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Cysticercosis is an increasingly important disease in the United States, but information on the occurrence of related deaths is limited. We examined data from California death certificates for the 12-year period 1989-2000. A total of 124 cysticercosis deaths were identified, representing a crude 12-year death rate of 3.9 per million population (95% confidence interval [CI] 3.2 to 4.6). Eighty-two (66%) of the case-patients were male; 42 (34%) were female. The median age at death was 34.5 years (range 7-81 years). Most patients (107, 86.3%) were foreign-born, and 90 (72.6%) had emigrated from Mexico. Seventeen (13.7%) deaths occurred in U.S.-born residents. Cysticercosis death rates were higher in Latino residents of California (13.0/[10.sup.6]) than in other racial/ethnic groups (0.4/[10.sup.6]), in males (5.2/[10.sup.6]) than in females (2.7/[10.sup.6]), and in persons >14 years of age (5.0/[10.sup.6]). Cysticercosis is a preventable cause of premature death, particularly among young Latino persons in California and may be a more common cause of death in the United States than previously recognized.

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Cysticercosis, an infection caused by the larval form of the pork tapeworm, Taenia solium, is recognized as an increasingly important cause of severe neurologic disease in the United States (1-3). In the typical transmission cycle, eggs from the adult tapeworm are shed in the feces of a human carrier and subsequently ingested by pigs, the usual intermediate host (4). Larvae emerge from the eggs, penetrate the intestinal mucosa and disseminate through the bloodstream to various tissues where the larval stage or cysticercus develops. The cycle is completed when humans, the only naturally infected definitive host, consume raw or undercooked pork containing cysticerci, which attach to the small bowel and develop into adult tapeworms, thereby completing the cycle. However, humans may also become infected with the larval stage when eggs, which are directly infectious, are ingested, typically through contaminated food or water. Neurocysticercosis, the most severe form of the disease, occurs when larvae invade tissue of the central nervous system. While cysticercosis in the United States principally affects immigrants from cysticercosis-endemic areas of Latin America, it has been increasingly recognized in U.S.-born residents as well (5-7).

Despite the growing importance of cysticercosis, surveillance systems for cysticercosis have rarely been implemented (6,8), and the true impact of the disease in the United States is largely unknown. Although several case series have been published (1,2,9-11), these have been facility-based efforts and, consequently, may not provide an accurate measure of either the incidence or severity of the disease. Such facility-based reports have suggested that deaths from cysticercosis in the United States are uncommon. Although population-based data would provide a more accurate assessment of cysticercosis death rates, such data are scarce. To measure cysticercosis-related death rates in California, we reviewed state mortality records for the 12-year period 1989-2000.

Methods

Data Source

Data on deaths were obtained from the State of California, Center for Health Statistics, Office of Vital Records. Completion of a death certificate is required by state law. All death certificates in California require the assignment of a cause or sequence of events leading to death as determined by the attending physician. If a physician is not in attendance, of the death is accidental or occurs under suspicious circumstances, cause of death is determined by the local coroner or medical examiner. Completed death certificates are transmitted from county jurisdictions to the California Department of Health Services, where the causes or sequence of events for each death record are keyed into a computer to create an input data file, which is subsequently sent to the National Center for Health Statistics (NCHS), which produces codes for both the underlying cause of death and multiple cause for each death record. The resulting coded file is then returned to the California Department of Health Services, Office of Vital Records. Data from the State of California's Multiple Cause of Death Files for the 12-year period 1989-2000 were searched for persons for whom cysticercosis (ICD-9 code 123.1 for years 1989-1998, and ICD-10 code B69 for years 1999 and 2000) was listed as a cause of death. Additional information extracted from the death record included age, gender, race/ethnicity, level of education, country of birth, place of death, and date of death.

Data Analysis

Cysticercosis death rates per million population were calculated for California and for its major counties by using mid-period population estimates (1994). Population data were obtained from the Department of Finance, Demographic Research Unit, State of California. Crude cysticercosis death rates and 95% confidence intervals were computed according to age, gender, race/ethnicity, and county of residence. Rate ratios and 95% confidence intervals were also calculated. The chi-square, Fisher exact, and Student t tests were employed when appropriate to assess apparent differences.

Results

A total of 124 cysticercosis deaths (mean 10.3 per year) were identified over the 12-year study period, representing a crude 12-year death rate of 3.9 per million population (95% confidence interval [CI] 3.2 to 4.6). Latino residents accounted for 115 (92.7%) of the total deaths recorded, while 5 (4.0%) were white, 3 (2.4%) were Asian, and 1 (0.8%) was black (Table 1). Eighty-two (66.1%) were male; 42 (33.9%) were female. The mean age at death was 39.9 years (range 7-81 years). Most case-patients (107, 86.3%) were born outside the United States, and 90 (72.6%) had emigrated from Mexico. All three fatal cases in Asians were in male immigrants >55 years of age. Cysticercosis was listed as the underlying cause of death for 92 (74.2%) of the patients.

Crude cysticercosis death rates are presented in Table 2. Rates were highest in Latino persons (13.0/[10.sup.6], 95% CI 10.6 to 15.3) compared with those for other racial/ethnic groups (0.4/[10.sup.6], 95% CI 0.1 to 0.7), in males (5.2/[10.sup.6], 95% CI 4.0 to 5.7) relative to females (2.7/[10.sup.6], 95% CI 1.9 to 3.5), and in persons >14 years of age (5.0/[10.sup.6], 95% CI 4.2 to 5.9). Cysticercosis deaths varied by year with the greatest number (16 deaths) observed in 1992 (Figure). The highest cysticercosis death rates were in the counties of Los Angeles (7.7/[10.sup.6]), Riverside (6.0/[10.sup.6]), and Ventura (5.7/[10.sup.6]). More than half of the deaths (70) were among Los Angeles County residents.

Seventeen cysticercosis deaths occurred in U.S.-born residents, representing 14% of all cysticercosis deaths. U.S.-born patients with fatal cysticercosis had higher educational levels (p = 0.02), were older (mean age 49.1 years versus 38.4 years, p < 0.05), and were more likely to be male (but this difference was not statistically significant) (Table 3). Although 71% of U.S.-born deaths occurred among Latino persons, this figure was lower than the proportion for foreign-born Latino residents (p < 0.01).

Principal coexisting conditions listed as contributing to death included hydrocephalus in 45 (36.3%) persons and epilepsy or convulsions in 20 (16.1%) deaths. Reported place of death included inpatient facility (69%), emergency room or outpatient clinic (10%), nursing home, (9%) and residence (9%).

Discussion

Our findings indicate that cysticercosis is an important and preventable cause of premature death in California, particularly among Latino youth, and the disease may be a more common cause of death in the United States than previously recognized. Although fatal cysticercosis principally affects Hispanic immigrants, our findings suggest that this larval tapeworm causes infection and death in U.S.-born residents as well.