This study is

used the vital registration data from urban areas of Maharashtra. In order to meet the

specification of the study the causes of death (COD) data has been compiled from reports of

MCCD.

At the national level, the Registrar General of India is responsible for collection,

compilation and publication of cause of death statistics. Information about MCCD is

generated as a part of the Civil Registration System (CRS) wherein the registration of the

cause of death for all the deaths attended by medical personnel is mandatory. Thus of the

MCCD data come from urban areas, though this scheme is extended to rural hospitals as

well. The death reports are prepared in the format similar to what WHO has prescribed for

the International Classification of Diseases (ICDs).

It is the responsibility of the doctor or healthcare provider who last attended the

deceased to report the cause of death. The medical attendant is supposed to follow

guidelines contained in the physician’s manual on MCCD. MCCD essentially implements

ICD coding and guidelines and the design of the system. Up to the fifth of every month, the

forms are sent to the local municipal authorities for onward submission. Age-sex-wise

classification along with causes is available for about two lakh deaths every year. In 2006

the information recorded is for 2, 09,515 deaths. The medically certified causes of death

scheme were introduced in the early 1970s to ensure that all deaths had a medical certificate

stating the cause of death.

The Office of the registrar general of India supervises the ‘medical certification of

cause of death’ scheme through which data about causes of death are collected and

compiled on a regular basis in urban India. Information regarding hospital deaths is



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collected on Form 4(MCCD 2006) and data for non‐institutional deaths is recorded on Form

4A( MCCD 2006). The data derived from Medically Certified Causes of Death has been

tabulated in consistency with the International Statistical Classification of Diseases (ICD).

Medical certification of cause of death is an important tool of obtaining authentic &

scientific information regarding causes of mortality (Source year). MCCD data have been

used to classify and analyze various causes of death by age and sex for urban Maharashtra.

For Maharashtra, the MCCD data is classified on ICD-X and related Health Problem

10th

revision (ICD-X).Tenth revision ICD provides coding of disease and signs, symptom

and external causes of injury or disease. This classification is done by WHO and revised;

the data is available for urban Maharashtra from 1990 to 2006. The different causes of death

is clubbed taking into consideration the nature of cause of death in three broad groups –

communicable diseases, non-communicable diseases and other causes of death. .

Cause group Cause categories International Classification of Disease.

ICD IX ICD X

Group I

Communicable Disease

1.Infectious and Parasitic

Diseases

2.Endocrine, Nutritional and

Metabolic Diseases

3.Complications of Pregnancy

4.Certain Conditions Originating

in the Perinatal Period

(001-139).

(243,260-269,279,280-

285,320-323,381-382).

(614-616,630-676).

(760-779).

A00-B99,G00-

G04,N70-N73,J00-

J06,J10-J18,J20-

J22,H65-H66,O00-

O99,P00-P96,E00-

E02,E40-

E46,E50,D50-D64.

Group II

Non-communicable

Disease

Neoplasm

Disease of Blood and Blood

forming Organs.

Mental Disorders.

Disease of Nervous System and

Sense Organs.

Disease of Circulatory System.

Disease of Respiratory System.

Disease of Digestive System.

Disease of Genitourinary System.

Disease of Skin and

Subcutaneous Tissue.

Disease of Musculoskeletal

System and Connective Tissue.

Congenital Anomalies.

Disease of The Eye and Adnexa.

Disease of The Ear Mastoid

Process.

(140-242,244-259)

(270-279,280-289).

(286-319,)

(324-380).

(383-459).

(460-465,466,480-

487,470-478).

(419-613).

(617-629).

(680-709)

C00-C97,D00-

D48,D65-D89,E03-

E07,E10-E16,E20-

E34,E51-E89,F01-

F99,G06-G99,

H00-H61,H68-

H95,I00-I99,J30-

J99,K00-K92,N00-

N64,N75-N99,L00-

L99,M00-M99,Q00-

Q99.



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(710-739).

(740-759)

Group III

Other Diseases

Symptoms, Signs and Ill-Defined

Conditions.

Injury and Poisoning.

(780-799)

(800-999)

R00-R99

V01-Y98

The study also used the data for age, sex distribution and ASSDR of population has been

collected from Sample Registration System (SRS) for year 1990 to 2006 for urban

Maharashtra. The data comes from various volumes of the sample registration system of the

office of registrar general of India. The SRS is most reliable source of demographic

statistics in India. The SRS provides annual estimates of population composition, fertility

and mortality.

Results and Discussion:

The analysis of the medically certified causes of death in Urban Maharashtra fosters number

of key insights in epidemiological transition. Since, 1990 to 2006, the non communicable

diseases have taken the largest toll of deaths in urban Maharashtra. Deaths due to non-

communicable diseases has accounted on average 50% of total medically certified causes of

death from 1990 to 2006. Non-communicable diseases are more among females as

compared to males, this trend changed from 2001 which reflects poor nutritional status, low

immunity etc. Deaths due to “certain conditions originating in the prenatal period” are the

main cause for Infant deaths in urban Maharashtra. Among youth, the leading cause of

death is “Injury and poisoning” from 1990 to 2006 for both males and females. In the adult

groups, leading cause of death is” Infectious and parasitic disease”. Among adult males the

leading cause of death is” Infectious and parasitic disease” and among adult female it is

“disease of circulatory system”. For the old age group, “Disease of circulatory system is the

leading cause of death in Urban Maharashtra for both males and females. Among all the

diseases that causes death “Diseases of the Circulatory System” is ranked first from 1990 to

2006. This disease takes the largest toll of mortality in both males and females in urban

Maharashtra.

Over the years in urban Maharashtra the non communicable diseases are increasing, this

increase in trend of non communicable disease reflects the disease of life style, improved

standard of living and prosperity. Though the communicable diseases are decreasing over



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the period but considering the huge size of population it still takes a heavy toll of mortality.

Other diseases like accidents, injury and symptoms are also responsible for a large number

of deaths in urban Maharashtra. Though Maharashtra is a developed state it also bears the

double burden of disease, the state is still fighting with malaria, dengue and other viral

illnesses. Among the youth and adults, the main causes of death has been due to”

Infectious and parasitic disease”, more so among males. Most adult females are likely to

die from “Diseases of the Circulatory System”.

Limitations of the study:

The MCCD data covers only 16% (approximate) of all deaths in country. It covers around

45 %( MCCD 2006) of urban deaths; however Maharashtra covers more than 50% of urban

deaths. Some disease like respiratory disease, complications of pregnancy etc. includes

some communicable and non-communicable disease; therefore these diseases due to higher

proportion of share of death in data set belonged to non communicable diseases. The age

group category in MCCD and SRS data set are different therefore compiling age group for

further analysis is restricted. Data for the year 1995 is not available in required format

therefore it is excluded from data set.

References:

Gulliford M.(2003): “Epidemiological transition and socioeconomic inequalities in blood

pressure in Jamaica”, International Journal of Epidemiology 32,pp.408‐409.

Jha P. Jacob B., Gajalakshmi V. et al. (2008): “A nationally representative case control

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Death in Rural India – Mortality Data from the Andhra Pradesh Rural Health Initiative”,

International Journal of Epidemiology, 35(6),pp.1522-29.

Medical certification of causes of death report, New Delhi: Office of the registrar General,

India, Ministry of Home affairs, Government of India: 1990 to 2006.

Omran A. (1971): “The Epidemiologic Transition: A Theory of the Epidemiology of

Population Change”, Milbank Memorial fund Quarterly 49,pp.509-38.

Omran A. (1977): “Epidemiologic Transition in the US”, Population Bulletin, 32(2).

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World Health Statistics Quarterly, 51(2-4), pp.99-119.



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Quigley, Maria A (2006): “Commentary: Shifting Burden of Disease – Epidemiological

Transition in India”, International Journal of Epidemiology, 35(6),pp.1530-31.

Reddy S. (2003): “Prevention and control of non-communicable Diseases: status and

strategies”.Indian council for research on international economic relations, 104, pp. 7-32.

S. Yusuf, S. Reddy, S. Ounpuu, S. Anand. (2001): “Global burden of cardiovascular

diseases:Part II (variations in cardiovascular disease by specific ethnic groups and

geographic regions and prevention strategies)” Circulation 104,pp.2855-64.

Sample Registration System (2007): Statistical Report 2007, Office of Registrar General,

India, Ministry of Home affairs, Government of India, New Delhi.

Radkar A., Kanitkar T.,Talwalkar M.(2010):“The Epidemiologic Transition in Urban

Maharashtra”, Economic & Political Weekly Vol XIV no 3,pp.23-27.

United Nations (1998): “Health and Mortality: A Concise Report”, Department of

Economic and Social affairs, Population Division, New York, pp 29

Wahdan M. (1996): “The Epidemiological Transition”, Eastern Mediterranean Health

Journal, 2(1), 8-20.

World Health Organization, (2002): Non-communicable Diseases in the Southeast Asia

Region: A Profile. New Delhi: WHO, Southeast Asia Regional Office.

World Health Organisation.(2003):Shaping the future: Chapter 7: Health Systems:

Principled integrated care. The World Health Report. Geneva, pp.116-118.



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Figure 1 (A): Prevalence of Communicable and Non-Communicable deaths in urban

Maharashtra. 1990-2006

Figure 1(B): Ratio of Non-communicable to communicable deaths and proportion of old age in urban


30

40

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Figure 2 (A): Prevelance of communicable and Non-communicable deaths among males in urban


Figure 2(B): Ratio of Non-communicable to communicable deaths and old age population

proportion among males in urban Maharshtra, 1990-2006

15

25

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Figiure 3(A): Prevelance of communicable and non-communicable deaths in urban

Maharashtra,1990-2006

Figure 3(B): Ratio of non-communicable to communicable and old age population

proportion in urban Maharashtra, 1990-2006

0

10

20

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Note: This is an extended abstract only. We have presented some of entire analyses carried out for this study. We will full interpretation of results and

analyses tables and figures in full paper

12

Table 2(A) : Main Causes of death among 0-1 age group and Childerns according to their percentage prevelance,Urban Maharashtra,

1990-2006

Cause of Death Infant death Children Deaths

1991 1996 2001 2006 1991 1996 2001 2006

Infectious and Parasitic Diseases. 12.5 9.9 8.63 11 18.3 14 13.1 15.5

Certain Conditions Originating in the Perinatal Period 44.1 51.7 48.07 50.7 27.6 33.3 32.8 33.9

Diseases of the Circulatory System 2.3 2.4 0.7 3.3 3.1 3.5 4.7 5.8

Diseases of the Respiratory System 13.4 15.1 14.1 15.5 14.5 16.6 15.6 16.9

Congenital Anomalies 2.2 2.2 17.06 5.2 1.5 1.6 12.1 4.2

Symptoms, Signs and Ill-Defined Conditions 12.8 14.5 4.19 6.8 13.6 15.4 6 7.3

Injury and Poisoning 6.9 0.5 2.18 1.4 12 4.8 7.1 5.1

Table 2(B) : Main Causes of death among youth according to their percentage prevelance,urban Maharashtra, 1990-2006

Cause of Death Youth deaths Male youth Death Female youth death

1991 1996 2001 2006 1991 1996 2001 2006 1991 1996 2001 2006

Infectious and Parasitic Diseases. 17.6 19.2 19.5 23.7 18.5 20.5 17.9 22.4 16.7 17.8 21.4 25.5

Diseases of the Circulatory System 7.1 5.5 11.5 8.1 8.1 5.8 12.1 7.9 6.2 5.2 10.9 8.3

Diseases of the Respiratory System 4.5 4.3 8.7 7.5 4.7 4.7 10 8.2 4.3 3.9 7.1 6.6

Symptoms, Signs and Ill-Defined Conditions 11.1 19.4 9.8 13.1 14.2 23.9 10.5 13.7 7.9 14.8 8.9 12.4

Injury and Poisoning 42.9 36.1 38.5 33.7 40.8 30.8 38.7 35 45.1 41.4 38.3 31.7

Complication of Pregnancy 8.4 4.9 4.9 2.3



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Table 2(C) : Main Causes of death among adults according to their percentage prevelance,Urban Maharashtra, 1990-2006

Cause of Death Adult deaths Male Adult deaths Female Adult deaths

1991 1996 2001 2006 1991 1996 2001 2006 1991 1996 2001 2006


Diseases of the Circulatory System 22 21.1 26.8 22 23.2 21.8 26.8 22 18.9 19.2 26.5 21.8

Diseases of the Respiratory System 6.3 5.8 10.9 9.6 6.4 5.8 10.6 9.4 6 5.6 11.2 10

Symptoms, Signs and Ill-Defined

Conditions 10.6 16.1 7.8 8.2 10.9 16.5 8.2 8.6 9.8 15 7 7.3

Injury and Poisoning 23.8 18.6 17.7 16.3 20.4 15.6 17.1 16.5 29.3 24 18.7 15.6

Diseases of the Digestive System 5.8 6.4 5.3 6.1 6.7 7.6 6.4 7.4

Neoplasms 6.9 6.1 6.2 9

Table 2(D) : Main Causes of death among adults according to their percentage prevelance,Urban Maharashtra, 1990-2006

Cause of Death Old age deaths Old age Male deaths Old age female deaths

1991 1996 2001 2006 1991 1996 2001 2006 1991 1996 2001 2006


Diseases of the Circulatory System 37.2 41.8 49 44.8 35.1 38.7 45.4 39.3 35.7 41.1 48.6 45.2

Diseases of the Respiratory System 13.9 13.8 17 16.8 12.6 12.6 15.3 15.5 14.1 13.9 17.4 15.8

Symptoms, Signs and Ill-Defined Conditions 29.4 23.2 16 14 25 19.7 13.4 11.1 31.9 25.1 17.6 15.7

Diseases of the Digestive System 2.3 4 2.3 2.7

Neoplasms 5 4 4.2 6.5 5.1 3.8 4.2 5.8 4.3 3.8 3.8 6.5

Endocrine, Nutritional and Metabolic Diseases

and Immunity Disorders 3.4 4.2 3.2 5 3.7 4.2 3.3 5.1



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Table 3(A): Rank order of deaths by various causes for all age groups based on Three year moving average for Urban Maharashtra 1990-2006

Note: 1: Here I, II, III...XIX are showing the Cause of death codes given By WHO. (ICD X)

2: 1, 2, 3....19 are showing their respective rankings.

Year I II III IV V VI VII VIII IX X XI XII XIII XIV XV XVI XVII XVIII XIX

1990-92 3 7 11 9 15 10 18 18 1 4 8 16 17 12 13 6 14 2 4

1991-93 3 8 11 9 16 10 18 18 1 4 7 16 17 12 13 6 14 2 5

1992-94 3 8 11 9 16 10 18 18 1 4 7 15 16 12 13 6 14 2 5

1993-96 3 8 11 9 17 10 18 18 1 5 7 15 16 12 13 6 14 2 4

1994-97 3 8 10 9 17 11 18 18 1 5 7 15 16 12 13 6 14 2 4

1996-98 3 8 10 9 17 11 18 18 1 5 7 15 16 12 14 6 13 2 4

1997-99 3 8 10 9 17 11 17 18 1 5 7 15 16 12 14 6 13 2 4

1998-00 3 8 11 9 18 10 18 18 1 5 7 15 16 12 14 6 13 2 4

1999-01 3 8 12 9 18 10 18 18 1 4 7 15 16 12 14 6 13 3 4

2000-02 2 8 12 9 17 10 19 18 1 4 7 15 16 11 14 6 12 4 4

2001-03 2 7 13 9 17 10 18 19 1 3 8 15 16 11 14 6 12 5 4

2002-04 2 7 13 10 16 10 18 19 1 3 8 15 17 10 14 6 12 5 4

2003-05 2 6 12 10 16 10 18 18 1 3 8 16 17 10 14 7 13 5 4

2004-06 2 6 12 10 15 10 18 18 1 3 8 16 17 10 14 7 13 5 4



15

Table 3(B): Rank order of deaths by various causes for all age groups of males based on Three year moving average for males

in Urban Maharashtra 1990-2006



Year I II III IV V VI VII VIII IX X XI XII XIII XIV XVI XVII XVIII XIX

1990-92 2 8 11 10 14 9 NA NA 1 4 7 15 16 12 6 13 3 5

1991-93 2 8 11 9 15 10 NA NA 1 4 7 15 16 12 6 13 3 5

1992-94 2 8 11 9 15 10 NA NA 1 4 7 14 15 12 6 13 3 5

1993-96 2 8 11 9 16 10 NA NA 1 5 7 14 15 12 6 13 3 4

1994-97 2 8 11 9 16 10 NA NA 1 5 6 14 15 12 7 13 3 4

1996-98 2 8 11 9 16 10 NA NA 1 5 6 14 15 12 7 13 3 4

1997-99 2 9 11 8 16 10 15 18 1 5 7 14 15 12 6 13 3 4

1998-00 3 9 11 8 17 10 17 17 1 5 7 14 15 12 6 13 2 4

1999-01 3 9 12 9 17 10 17 17 1 4 6 14 15 11 7 13 3 4

2000-02 2 8 12 10 16 9 18 17 1 4 6 14 15 11 7 12 4 4

2001-03 2 8 13 11 15 10 17 18 1 4 6 14 16 10 7 12 5 3

2002-04 2 8 13 11 15 10 17 18 1 4 6 14 16 10 7 12 5 3

2003-05 2 7 12 10 14 10 17 18 1 4 6 15 16 9 8 13 5 3

2004-06 2 7 12 10 14 10 17 17 1 3 6 15 16 10 8 13 5 4



16

Table(C): Rank order of deaths by various causes for all age groups of females based on Three year moving average for females Urban Maharashtra 1990-2006



Year I II III IV V VI VII VIII IX X XI XII XIII XIV XV XVI XVII XVIII XIX

1990-92 3 7 11 8 16 10 NA NA 2 4 9 15 17 13 12 6 14 1 4

1991-93 3 7 11 8 17 10 NA NA 2 4 9 15 16 13 12 6 14 1 5

1992-94 3 7 10 8 17 11 NA NA 1 4 9 15 16 13 12 6 14 2 5

1993-96 3 7 11 8 17 10 NA NA 1 5 9 15 16 13 12 6 14 2 4

1994-97 3 7 10 8 17 11 NA NA 1 5 9 15 16 12 13 6 14 2 4

1996-98 3 7 10 8 17 11 NA NA 1 5 9 15 16 12 13 6 14 2 4

1997-99 3 7 10 8 17 11 16 19 1 5 9 15 16 12 13 6 14 2 4

1998-00 3 7 10 8 17 11 18 19 1 5 9 15 16 12 13 6 14 2 4

1999-01 3 7 11 8 17 11 18 18 1 4 10 15 16 11 14 6 12 2 4

2000-02 3 7 12 8 17 11 18 18 1 3 10 15 16 10 14 6 12 3 4

2001-03 3 6 13 8 17 11 18 18 1 2 11 15 16 9 14 7 11 4 5

2002-04 3 6 13 8 17 10 18 18 1 2 10 16 16 10 14 7 12 4 5

2003-05 2 6 12 8 16 10 18 18 1 3 11 16 16 9 14 7 13 4 5

2004-06 2 6 12 8 15 10 18 18 1 3 11 17 16 9 14 7 13 4 5

Note: This is an extended abstract only. We have presented some of entire analyses carried out for this study. We will full

interpretation of results and analyses tables and figures in full paper

17

Appendix I ICD-X revision of causes of death by WHO

I Infectious and Parasitic Diseases (001-139)

II Neoplasm (140-239)

III Diseases of Blood and Blood Forming Organs (280-289)

IV

Endocrine, Nutritional and Metabolic Diseases and Immunity

Disorders (240-279)

V Mental Disorders (290-319)

VI Diseases of the Nervous System and Sense Organs (320-389)

VII Diseases of The Eye and Adnexa (H00-H59)

VIII Diseases of The Ear and Mastoid Process (H60-H95)

IX Diseases of the Circulatory System (390-459)

X Diseases of the Respiratory System (460-519)

XI Diseases of the Digestive System (520-579)

XII Diseases of the Skin and Subcutaneous Tissue (680-709)

XIII

Diseases of the Musculoskeletal System and Connective Tissue

(710-739)

XIV Diseases of the Genitourinary System (580-629)

XV Complication of Pregnancy (630-676)

XVI Certain Conditions Originating in the Perinatal Period (760-779)

XVII Congenital Anomalies (740-759)

XVIII Symptoms, Signs and Ill-Defined Conditions (780-799)

XIX Injury and Poisoning (800-999)



18

Appendix II: Population composition by broad age group, Urban Maharashtra, 1990-2006.

Source: SRS, 1990-2006

Year

Male Female Total

0-4 15-59 60+ 0-4 15-59 60+ 0-4 15-59 60+

1990 11 63.1 4.5 11.7 61 5.8 11.3 62.1 5.1

1991 10.8 63.1 4.8 11.3 61.6 5.9 11 62.3 5.3

1992 10.4 63.5 5 10.8 61.7 6.1 10.6 62.7 5.5

1993 10.7 61.4 5.4 11.2 59.5 6.3 10.9 60.5 5.8

1994 10.3 62.1 5.2 10.7 60.1 6.4 10.5 62.1 5.2

1996 9.9 63.1 5.5 10.1 61.3 6.6 10 62.3 6.1

1997 9.8 63.6 5.5 9.9 62.2 6.8 9.9 63 6.1

1998 10.1 63.7 6.2 9.9 62.6 7.3 10 63.2 6.5

1999 10.2 63.4 6.4 9.9 62.8 7.5 10 63.2 6.9

2000 9.9 64.4 6.3 9.5 63.4 7.4 9.7 64.1 6.8

2001 10.2 63.7 6.1 9.5 63.4 7.3 9.9 63.5 6.9

2002 9.6 65 6.3 9.1 64 7.6 9.4 64.5 7.1

2003 9.3 65.1 6.7 8.9 64.4 8.3 10.3 65.8 7.5

2004 9.3 65.6 6.4 9 64.9 7.4 9.6 65.2 6.8

2005 9.1 65.8 6.5 8.9 65.3 7.5 9 65.5 7

2006 8.9 65.9 6.8 8.8 66.1 7.3 8.8 66.1 7.1

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