Age Standardization of Rates: A New WHO Standard

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AGE STANDARDIZATION OF RATES:
A NEW WHO STANDARD
Omar B. Ahmad
Cynthia Boschi-Pinto
Alan D. Lopez
Christopher JL Murray
Rafael Lozano
Mie Inoue
GPE Discussion Paper Series: No.31
EIP/GPE/EBD
World Health Organization 2001

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Summary
A recent WHO analysis has revealed the need for a new world standard population (see
attached table). This has become particularly pertinent given the rapid and continued
declines in age-specific mortality rates among the oldest old, and the increasing
availability of epidemiological data for higher age groups. There is clearly no conceptual
justification for choosing one standard over another, hence the choice is arbitrary.
However, choosing a standard population with higher proportions in the younger age
groups tends to weight events at these ages disproportionately. Similarly, choosing an
older standard does the opposite. Hence, rather than selecting a standard to match the
current age-structure of some population(s), the WHO adopted a standard based on the
average age-structure of those populations to be compared (the world) over the likely
period of time that a new standard will be used (some 25-30 years), using the latest UN
assessment for 1998 (UN Population Division, 1998). From these estimates, an average
world population age-structure was constructed for the period 2000-2025. The use of an
average world population, as well as a time series of observations, removes the effects of
historical events such as wars and famine on population age composition. The terminal
age group in the new WHO standard population has been extended out to 100 years and
over, rather than the 85 and over as is the current practice. The WHO World Standard
population has fewer children and notably more adults aged 70 and above than the world
standard. It is also notably younger than the European standard.
It is important to note, however, that the age standardized death rates based on the new
standard are not comparable to previous estimates that are based on some earlier
standard(s). However, to facilitate comparative analyses, WHO will disseminate trend
analyses of the “complete” historical mortality data using on the new WHO World
Standard Population in future editions of the World Health Statistics Annual.

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Introduction
In epidemiology and demography, most rates, such as incidence, prevalence, mortality,
are strongly age-dependent, with risks rising (e.g. chronic diseases) or declining (e.g.
measles) with age. In part this is biological (e.g. immunity acquisition), and in part it
reflects the hazards of cumulative exposure, as is the case for many forms of cancer. For
many purposes, age-specific comparisons may be the most useful. However,
comparisons of crude age-specific rates over time and between populations may be very
misleading if the underlying age composition differs in the populations being compared.
Hence, for a variety of purposes, a single age-independent index, representing a set of
age-specific rates, may be more appropriate. This is achieved by a process of age
standardization or age adjustment.
There are several techniques for adjusting age-specific rates. Among them are direct and
indirect standardization (Wolfenden, 1923), the geometric mean (Schoen, 1970),
equivalent average death rates (Hill, 1977), life table rates, Yerushalmy’s index
(Yerushalmy, 1951), cumulative death rates (Breslow and Day, 1981), absolute
probabilities of death and the comparative mortality index ((Peto et al, 1994, Breslow &
Day, 1980, 1981; 1987; Esteve et al, 1994). However, with the increasing availability of
age-specific rates, the use of direct age standardization has become the predominant
technique in most applications of demography and epidemiology.
Direct standardization yields a standardized or age-adjusted death rate, which is a
weighted average of the age-specific rates, for each of the populations to be compared.
The weights applied represent the relative age distribution of the arbitrary external
population (the standard). This provides, for each population, a single summary rate that
reflects the number of events that would have been expected if the populations being
compared had had identical age distribution. Symbolically, the directly standardized
mortality rate for populations A and B are given by the following equations:
where nis is the mid-year population in the ith age group of the standard population, ria
and rib are the death rates in age group i in populations A and B, respectively. The ratio of
two such standardized rates is referred to as the Comparative Mortality Ratio (CMR), a
very useful measure. If the age-specific rates in the populations being compared have a
roughly consistent relationship from one age group to the next, the selection of a standard
population will not substantially affect comparisons among groups or time periods. In
reality, however, the relative differences are usually not constant from one age group to
another. As such, both the comparison as well as the conclusions drawn are influenced
by the chosen standard.
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In this paper, we review the existing standard populations currently in use for
international comparison, the Segi (“world”) and the Scandinavian (“European”) standard
populations. Based on this review, a new WHO World Standard age-structure is
presented for epidemiological comparisons using the direct approach. The age
composition of the new standard has been chosen to better reflect the future age structure
of the world’s population for which comparative rates will be needed.
History of Direct standardization
By the middle of the nineteenth century, public health practitioners in England had began
to recognize that simple crude rates were inappropriate summary measures for comparing
population health when the age distribution of the geographic areas were markedly
different. Discussions centered around the development of a summary mortality index
free from the effect of age differences. In a paper he read to the Statistical Society of
London, Sir Edwin Chadwick, one of the early public health reformers in England,
proposed the use of “the mean age at death” as a summary measure for comparing the
health condition of the various “sanitary districts” around London (Finer, 1952; Lewis,
1991). This index, he argued, represented a true summary of the age-specific risks of
dying. In response, Neison, a practicing actuary, disagreed with Chadwick’s underlying
logic. He argued that since mortality increased with age, Chadwick’s mean age at death
for geographic areas with a relatively older population would tend to overstate excess
mortality. In a subsequent article, Neison demonstrated the fallacy in Chadwick’s
argument by comparing the crude mean age at death with the mean age computed by a
method of direct standardization (Neison 1844). Neison was, thus, the first to introduced
both the concepts of direct and indirect standardization, as well as the term standard
population.
The Registrar General’s report of 1883 was the first reported use of Neison’s direct
standardization method, using the 1881 population census of England and Wales as the
standard (most current at the time). In subsequent reports, the standard was changed each
time there was a new census, i.e., every ten years (Woolsey, et al., 1959; Benjamin, et al.,
1980). These frequent changes of the standard were cumbersome since historical rates
had to be recalculated each time in order to assess current trends. As a solution, the 1901
population census was eventually adopted as a general standard in England and Wales,
and remained unchanged even when a new census became available.
In order to facilitate comparison with mortality rates in England and Wales, the United
States adopted the 1901 British standard. This practice continued until the early 1940s
when it was decided that the difference between the US population at the time and the
1901 English population was significant enough to warrant a change in standard. As a
result, the US adopted its 1940 census population (the most current at the time) as the
new standard. Recently, however, there has been growing concern that the 1940 standard
no longer reflects the increasingly older US age structure. In response, the National
Center for Health Statistics sponsored two national workshops in 1991 and 1997 on the
issue of a new US standard. The final report of these workshops recommended the
adoption of a new standard based on the projected 2000 population age distribution
(NCHS, 1998).

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An International Standard Population
The idea of a truly international standard was first suggested by Ogle in 1892. His
proposed standard was an amalgam based on the experience of seven European countries
(Ogle, 1892). There is, however, no evidence of its subsequent adoption for international
comparison by any country. Various standards have been proposed since then but none
adopted widely. The debate has centered largely around the question of whether any one
standard is more suitable than others. This question was discussed at a May 1965
subcommittee meeting of the International Union Against Cancer (IUAC) Conference in
London. Three standard populations were suggested. Each was deemed appropriate for
particular population types. One standard had a high proportion of young people and was
considered appropriate for making comparisons with populations in Africa (Knowelden
and Oettlé, 1962). The second (“European”) standard was based on the experience of
Scandinavian populations, which contained a relatively high proportion of old people and
was judged particularly suitable for comparison within Western Europe (Doll and Cook,
1967). The third was proposed by Segi (1960) as an intermediate “world” standard based
on the experience of 46 countries. The “European” and “world” standards were
subsequently adopted by WHO for use in calculating age-standardized death rates. These
standards are shown in Table 1 together with the new WHO World Standard (shown in
abbreviated form for purposes of comparison).
As discussed earlier, the choice of a standard can markedly alter comparisons between
populations. Table 2 shows a time series of circulatory disease mortality among US
males for the period 1970-1995 using the three standards (Segi, Scandinavian and the
WHO World Standard). Even though the overall percentage decline from 1970 to 1995
is almost the same for all three standards (48-49%), the relative differences in the
standardized rates, using the WHO standard as baseline, varies from –20% in one
standard to +24% in the other. Table 3 compares twenty countries on the standardized
death rates for respiratory infections as well as the ranking of countries according to
rates. In general, the Scandinavian standard tends to yield rankings that are closer to
those obtained with the WHO World Standard. In about half the cases, there are only
minor differences in ranking between the three standards. In other cases, however,
substantial shifts in ranking occur when the standard is changed. For instance, the
Russian Federation ranks 9th on the Segi but 13th on the Scandinavian and WHO
standards. Similarly, Cuba ranks 10th on the Scandinavian, 11th on the WHO and 14th on
the Segi. The differences in the actual rates are even more dramatic. The age-
standardized mortality rate for respiratory infections for Hong Kong ranges from 44.9
using the Segi standard to 76.9 using the Scandinavian (“European”). Much larger
differences are evident in some of the other countries. If the choice of a population
standard for direct age-standardization can have such marked influence on comparisons
over time and between populations, how should a world standard be selected?
A New WHO World Standard Population
Age-structure varies tremendously across populations of the world at different levels of
the demographic transition. Should one, therefore, choose a standard population with
higher proportions in the younger age groups (thereby weighting events at these ages
disproportionately), or choose an older standard, or rather something in-between? There

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is clearly no conceptual justification for choosing one standard over another, hence the
choice will eventually be arbitrary. Whatever standard is chosen should ideally be
maintained for a number of years, during which time the age-structure of populations will
alter. For this reason, attempting to match a particular standard to current population age
structures is insufficient justification for choosing one standard over another. Hence,
rather than selecting a standard to match the current age-structure of some population(s),
the standard must be chosen to reflect the average age-structure of all populations to be
compared over the period of use.
The approach proposed by WHO is to base the standard on the average age-structure of
those populations to be compared (the world) over the likely period of time that a new
standard will be used (some 25-30 years). The United Nations Population Division
carries out two-yearly comprehensive assessment of population age-structure for each
country by age and sex (the latest assessment is for 1998 - UN Population Division,
1998). Estimates are prepared for countries for each quinquinnial year from 1950 and
projected to 2025, based on population censuses and other demographic sources, adjusted
for enumeration errors. From these estimates, an average world population age-structure
is constructed for the period 2000-2025. Figure 1 shows the expected evolution of the
world’s population age-structure over the first quarter of the 21st century, and the average
composition which defines the new WHO World Standard.
The use of an average world population, as well as a time series of observations removes
the effects of historical events such as wars and famine on population age composition.
Table 4 gives the percentage of the population in each 5-year age group in the new WHO
World Standard population. Given the rapid and continued declines in age-specific
mortality rates among the oldest old, and the increasing availability of epidemiological
data for higher age groups, the terminal age group in the new standard population has
been extended out to 100 years and over, rather than the 85 and over as is the current
practice. The difference with respect to the Segi and Scandinavian standards can be seen
in Figure 2. The WHO World Standard population has fewer children and notably more
adults aged 70 and above than the Segi standard. It is also notably younger than the
Scandinavian standard. Implementation of this new standard will facilitate international
comparative analysis and reduce confusion among data users.
Discussion
To facilitate comparisons of sets of age-specific epidemiological and demographic rates
across populations with different age composition, it is useful to calculate summary
health statistics which remove the effects of variation in age structure. The dominant
method currently in use is the direct age-standardization of rates using an arbitrary
standard population. National (as exemplified by the United Kingdom and the United
States) and international experience suggest that population standards have been adopted
for arbitrary reasons and once adopted have been used for many decades. Given current
WHO initiatives, which involve comparisons of vastly different populations, existing
standards appear too extreme. We present a new WHO World Population Standard which
is especially defined to reflect the average age structure of the world’s population
expected over the next generation, from the year 2000 to 2025. Comparisons across
populations of the world should preferably be based on an average world population age

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structure and that average age structure should correspond to the period of likely use of a
standard (20-30 years).
To facilitate comparisons globally, all age-standardized rates produced by WHO will be
made according to the new WHO World Standard Population. Hopefully, this single
standard will be widely adopted for global comparisons.

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REFERENCES
Breslow NE, Day NE. Fundamental Measures of Disease Occurrence and Association.
In: Statistical Methods in Cancer Research, Vol. I, The Analysis of Case-Control Studies
(IARC Scientific Publications No. 32), Lyon, International Agency for Research on
Cancer, 1980. pp.42-81.
Breslow NE, Day NE. Rates and Rate Standardization. In: Statistical Methods in Cancer
Research, Vol. II, The Design and Analysis of Cohort Studies (IARC Scientific
Publications No. 82), Lyon, International Agency for Research on Cancer, 1987. pp.48-
79.
Day NE . A New Measure of Age Standardized Incidence, the Cumulative Rate. In:
Waterhouse JAH, Muir CS, Correa P, Powell J (eds.). Cancer incidence in Five
Continents, Vol. III (IARC Scientific Publications No. 15), Lyon, International Agency
for Research on Cancer, 1976. pp.443-52.
Day NE . Cumulative Rate and Cumulative Risk. In: Waterhouse JAH, Muir CS,
Shanmugaratnam K, Powell J (eds.). Cancer incidence in Five Continents, Vol. IV
(IARC Scientific Publications No. 42), Lyon, International Agency for Research on
Cancer, 1982. pp.668-70.
Doll R, & Cook P. Summarizing indices for comparison of cancer incidence data. Int J
Cancer 2:269-79, 1967.
Doll R. Comparison between Registries . Age-Standardized Rates. In: Waterhouse JAH,
Muir CS, Correa P, Powell J (eds.). Cancer incidence in Five Continents, Vol. III (IARC
Scientific Publications No. 15), Lyon, International Agency for Research on Cancer,
1976. pp.453-59.
Esteve J, Benhamou E, Raymond L . Techniques for the Analysis of Cancer Risk. In:
Statistical Methods in Cancer Research, Vol. IV, Descriptive Epidemiology (IARC
Scientific Publications No. 128), Lyon, International Agency for Research on Cancer,
1994. pp.49-105.
Kleinbaum DG, Kupper LL, Mor genstern H. Measures of Disease Frequency:
Incidence. In: Epidemiologic Research. Principles and Quantitative Methods. New York,
Van Nostrand Reinhold, 1982. pp.96-116.
Miettinen OS. Estimability and estimation in case-referent studies. Am J Epidemiol 103:
226-35, 1976.
Morgenstern H, Kleinbaum DG, Kupper LL . Measures of disease incidence used in
epidemiologic research. Int J Epidemiol 9:97-104, 1980.
Peto R, Lopez A, Boreham J, Thun M, Heath Jr. C . Mortality from Smoking in
Developed Countries. 1950-2000. Oxford, Oxford University Press, 1994. pp.A.30.

9
UICC. Cancer incidence in Five Continents, Vol. I. A Technical Report. Eds. Doll R,
Payne P, Waterhouse J. Berlin, Springer-Verlag, 1966.
standardization/wpd
Wolfenden HH . On the methods of comparing the mortalities of two or more
communities and the standardization of death rates. Journal of the Royal Statistical
Society. 1923. 86:399-411.
Yerushalmy J. A mortality index for use in place of the age adjusted death rate. Am. J
Public Health. 1951. 41:907-22.
Neison FGP . On a method recently proposed for conducting inquiries into the
comparative sanitary conditions of various districts. London J Royal Stat Soc. 1844.
7:40-68.
National Center for Health Statistics . Report of the workshop on age adjustment.
Vital and Health Statistics. Series 4. No. 30. December 1998.
Ogle MW. Proposal for the establishment and international use of a standard population,
Bulletin de l’Institut International de Statistique, tome VI, livre 1:83-5. Rome. 1892.
Knowelden J, Oettlé AG. Cancer incidence of the African population of Kyadondo
(Uganda). Lancet, ii, 328-330. 1962.
Segi M. Cancer mortality for selected sites in 24 countries (1950-57). Department of
Public Health, Tohoku University of Medicine, Sendai, Japan. 1960.
Schöen R (1970). The geometric mean of the age-specific death rate as a summary index
of mortality. Demography. 7:317-24. 1970.
Hill AB. A short textbook of medical statistics. 9th ed. London: Hodder and Stoughton.
1977.
United Nations Population Division. World Population Prospects. 1998 Revision. Vol.
I. ESA/WP.150. 24 November, 1998.
Doll R, Payne PM, Waterhouse JAH. Cancer incidence in five countries. International
Union Against Cancer, Springer-Verlag. Berlin. 1966.
Woolsey TD. Adjusted death rates and other indices of mortality. In: Linder, F.E, R.D.
Grove, eds. Vital Statistics in the United States, 1900-40. Washington: U.S. Government
Printing Office. 1959
Benjamin B, Pollard JH . The analysis of mortality and other actuarial statistics.
London: Heineman. 1980
Lewis J (1991). The origins and development of public health in the United Kingdom.
In: The Oxford textbook of public health, 2nd ed. Vol I. Influences of Public Health
23-33, New York: Oxford University Press.
Finn, SE. 1952. The life and times of Sir Edwin Chadwick. London: Methuen. 1952.

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Table 1. Standard Population Distribution (percent)
Age group Segi (“world”) standard Scandinavian (“European”) standard WHO World Standard*
0-4 12.00 8.00 8.86
5-9 10.00 7.00 8.69
10-14 9.00 7.00 8.60
15-19 9.00 7.00 8.47
20-24 8.00 7.00 8.22
25-29 8.00 7.00 7.93
30-34 6.00 7.00 7.61
35-39 6.00 7.00 7.15
40-44 6.00 7.00 6.59
45-49 6.00 7.00 6.04
50-54 5.00 7.00 5.37
55-59 4.00 6.00 4.55
60-64 4.00 5.00 3.72
65-69 3.00 4.00 2.96
70-74 2.00 3.00 2.21
75-79 1.00 2.00 1.52
80-84 0.50 1.00 0.91
85+ 0.50 1.00 0.63
Total 100.00 100.00 100.00
* For purposes of comparison, the WHO Standard age group 85+ is an aggregate of the age groups 85-89, 90-94, 95-99
and 100+.
Table 2. Trend in Age-adjusted Circulatory Disease Mortality Rates Based on the Segi, Scandinavian and WHO
World Standard Populations and the Cumulative Death Rates - US Males (1970-1995)
Rates per 100,000
Standard 1970 1975 1980 1985 1990 1995 % Change 1970-1995
Segi 459.5 399.0 350.3 305.8 256.8 232.3 -49.4
WHO World 550.9 482.2 426.7 373.7 315.0 285.4 -48.2
Scandinavian 720.1 630.4 557.8 488.4 411.6 372.4 -48.3
Percent Difference in Rates Relative to WHO World Standard
Segi -20% -21% -22% -22% -23% -23%
Scandinavian 23% 24% 24% 23% 23% 23%

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Table 3. Directly standardized male death rates from respiratory infections
and ranking of twenty countries using three different standard populations - (Around 1995)
Rates Per 100,000 Ranking of Countries ( by age-adjusted death rates)
Segi Scandinavian WHO World Segi Scandinavian WHO world
Australia 6.3
10.1
7.9
23
23
23
Barbados 28.8
41.9
33.8
12
12
12
Bulgaria 34.2
43.5
36.7
8
11
10
Canada 14.5
25.6
19.7
18
18
18
Cuba 27.2
44.2
34.6
14
10
11
Estonia 27.5
36.2
29.6
13
15
15
Germany 11.0
19.0
14.7
19
19
19
Hong Kong 44.9
76.9
59.1
5
3
4
Hungary 9.6
13.1
10.7
21
22
22
Iceland 26.9
49.1
37.9
15
8
8
Ireland 37.0
65.6
50.4
7
6
7
Japan 37.8
67.5
51.8
6
5
6
Latvia 29.5
38.1
31.7
11
14
14
Luxembourg 8.4
15.1
11.7
22
21
21
Mauritius 45.2
72.6
56.6
4
4
5
New Zealand 15.3
27.7
21.5
17
17
17
Portugal 21.0
35.1
27.4
16
16
16
Russian Federation 32.7
38.3
33.1
9
13
13
Singapore 71.9
120.8
93.3
3
1
1
Spain 10.9
18.6
14.5
20
20
20
Trinidad and Tobago 30.2
46.7
37.2
10
9
9
Turkmenistan 114.2
87.9
91.2
1
2
2
Uzbekistan 80.6
63.6
65.1
2
7
3

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Table 4. WHO World Standard Population Distribution (%),
based on world average population between 2000-2025
Age group World Average 2000-2025
0-4 8.86
5-9 8.69
10-14 8.60
15-19 8.47
20-24 8.22
25-29 7.93
30-34 7.61
35-39 7.15
40-44 6.59
45-49 6.04
50-54 5.37
55-59 4.55
60-64 3.72
65-69 2.96
70-74 2.21
75-79 1.52
80-84 0.91
85-89 0.44
90-94 0.15
95-99 0.04
100+ 0.005
Total 100

Figure 1. World population by age group in percent of total population
2000 to 2025 and average of 2000 to 2025
0
2
4
6
8
10
0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69
70-74
age group
percent of total population
2000
2025

Figure 2. Comparison of "Segi" and "Scandinavian" standards with world 2000-2025 average
population
-60
-40
-20
0
20
40
60
80
0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59
60-64
Age group
percent difference with world 2000-2025 average population
Segi standard population
Scandinavian standard population