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Background  Reducing premature mortality is a crucial public health objective. After a long gap in the publication of Belgian mortality statistics, this paper presents the leading causes and the regional disparities in premature mortality in 2008–2009 and the changes since 1993.    Methods  All deaths occurring in the periods 1993–1999 and 2003–2009, in people aged 1–74 residing in Belgium were included.  The cause of death and population data for Belgium were provided by Statistics Belgium , while data for international comparisons were extracted from the WHO mortality database.  Age-adjusted mortality rates and Person Year of Life Lost (PYLL) were calculated. The Rate Ratios were computed for regional and international comparisons, using the region or country with the lowest rate as reference; statistical significance was tested assuming a Poisson distribution of the number of deaths.    Results  The burden of premature mortality is much higher in men than in women (respectively 42% and 24% of the total number of deaths). The 2008–9 burden of premature mortality in Belgium reaches 6410 and 3440 PYLL per 100,000, respectively in males and females, ranking 4th and 3rd worst within the EU15. The disparities between Belgian regions are substantial: for overall premature mortality, respective excess of 40% and 20% among males, 30% and 20% among females are observed in Wallonia and Brussels as compared to Flanders. Also in cause specific mortality, Wallonia experiences a clear disadvantage compared to Flanders. Brussels shows an intermediate level for natural causes, but ranks differently for external causes, with less road accidents and suicide and more non-transport accidents than in the other regions.  Age-adjusted premature mortality rates decreased by 29% among men and by 22% among women over a period of 15 years. Among men, circulatory diseases death rates decreased the fastest (-43.4%), followed by the neoplasms (-26.6%), the other natural causes (-21.0%) and the external causes (-20.8%). The larger decrease in single cause is observed for stomach cancer (-48.4%), road accident (-44%), genital organs (-40.4%) and lung (-34.6%) cancers. On the opposite, liver cancer death rate increased by 16%.  Among female, the most remarkable feature is the 50.2% increase in the lung cancer death rate. For most other causes, the decline is slightly weaker than in men.    Conclusion  Despite a steady decrease over time, international comparisons of the premature mortality burden highlight the room for improvement in Belgium. The disadvantage in Wallonia and to some extent in Brussels suggest the role of socio-economic factors; well- designed health policies could contribute to reduce the regional disparities. The increase in female lung cancer mortality is worrying.    Electronic supplementary material  The online version of this article (doi:10.1186/2049-3258-72-34) contains supplementary material, which is available to authorized users.

Premature mortality in Belgium in 1993-2009: leading causes, regional disparities and 15 years change