Cancer in the mid-west: 1994-2002/ T. Greally, H. Comber

Item Type Report

Authors Health Service Executive (HSE)

Rights HSE

Download date 23/09/2021 17:46:42

Link to Item http://hdl.handle.net/10147/44537

Find this and similar works at - http://www.lenus.ie/hse Cancer in the Mid-West 1994- 2002

Introduction

Cancer is not a single disease; it is rather a group of diseases of differing impact and cause, which one in three individuals will develop in the course of their lifetime. Over 18,000 new cases of malignant cancer are recorded annually in with approximately 1,500 in the three counties of Clare, and North Tipperary. About 3 in 10 registered cancers are non-melanoma skin cancers which are excluded from this report.

Background

Information has been collected by the National Cancer Registry of Ireland (NCRI) on new cancer registrations in Ireland since 1994; national and regional data are available through NCRI annual reports and on their website (www.ncri.ie). Information on the incidence of cancer and other diseases is not usually available for areas smaller than county level in Ireland, as addresses in Ireland (with the exception of Northern Ireland) do not have local area coding (e.g. postcodes or zip codes.). However, addresses can be assigned, using various data sources, to a small area of residence (electoral district, ‘ED’), and the National Cancer Registry is currently in the process of assigning all cancer cases registered since 1994 to an ED of residence; this has already been done for cases registered up to the end of 2002 for Clare, Limerick and north Tipperary. Because of concerns arising from animal health in and its environs during the 1990s a number of studies in recent years have used NCRI data to examine cancer rates in this area, including: • A study of human health indicators which compared health indices in the Askeaton area including cancer incidence for 1994-95 . • A PhD thesis by Dr. Avril Hegarty of the University of Limerick using 1994-95 NCRI data with new methods of mathematical and statistical modelling. • A report on cancer incidence levels across the whole Mid-West region for 1994-99 • Local cancer incidence data for 2000 and 2001 presented by the National Cancer Registry Director, Dr. Harry Comber, to local residents in Askeaton and in 2003 None of these studies showed a significant excess of cancer incidence in the Askeaton area, although significantly elevated rates were noted in parts of Limerick City. This report extends the study of cancer registration in the Mid-West by a further year to cover the 1994-2002 period and describes cancer incidence levels across the whole Mid- West region.

Data collection methods

The National Cancer Registry of Ireland ( NCRI) is the only source of national cancer incidence in Ireland. Nurses trained in cancer registration methods are employed as tumour registration officers (TROs) by the Cancer Registry and are based in 18 hospitals around the country. Each is responsible for gathering cancer data from a group of

1 hospitals, and from other sources within a designated geographical area. Within their catchment areas, they liaise with hospital pathology and haematology laboratories, special clinics, hospital administrators and medical records staff, Hospital Inpatient Enquiry (HIPE) and casemix staff, public health nurses, hospices, nursing homes and any other persons they consider to be a useful source of registration data. Death certificate information is also used, but represents less than 5% of primary notifications. The Registry carries out internal quality control checks on the data throughout collection and processing and collates and updates information under three headings: patient, tumour and treatment information. The Registry has carried out a number of checks on the completeness of registration of cancer, and all have confirmed that at least 96-97% of all new cancers are picked up by the NCRI; this compares well with international cancer registration standards. However, to ensure that few cancers are missed, an intensive search process, as described above, has to be undertaken, using many sources of information. This process takes some time, so there is an interval of three to four years between the date of diagnosis of a cancer incidence and the time that the Registry is satisfied that all the data are complete. Detailed reports are published annually with geographical information at county or HSE area level. County level data are also available in interactive tables on the Registry’s website. The NCRI was requested to prepare a report on cancer incidence at the level of electoral division (ED)* in Clare, Limerick and north Tipperary (the former Mid-Western Health Board area) between 1994 and 2002. Each cancer case was assigned to an ED using software developed by the Registry to match addresses to two databases—the GeoDirectory, produced by An Post, and the Register of Electors provided by each local authority. Approximately 96% of cases were assigned to a unique ED. The remainder had incomplete addresses, but could be assigned to one or two or three neighbouring EDs. The small number of cases (4%) which could not be allocated to a specific ED were distributed among all EDs according to population, so the number of cases recorded as “observed” in each ED is about 4% higher than the number actually found. This had no impact on the findings.

Interpreting the results

The results for each ED have been expressed as standardised incidence ratios (SIRs). This figure gives the ratio between the number of cancer cases that were found in an area and the number that would have been expected based on a reference incidence rate. If 5 cases were found and 4 were expected, the SIR was 5/4 or 1.2. An SIR less than 1 is an indication that the actual number of cancers registered was less than expected; an SIR greater than 1 indicates that the number was greater than expected. The number of cancers expected was calculated from two pieces of information—the overall average cancer rate for the entire area (Ireland or the former MWHB area) and the population of the ED. This calculation was done separately for each age group, so the expected value allows for the fact that the average population age may be older for

* An electoral division (ED) is an area with a population of, on average, about 1000 persons. It is the smallest area for which full population information is provided by the census and also usually the smallest area to which most addresses can be confidently assigned. Each ED contains, in rural areas, a number of townlands and in urban areas, a number of streets.

2 some EDs than for others. As cancer is mainly a disease of the over-65s, it is essential to make this adjustment for the age composition of the population. The number of cancers diagnosed in most EDs is small and varies considerably from year to year (Table 1). This makes comparison between areas difficult. For Askeaton East, for instance, the number of cases has varied from none to 7 per year. Although the number of cases in Askeaton East, Askeaton West and was similar for the period 1994- 2000, in the three years 1994-1996 there were more cases in Askeaton West and Croagh, and in the three years 1997-1999 there were more cases in Askeaton East. This is known as “random variation” and is due to the fact that the number of cases arising in an area, or during a specific time, can vary unpredictably. However, this variation can be seen to lie within certain limits. For Askeaton East, Askeaton West and Croagh, in most years the number of cases was between 0 and 4, so we could predict with some degree of confidence that in most future years, if the population size and structure of these areas were to remain unchanged, then the number of cases will continue to be between 0 and 4, and that, for instance, although we see that there were 7 cases in one year in Askeaton East, 20 cases in a year would be very unlikely. This confidence is usually expressed as a “confidence limit” and in most studies of variation we use the “95% confidence limits”. This means that we could predict that in 95 of the next 100 years (or in 19 of the next 20) the number of cases will lie within these limits. Similarly, when we calculate the ratio between the actual number of cases and the number expected (the SIR) this will also have to be given confidence limits based on the confidence limits of the number of observed cases. Only if the confidence limits are both greater than 1 can we conclude confidently that the incidence rate for the area is really larger than expected. In this case, we describe the difference from average as “statistically significant”; otherwise we consider that the difference from average is almost certainly due to random variation. Table 1. Total number of invasive cancers in a number of rural Limerick EDs, 1994- 2002 year of Askeaton Askeaton Aughinish Bally- Ballyna- Castle- Craggs Croagh diagnosis East West allinan carriga town 1994 0 5 0 0 1 0 1 1 1995 0 0 0 2 2 2 1 3 1996 1 2 1 4 2 1 0 3 1997 7 2 0 2 1 2 0 3 1998 4 2 0 2 2 0 0 2 1999 2 4 2 1 1 1 1 3 1994-1999 14 15 3 11 9 6 3 15

3 Findings

Proportion of invasive cancers by site in Mid-West residents 1994-2002 colorectal lung oesophagus stomach bladder melanoma pancreas lymphoma leukaemia female breast ovary prostate cervix other Figure 1. Types of cancer diagnosed in the Mid-Western area 1994-2002 9505 invasive cancers were registered in residents of the Mid-West between 1994 and 2002, divided by site as shown in Fig 1. 18 of 409 (4%) EDs in the Mid-West had cancer incidence rates between 1994-2002 which were significantly higher than the rate for the Mid Western counties ; however only six of those (marked with an asterisk *) were significantly higher than the national rate (Table 2). Three were in Limerick City and there was one each in Counties Tipperary, Limerick and Clare.

Table 2. EDs with incidence above MWHB average ED Name ED number Local authority Boherglass * 16121 Clare 16037 Clare 16059 Clare Kyle 16148 B * 20002 Limerick County Borough Ballinacurra B * 20006 Limerick County Borough Ballynanty* 20007 Limerick County Borough Prospect B 20031 Limerick County Borough Glentworth A 20021 Limerick County Borough Johns B 20025 Limerick County Borough 21044 Limerick County * 21012 Limerick County Patricks Well 21067 Limerick County Ballintober 21080 Limerick County Thurles Urban 22004 Tipperary North Riding

4 Cloghjordan* 22010 Tipperary North Riding Rathcabban 22019 Tipperary North Riding Foilnaman 22065 Tipperary North Riding 51 (12%) EDs had rates significantly lower than the national rate; of these 25 (6%) were also significantly below the overall Mid-West rate (Detailed data by ED is given in Appendix 3). The rates for all EDs in the Mid-Western Health Board are plotted in Maps 1-4. These show that, in general, higher rates were found in urban areas. None of the EDs with significantly higher rates was located in the area surrounding Askeaton.

5 Maps 1-4

6

7 Askeaton and surrounding areas Cancer registrations for the Askeaton area were further analysed in detail by the NCRI to demonstrate incidence in the “High Risk” and “Medium Risk” areas defined by the earlier Askeaton Human Health Investigation (see Appendix 1). These are shown in Table 3.

Table 3. Cancer incidence in Askeaton areas 1 and 2 Based on MWHB rates Based on all-Ireland rates Lower Upper Lower Upper Observed Expected SIR Expected SIR 95% CI# 95% CI 95% CI 95% CI MWHB 9505* 9505 1.00 10654 0.89 0.88 0.91 Area 1 ”High-risk 109* 114 0.96 0.78 1.15 128 0.85 0.70 1.03 area” Area 2 “Medium risk 305* 299 1.02 0.90 1.14 335 0.91 0.81 1.01 area” # CI= confidence interval The number of registrations was lower for both areas than the number expected from national rates ; in the case of Area 1 the number was also lower than expected from regional rates while in Area 2 it was marginally above the regional level . None of the differences from the expected rate was statistically significant. Three of the eight EDs in Area 1 (Riddlestown ,Aughinish and Askeaton East ) and 9 of the 17 EDs in Area 2 ( , Ballyallinan,Croagh, Rathkeale Urban, Rathkeale Rural, Shanagolden, Castletown, and Dunmoylan East ) had a higher number of cancers registered than expected by Mid-West rates. This corresponds with what we would have expected; roughly half of the areas having an incidence above average and half an incidence below average. No ED in the Askeaton area had a cancer incidence which was statistically significantly different from the average. As many of the individual EDs in both areas had cancer incidence lower than expected, the overall adjusted rate for both Areas 1 and 2 (ie grouped EDs) was at the expected level. The number of invasive cancers registered in Shanagolden over the 9 year period was 34— two more than the number expected from Mid-West rates (32) but two fewer than the number expected (36) if national rates were applied. Analysis of the types of cancers registered in Areas 1 and 2 was undertaken to ensure that a cluster of unusual cancers had not occurred. The pattern reflected the regional and national experience with the most common cancers being colorectal, lung, breast and prostate cancers. In Area 1 cancers of the lung, oesophagus, prostate and lymphoma were slightly above the regional rate and in Area 2 lung, melanoma, colorectal and oesophageal cancer had a higher than average incidence; however the differences were small and not statistically significant (that is, they were almost certainly due to chance). All other major cancers (stomach, bladder, pancreas, leukaemia, female breast, ovary and cervix) occurred less frequently than predicted in both areas, resulting in an overall rate that was lower than expected.

* This total has been adjusted upward by 4% to include cases not assigned to an ED, as described on page 2

8 Maps 5- SIRs (relative to MWHB rate) for common cancers in Limerick city and environs

Cancer in other parts of the Mid-West The outstanding feature of the results for the Mid-West is the concentration of significantly elevated cancer rates in Limerick inner city. The entire population of approx 60,000 living within the current boundary of Limerick City had a cancer incidence significantly higher than the Mid-West rate for 1994-2002 (Table 4) while the 30,000 people living within the 6 EDS making up the Limerick City environs (Ballycummin, Ballysimon, Ballyglass, Limerick North Rural, Limerick South Rural and Roxborough) had a significantly lower rate. However, when these two areas (Limerick city and the city environs) are combined, the difference from the average is reduced and the resulting SIR, while still significantly high, is much closer to 1.00.

Table 4. Cancer incidence in Limerick city and environs Based on MWHB rates Based on All-Ireland rates Observed Expected SIR Lower Upper Expected SIR Lower Upper 95% CI 95% CI 95% CI 95% CI MWHB 9505 9505 1.00 10654 0.89 0.88 0.91 Limerick City 1730 1493 1.16 1.10 1.22 1672 1.03 0.98 1.08 City environs 565 652 0.87 0.80 0.93 726 0.78 0.72 0.83 Limerick City & 2296 2145 1.07 1.02 1.11 2399 0.96 0.92 0.99 environs

9 Within Limerick City there were also contrasts as shown in Map 5. Approximately 16% more invasive cancers occurred in Limerick City over the 9 year period compared with the Mid-West rate but most of this excess occurred in a small number of EDs (namely Abbey B, Ballinacurra B, Ballynanty, Glentworth A, Johns B and Prospect B). In contrast approximately 13% less invasive cancers than expected occurred in the 6 surrounding EDs which comprise the suburbs of Limerick City. The incidence was significantly higher than average in Limerick city for colorectal, lung and bladder cancers, and for melanoma, while it was lower in the surrounding area for cancer of the lung, bladder and oesophagus (Table 5).

Table 5. Cancer incidence in Limerick city and its surrounding EDs Limerick city Limerick city environs observed expected SIR (95% CI) observed expected SIR (95% CI) (based on (based on MWHB rates) MWHB rates) all cancers 1730 1493 1.16 (1.10, 1.22) 565 652 0.87 (0.80, 0.93) female breast 229 211 1.08 (0.95, 1.23) 94 105 0.90 (0.72, 1.09) colorectal 236 204 1.15 (1.01, 1.31) 76 84 0.91 (0.72, 1.14) lung 248 170 1.46 (1.28, 1.65) 50 67 0.75 (0.55, 0.98) prostate 125 143 0.87 (0.73, 1.04) 53 54 0.98 (0.72, 1.27) lymphoma 56 60 0.93 (0.70, 1.20) 31 30 1.03 (0.70, 1.46) melanoma 58 44 1.33 (1.00, 1.71) 29 22 1.31 (0.86, 1.86) bladder 74 52 1.42 (1.11, 1.78) 12 21 0.59 (0.30, 1.00) leukaemia 60 54 1.11 (0.84, 1.42) 20 25 0.82 (0.49, 1.23) stomach 54 48 1.12 (0.84, 1.46) 18 20 0.90 (0.52, 1.41) pancreas 57 44 1.28 (0.97, 1.66) 14 17 0.80 (0.43, 1.34) ovary 38 43 0.87 (0.61, 1.20) 17 21 0.81 (0.46, 1.29) oesophagus 34 33 1.03 (0.71, 1.44) 4 13 0.30 (0.08, 0.76) cervix 22 20 1.14 (0.71, 1.70) 7 12 0.61 (0.24, 1.23) *statistically significant SIRs are highlighted in bold font

Common cancers Table 6. Observed cases in the MWHB and expected cases based on national rates observed cases expected cases SIR lwr 95%CI upr 95%CI all cancers (other than 9505 10654 0.89 0.88 0.91 non-melanoma skin) female breast 1299 1431 0.91 0.86 0.95 colorectal 1296 1511 0.86 0.81 0.90 lung 1067 1298 0.82 0.78 0.87 prostate 993 1220 0.81 0.77 0.86 lymphoma 379 414 0.92 0.83 1.00 leukaemia 346 303 1.14 0.99 1.27 bladder 332 379 0.88 0.79 0.96 stomach 313 389 0.80 0.72 0.88 pancreas 283 291 0.97 0.86 1.08 melanoma 277 338 0.82 0.73 0.91 ovary 262 268 0.98 0.86 1.10 oesophagus 208 249 0.83 0.73 0.94 cervix 121 143 0.85 0.71 0.98

10 For all cancers combined, and for all common cancers other than leukaemia, the incidence in the MWHB area was lower than the national average (Table 6). For most of the cancer types, the difference from the national average was statistically significant. Although the incidence of leukaemia in the MWHB area was higher than expected, this was not statistically significant. Almost all leukaemias are diagnosed in the elderly, often as a result of a routine blood test, and so variation in their incidence from area to area is mainly related to the amount of screening of the older population for the condition. Detailed analysis indicated that a small number of the 409 EDs in the Mid- West had a significant excess of cases of a single cancer type (Table 7); all others had either significantly fewer cases than expected or were not significantly different from average (Maps 6-17).

Maps 6-11. Incidence of common cancers in MWHB, by ED

11

12

Maps 12-16. Incidence of common cancers in MWHB, by ED

None of the EDs in the Askeaton Study areas had a significant excess for a single cancer site over the nine-year period, with the exception of lung cancer in Kildimo ED, which was significantly raised compared to Mid-West rates, but not compared to national rates.

13

Table 7. EDs with significantly raised cancer incidence relative to Midwest and National average cancer ED ED with significantly significantly raised high rate relative to relative to national Midwest average average colorectal 20002 Abbey B + + 16080 + 21049 Abington + 21050 Ballybricken + 21088 + 21136 Templebredon + 22049 Newport + 22080 Twomileborris + + lung 16066 + + 20004 Abbey D + 20007 Ballynanty + 20013 Custom House + 20019 Galvone A + + 20020 Galvone B + + 20029 Market + 20035 Shannon B + + 20036 Singland A + + 21029 + 21044 Knocklong + 21067 Patrick’s Well + + 21099 + 21120 Kildimo + 22061 Ballycahill + + 22068 Holycross + oesophagus No EDs significantly high stomach 22004 Thurles Urban + + 20026 Johns C + + 22049 Newport + 22057 Killea + + bladder 20014 Dock A + + 21017 Grange + + 21029 Bruree + + 21054 East + + 22031 Birdhill + 22071 Littleton + melanoma 20001 Abbey A + + 21042 Kilteely + + 20009 Castle B + 21091 Garryduff + 21123 Loghill + + pancreas 16037 Kilnamona + + 16090 + + 20036 Singland A + + 21056 Caherelly + + lymphoma 16092 Kilmurry + + 16103 Tullig + +

14 21056 Caherelly + 22042 Kilnaneave + +

Table 7. EDs with significantly raised cancer incidence relative to Midwest and National average (contd) cancer ED ED with significantly significantly raised high rate relative to relative to national Midwest average average leukaemia 16011 + + 16048 Ballyea + + 16083 Drumellihy + + 16129 Derrynagittagh + + 16136 Ogonelloe + + 20035 Shannon B + + 21038 Hospital + + 22063 Borrisoleigh + + 22074 Moyaliff + + 21005 + 22006 Ballingarry + breast 16047 Ballagh + + 16066 Ballynacally + + 20001 Abbey A + + 20010 Castle C + 22004 Thurles Urban + + 22015 Kilbarron + 22026 Ardcrony + + ovary 16091 + + 16111 + + 20023 Glentworth C + + 21005 Ballyagran + + 21062 Doon West + + 22061 Ballycahill + + 22062 Ballymurreen + + 22077 Rahelly + + prostate 22048 Rural + + 22080 Twomileborris + + 16075 Lisheen + 16135 + 16136 Ogonelloe + 20017 Dock D + 22003 Templemore + 22019 Rathcabban + 22062 Ballymurreen + cervix 16012 + + 20032 Rathbane + + 21005 Ballyagran + + 21031 Cahercorney + +

15 Conclusions

Cancer rates in the Mid-West area from 1994-2002 for all cancers combined, and for all of the major cancers other than leukaemia were significantly lower than the national average. Cancer incidence was higher in Limerick city than in rural areas of the Mid- West, but was lower than average in the area immediately surrounding the city. The incidence of cancers of the lung, bladder and oesophagus (all smoking-related cancers) was more than twice as high in the city as in its immediate environs. Although detailed analysis by cancer and ED showed a wide range of EDs with higher than expected cancer incidence, there was no geographical pattern to these differences (other than the urban rural differences discussed above). Cancer rates in 1994-2002 in Askeaton study Areas 1 were lower than the regional and national averages and in Area 2 were below the national average and equivalent to the regional level. In neither area was there any evidence that rates for a particular cancer were higher than would be expected. This analysis shows that: 1. there was no increased risk of cancer to residents of Askeaton or the surrounding areas over the period 1994-2002; 2. there was a significantly raised risk of cancer for some of the population of Limerick city particularly for those cancers where risk is largely attributable to smoking. Ongoing monitoring of cancer incidence is desirable for areas with significantly higher cancer registration rates. The decision by COMREG to introduce postcoding in Ireland should be expedited to enable ongoing monitoring of local cancer incidence Dr. T. Greally, Health Service Executive Dr H. Comber, National Cancer Registry of Ireland

16 Appendix 1. Allocation of EDs to “high” and “medium” risk areas Area 1 (“High Risk”) Area 2 (“Medium Risk”) ED number ED name ED number ED name 21118 Iveruss 21111 Ballynacarriga 21109 Aughinish 21126 Pallaskenry 21108 Askeaton West 21131 Shanid 21107 Askeaton East 21123 Loghill 21113 Craggs 21130 Shanagolden 21129 Riddlestown 21128 Rathkeale Urban 21125 Nantinan 21127 Rathkeale Rural 21122 Lismakeery 21114 Croagh 21121 Kilscannell 21120 Kildimo 21112 Castletown 21119 21115 Dromard 21110 Ballyallinan 21116 Dunmoylan East 21124 Mohernagh 21117 Dunmoylan West

17 Appendix 2. Electoral divisions in Limerick city and environs Limerick city electoral divisions ED Number ED Name 20001 Abbey A 20002 Abbey B 20003 Abbey C 20004 Abbey D 20005 Ballinacurra A 20006 Ballinacurra B 20007 Ballynanty 20008 Castle A 20009 Castle B 20010 Castle C 20011 Castle D 20012 Coolraine 20013 Custom House 20014 Dock A 20015 Dock B 20016 Dock C 20017 Dock D 20018 Farranshone 20019 Galvone A 20020 Galvone B 20021 Glentworth A 20022 Glentworth B 20023 Glentworth C 20024 John A 20025 John B 20026 John C 20027 A 20028 Killeely B 20029 Market 20030 Prospect A 20031 Prospect B 20032 Rathbane 20033 St Laurence 20034 Shannon A 20035 Shannon B 20036 Singland A 20037 Singland B

Limerick city environs electoral divisions 16106 Ballyglass (Co. Clare) 21051 Ballycummin 21052 Ballysimon 21065 Limerick North Rural 21066 Limerick South Rural 21068 Roxborough

18 Appendix 3. Cancer incidence by ED: all invasive cancers excluding non melanoma skin cancer SIR figures in blue are significantly below average; those in red are significantly above average (p=.05) Based on MWHB average rates Based on Irish average rates ED number observed expected SIR 95% confidence limits expected SIR 95% confidence limits cases cases of SIR cases of SIR ED name lower upper lower upper Clare No. 1 Urban 16001 62 58 1.07 0.81 1.36 65 0.95 0.72 1.21 Ennis No. 2 Urban 16002 42 52 0.79 0.57 1.07 59 0.71 0.51 0.96 Ennis No. 3 Urban 16003 15 20 0.74 0.40 1.20 23 0.66 0.35 1.07 Ennis No. 4 Urban 16004 56 58 0.96 0.72 1.24 65 0.85 0.64 1.10 Urban 16005 109 101 1.07 0.88 1.29 114 0.95 0.78 1.15 Abbey 16006 4 13 0.33 0.08 0.79 15 0.29 0.07 0.70 16007 2 4 0.53 0.06 1.80 5 0.47 0.05 1.60 Castletown 16008 0 3 0.00 0.00 1.46 3 0.00 0.00 1.30 Derreen 16009 4 6 0.68 0.17 1.64 7 0.61 0.16 1.46 16010 14 15 0.92 0.48 1.52 17 0.82 0.43 1.36 Gleninagh 16011 5 4 1.40 0.43 3.06 4 1.25 0.38 2.74 Lisdoonvarna 16012 36 40 0.91 0.64 1.26 45 0.81 0.57 1.12 Mountelva 16013 3 5 0.71 0.14 1.95 5 0.63 0.12 1.72 16014 3 5 0.70 0.14 1.92 5 0.62 0.12 1.71 16015 5 5 1.08 0.33 2.37 6 0.96 0.29 2.10 16016 2 3 0.65 0.07 2.21 4 0.58 0.07 1.98 Boston 16018 13 8 1.58 0.81 2.67 9 1.41 0.72 2.38 Corrofin 16019 29 32 0.89 0.59 1.27 36 0.79 0.52 1.13 Ballyeighter/Glenroe 16017/16020 2 5 0.40 0.05 1.36 6 0.36 0.04 1.21 Killinaboy 16021 9 10 0.84 0.37 1.62 11 0.75 0.33 1.45 16022 4 8 0.54 0.14 1.29 9 0.48 0.12 1.15 Muckanagh 16023 14 10 1.33 0.70 2.19 12 1.18 0.62 1.94 Rath 16024 11 11 1.00 0.48 1.79 12 0.89 0.43 1.59 Ruan 16025 18 16 1.13 0.66 1.77 18 1.01 0.59 1.58 16026 66 58 1.14 0.88 1.45 65 1.02 0.79 1.30 Clenagh 16027 157 164 0.95 0.81 1.11 182 0.86 0.73 1.01 16028 9 14 0.60 0.27 1.17 16 0.54 0.24 1.04 Doora (part) * 16029 25 27 0.91 0.58 1.34 30 0.81 0.52 1.20 Drumline 16030 22 22 1.02 0.63 1.52 24 0.92 0.57 1.37 Dysert 16031 9 10 0.87 0.38 1.67 11 0.77 0.34 1.49 Ennis Rural (part) * 16032 275 308 0.89 0.79 1.00 345 0.79 0.70 0.89 Furroor 16033 5 9 0.62 0.19 1.36 10 0.55 0.17 1.21

19 Kilcloher 16034 7 17 0.44 0.17 0.86 19 0.40 0.15 0.77 Based on MWHB average rates Based on Irish average rates ED number observed expected SIR 95% confidence limits expected SIR 95% confidence limits cases cases of SIR cases of SIR ED name lower upper lower upper Killanniv 16035 17 17 1.01 0.58 1.61 19 0.90 0.52 1.43 16036 7 12 0.65 0.24 1.25 13 0.58 0.22 1.12 Kilnamona 16037 30 19 1.58 1.05 2.24 21 1.41 0.94 2.00 16038 9 8 1.05 0.47 2.03 9 0.94 0.42 1.81 Kinturk 16039 5 10 0.51 0.16 1.12 12 0.45 0.14 0.99 Newmarket 16040 42 62 0.68 0.48 0.91 69 0.60 0.43 0.81 16041 31 34 0.92 0.62 1.29 37 0.83 0.55 1.16 Spancelhill (part) * 16042 4 12 0.35 0.09 0.83 14 0.31 0.08 0.74 16043 20 24 0.86 0.52 1.31 26 0.77 0.47 1.18 16044 7 13 0.58 0.22 1.12 14 0.52 0.20 1.00 Urlan 16045 27 41 0.64 0.42 0.93 47 0.56 0.37 0.82 Annagh 16046 19 17 1.12 0.67 1.73 19 0.99 0.59 1.54 Ballagh 16047 9 8 1.06 0.47 2.05 9 0.94 0.42 1.82 Ballyea 16048 27 20 1.35 0.88 1.96 22 1.20 0.78 1.74 Ballysteen 16049 15 14 1.09 0.59 1.77 15 0.97 0.52 1.57 Ballyvaskin 16050 4 11 0.39 0.10 0.93 12 0.34 0.09 0.82 Cloghaun 16051 5 7 0.71 0.22 1.56 8 0.63 0.19 1.39 16052 6 13 0.49 0.17 0.99 15 0.43 0.15 0.88 Clooney 16053 4 8 0.51 0.13 1.22 9 0.45 0.11 1.08 Ennistimon 16054 76 80 0.94 0.74 1.18 90 0.84 0.66 1.05 Formoyle 16055 6 7 0.89 0.31 1.82 8 0.79 0.27 1.62 16056 12 15 0.80 0.40 1.39 16 0.71 0.36 1.24 16057 10 8 1.14 0.53 2.10 9 1.01 0.47 1.87 16058 17 18 0.93 0.54 1.49 20 0.83 0.48 1.33 Kilshanny 16059 10 4 2.21 1.03 4.09 5 1.97 0.91 3.64 16060 10 18 0.54 0.25 1.00 20 0.48 0.22 0.89 Lurraga 16061 1 7 0.15 0.00 0.77 8 0.13 0.00 0.69 Magherareagh 16062 9 11 0.77 0.34 1.48 13 0.68 0.30 1.31 16063 54 56 0.95 0.71 1.23 63 0.84 0.63 1.10 Moy 16064 15 21 0.73 0.39 1.17 23 0.65 0.35 1.05 Smithstown 16065 6 6 1.09 0.37 2.22 7 0.97 0.33 1.97 Ballynacally 16066 13 7 1.76 0.90 2.96 8 1.56 0.80 2.64 16067 2 12 0.17 0.02 0.59 14 0.16 0.02 0.53 16068 9 10 0.86 0.38 1.66 11 0.77 0.34 1.48 16069 12 13 0.90 0.45 1.56 15 0.80 0.40 1.39 Kilfiddane 16070 19 15 1.27 0.75 1.96 17 1.12 0.67 1.74 Killadysert 16071 19 26 0.73 0.44 1.14 29 0.65 0.39 1.01 16072 16 14 1.16 0.63 1.83 16 1.03 0.56 1.63

20 Based on MWHB average rates Based on Irish average rates ED number observed expected SIR 95% confidence limits expected SIR 95% confidence limits cases cases of SIR cases of SIR ED name lower upper lower upper Kilmurry 16073 10 13 0.73 0.34 1.35 15 0.65 0.30 1.20 Liscasey 16074 11 15 0.71 0.34 1.26 17 0.63 0.30 1.12 Lisheen 16075 16 13 1.19 0.65 1.88 15 1.06 0.58 1.68 Rinealon 16076 11 8 1.28 0.62 2.29 9 1.14 0.55 2.04 Cahermurphy 16077 9 10 0.85 0.38 1.64 11 0.75 0.33 1.45 Cloonadrum 16078 15 16 0.95 0.51 1.54 18 0.84 0.45 1.36 Clooncoorha 16079 7 14 0.54 0.20 1.05 15 0.48 0.18 0.94 Cooraclare 16080 25 19 1.27 0.82 1.88 22 1.13 0.73 1.68 Creegh 16081 21 17 1.27 0.78 1.92 19 1.13 0.69 1.70 16082 24 25 0.95 0.59 1.40 28 0.85 0.53 1.25 Drumellihy 16083 19 17 1.15 0.68 1.77 19 1.02 0.61 1.58 Einagh 16084 14 10 1.37 0.72 2.26 11 1.22 0.64 2.01 Glenmore 16085 11 15 0.69 0.33 1.24 17 0.62 0.30 1.10 16086 13 13 0.97 0.50 1.64 15 0.86 0.44 1.45 Kilfearagh 16087 10 11 0.90 0.42 1.66 12 0.80 0.37 1.47 16088 52 51 1.01 0.75 1.32 58 0.90 0.67 1.18 Killard 16089 11 11 0.93 0.45 1.67 13 0.83 0.40 1.48 Killimer 16090 16 18 0.89 0.49 1.41 20 0.79 0.43 1.26 Kilmihil 16091 28 21 1.34 0.88 1.93 23 1.19 0.78 1.72 Kilmurry 16092 20 25 0.82 0.49 1.24 28 0.73 0.44 1.11 Kilrush Rural 16093 18 18 0.98 0.58 1.55 21 0.88 0.52 1.38 Knock 16094 12 13 0.92 0.46 1.59 14 0.81 0.40 1.41 Knocknaboley 16095 13 13 0.97 0.50 1.64 15 0.86 0.44 1.46 Knocknagore 16096 11 10 1.06 0.51 1.90 11 0.94 0.45 1.68 Moveen 16097 6 3 1.89 0.65 3.87 4 1.68 0.58 3.43 16098 10 11 0.84 0.39 1.55 13 0.74 0.35 1.37 Mullagh 16099 9 10 0.89 0.39 1.71 11 0.79 0.35 1.53 Querrin 16100 10 8 1.25 0.58 2.31 9 1.11 0.52 2.05 Rahona 16101 17 15 1.15 0.67 1.83 17 1.02 0.59 1.63 St. Martin's 16102 3 4 0.82 0.16 2.26 4 0.73 0.14 2.00 Tullig 16103 3 5 0.65 0.13 1.78 6 0.58 0.11 1.58 Tullycreen 16104 5 5 1.00 0.31 2.20 6 0.89 0.27 1.95 16105 12 14 0.82 0.41 1.43 16 0.74 0.37 1.29 Ballyglass 16106 51 89 0.57 0.42 0.75 99 0.51 0.38 0.67 Cappavilla 16107 6 7 0.96 0.33 1.97 7 0.87 0.30 1.77 Castlecrine 16108 9 7 1.22 0.54 2.34 8 1.09 0.48 2.09 Cloghera 16109 9 12 0.74 0.33 1.42 13 0.66 0.29 1.27 Cloontra 16110 2 6 0.38 0.04 1.30 6 0.34 0.04 1.15 Based on MWHB average rates Based on Irish average rates

21 ED number observed expected SIR 95% confidence limits expected SIR 95% confidence limits cases cases of SIR cases of SIR ED name lower upper lower upper Cratloe 16111 40 34 1.15 0.81 1.55 38 1.03 0.72 1.39 Fahymore 16112 5 7 0.74 0.23 1.62 8 0.66 0.20 1.45 Killeely 16113 10 16 0.59 0.27 1.09 18 0.53 0.25 0.98 16114 3 4 0.82 0.16 2.24 4 0.73 0.14 2.00 16115 12 15 0.79 0.39 1.36 17 0.70 0.35 1.22 16116 20 29 0.70 0.42 1.07 32 0.63 0.38 0.96 Lackareagh 16117 2 3 0.73 0.08 2.46 3 0.64 0.07 2.18 Mountievers 16118 25 17 1.40 0.90 2.08 20 1.26 0.81 1.86 O'briensbridge 16119 12 13 0.94 0.47 1.62 14 0.84 0.42 1.45 Ayle 16120 9 9 0.93 0.41 1.78 10 0.83 0.37 1.59 Boherglass 16121 16 7 2.30 1.26 3.65 8 2.04 1.12 3.24 Caherhurley 16122 2 5 0.47 0.05 1.59 5 0.42 0.05 1.42 Cahermurphy 16123 0 2 0.00 0.00 1.96 2 0.00 0.00 1.76 Cappaghabaun 16124 2 4 0.50 0.06 1.71 5 0.45 0.05 1.52 Carrowbaun 16125 3 3 0.94 0.18 2.57 4 0.84 0.16 2.31 Cloonusker 16126 6 7 0.91 0.31 1.85 8 0.81 0.28 1.65 Coolreagh 16127 7 6 1.17 0.44 2.27 7 1.04 0.39 2.01 Corlea 16128 1 4 0.24 0.01 1.25 5 0.21 0.01 1.12 Derrynagittagh 16129 4 4 1.03 0.26 2.48 5 0.92 0.24 2.22 Drummaan 16130 21 20 1.05 0.64 1.58 23 0.93 0.57 1.40 16131 13 11 1.14 0.58 1.92 13 1.01 0.52 1.71 North 16132 Inishcaltra South 16133 Inishcaltra North/Inishcaltra South 16132/16133 9 8 1.06 0.47 2.04 9 0.95 0.42 1.82 Killaloe 16134 51 50 1.03 0.76 1.34 56 0.91 0.68 1.20 Mountshannon 16135 14 9 1.52 0.80 2.51 10 1.36 0.71 2.24 16136 20 16 1.27 0.76 1.93 18 1.13 0.68 1.73 16137 36 49 0.75 0.52 1.03 55 0.66 0.46 0.91 Ballyblood 16138 1 4 0.26 0.01 1.38 5 0.24 0.01 1.23 Ballynahinch 16139 4 10 0.43 0.11 1.04 11 0.38 0.10 0.92 Caher 16140 4 8 0.55 0.14 1.31 9 0.48 0.12 1.16 Clooney 16141 10 10 0.99 0.46 1.83 11 0.88 0.41 1.63 Dangan 16142 3 5 0.62 0.12 1.71 6 0.55 0.11 1.52 Glendree 16143 7 6 1.27 0.48 2.46 7 1.13 0.43 2.19 16144 24 18 1.27 0.79 1.87 21 1.14 0.71 1.67 16145 9 8 1.03 0.45 1.97 9 0.91 0.40 1.76 16146 6 15 0.43 0.15 0.89 17 0.38 0.13 0.78 Kiltannon 16147 0 5 0.00 0.00 0.80 5 0.00 0.00 0.71 Based on MWHB average rates Based on Irish average rates ED number observed expected SIR 95% confidence limits expected SIR 95% confidence limits

22 cases cases of SIR cases of SIR ED name lower upper lower upper Kyle 16148 16 9 1.83 1.01 2.91 10 1.63 0.90 2.59 Loughea 16149 4 3 1.22 0.31 2.94 4 1.09 0.28 2.62 Newgrove 16150 3 8 0.41 0.08 1.12 9 0.36 0.07 0.99 Quin 16151 17 20 0.87 0.50 1.39 22 0.78 0.45 1.24 Rathclooney 16152 2 5 0.42 0.05 1.41 6 0.37 0.04 1.25 Rossroe 16153 7 12 0.63 0.24 1.22 13 0.57 0.21 1.09 Toberbreeda 16154 1 4 0.24 0.01 1.26 5 0.21 0.01 1.11 16155 22 25 0.88 0.54 1.31 29 0.78 0.48 1.16

23

Based on MWHB average rates Based on Irish average rates ED number observed expected SIR 95% confidence limits expected SIR 95% confidence limits cases cases of SIR cases of SIR ED name lower upper lower upper Limerick urban area Abbey A 20001 113 101 1.12 0.92 1.34 113 1.00 0.82 1.20 Abbey B 20002 42 25 1.64 1.18 2.22 28 1.47 1.06 1.99 Abbey C 20003 17 17 0.99 0.57 1.59 19 0.88 0.50 1.41 Abbey D 20004 72 68 1.06 0.83 1.33 76 0.94 0.73 1.18 Ballinacurra A 20005 46 49 0.94 0.68 1.25 55 0.84 0.61 1.11 Ballinacurra B 20006 84 57 1.49 1.18 1.84 63 1.33 1.06 1.64 Ballynanty 20007 111 77 1.44 1.18 1.73 86 1.29 1.06 1.55 Castle A 20008 47 43 1.08 0.79 1.43 48 0.96 0.70 1.28 Castle B 20009 31 23 1.36 0.92 1.92 26 1.20 0.81 1.70 Castle C 20010 46 37 1.22 0.89 1.63 42 1.09 0.79 1.45 Castle D 20011 83 80 1.04 0.83 1.29 89 0.93 0.74 1.15 Coolraine 20012 65 72 0.89 0.68 1.13 81 0.80 0.61 1.01 Custom House 20013 16 10 1.62 0.91 2.64 11 1.45 0.82 2.37 Dock A 20014 23 20 1.17 0.73 1.74 22 1.04 0.65 1.54 Dock B 20015 39 28 1.38 0.96 1.87 32 1.22 0.85 1.65 Dock C 20016 51 42 1.21 0.89 1.58 48 1.07 0.79 1.40 Dock D 20017 27 26 1.05 0.69 1.53 29 0.93 0.61 1.35 Farranshone 20018 56 82 0.69 0.52 0.89 93 0.60 0.46 0.78 Galvone A 20019 52 41 1.27 0.94 1.66 45 1.15 0.85 1.49 Galvone B 20020 45 33 1.35 0.98 1.80 36 1.23 0.89 1.64 Glentworth A 20021 32 21 1.50 1.02 2.10 24 1.33 0.91 1.87 Glentworth B 20022 57 53 1.08 0.82 1.39 59 0.96 0.73 1.24 Glentworth C 20023 27 21 1.30 0.85 1.88 23 1.15 0.76 1.68 John's A 20024 43 33 1.30 0.94 1.75 36 1.17 0.84 1.58 John's B 20025 65 47 1.38 1.05 1.75 53 1.22 0.93 1.55 John's C 20026 15 9 1.62 0.89 2.68 10 1.44 0.80 2.39 Killeely A 20027 50 39 1.29 0.95 1.69 43 1.16 0.85 1.51 Killeely B 20028 29 30 0.97 0.65 1.39 34 0.87 0.58 1.24 Market 20029 31 29 1.06 0.72 1.50 33 0.94 0.64 1.33 Prospect A 20030 29 32 0.91 0.61 1.31 36 0.81 0.54 1.17 Prospect B 20031 46 30 1.53 1.11 2.03 33 1.37 0.99 1.82 Rathbane 20032 54 44 1.23 0.92 1.60 49 1.11 0.83 1.44 St. Laurence 20033 33 39 0.84 0.58 1.18 44 0.75 0.52 1.05 Shannon A 20034 1 4 0.29 0.01 1.57 4 0.26 0.01 1.40 Shannon B 20035 21 16 1.32 0.80 2.00 18 1.18 0.72 1.79 Singland A 20036 71 61 1.17 0.91 1.47 68 1.04 0.81 1.31 Singland B 20037 62 57 1.10 0.84 1.40 63 0.99 0.76 1.27

24

Based on MWHB average rates Based on Irish average rates ED number observed expected SIR 95% confidence limits expected SIR 95% confidence limits cases cases of SIR cases of SIR ED name lower upper lower upper Limerick county Abbeyville 21001 8 6 1.29 0.53 2.44 7 1.15 0.48 2.18 North 21002 14 15 0.91 0.49 1.54 17 0.81 0.44 1.38 Adare South 21003 61 58 1.06 0.80 1.35 65 0.94 0.72 1.21 Ballingarry 21004 28 22 1.25 0.83 1.81 25 1.12 0.74 1.61 Ballyagran 21005 25 20 1.27 0.81 1.85 22 1.13 0.71 1.65 Ballygrennan 21006 9 9 1.01 0.44 1.84 10 0.90 0.40 1.64 Ballynabanoge 21007 7 10 0.75 0.29 1.49 11 0.67 0.26 1.33 Ballynoe 21008 11 14 0.84 0.40 1.44 15 0.75 0.36 1.29 Castletown 21009 18 13 1.34 0.78 2.12 15 1.20 0.70 1.89 Coolrus 21010 8 11 0.75 0.31 1.42 12 0.67 0.28 1.27 Crean 21011 6 12 0.54 0.19 1.12 13 0.48 0.17 1.00 Crecora 21012 18 9 1.93 1.12 3.04 10 1.73 1.01 2.73 Croom 21013 46 46 1.00 0.73 1.33 51 0.89 0.65 1.18 Dunnaman 21014 10 13 0.79 0.37 1.40 15 0.71 0.33 1.26 21015 11 28 0.40 0.19 0.69 32 0.36 0.17 0.62 Garrane 21016 7 7 0.97 0.38 1.93 8 0.87 0.34 1.72 Grange 21017 19 13 1.39 0.82 2.16 15 1.24 0.73 1.93 Kilfinny 21018 7 8 0.96 0.37 1.90 9 0.85 0.33 1.69 Kilpeacon 21019 5 11 0.47 0.15 1.05 12 0.42 0.13 0.94 Rathmore 21020 8 8 1.06 0.44 2.02 9 0.95 0.39 1.80 Fleanmore 21021 2 6 0.33 0.04 1.14 7 0.29 0.03 1.02 Glin 21022 41 41 1.00 0.71 1.35 46 0.89 0.64 1.21 Kilfergus 21023 11 17 0.66 0.32 1.13 20 0.59 0.28 1.01 Kilmoylan 21024 19 20 0.95 0.56 1.48 22 0.84 0.50 1.31 21025 15 12 1.25 0.69 2.08 13 1.12 0.62 1.86 21026 18 11 1.58 0.92 2.50 13 1.41 0.82 2.23 Ballymacshaneboy 21027 16 14 1.13 0.64 1.84 16 1.00 0.57 1.63 21028 51 39 1.30 0.95 1.69 44 1.15 0.85 1.50 Bruree 21029 36 26 1.41 0.98 1.93 29 1.26 0.87 1.73 Bulgaden 21030 7 9 0.78 0.30 1.54 11 0.69 0.27 1.37 Cahercorney 21031 16 16 0.96 0.54 1.56 18 0.86 0.48 1.40 Colmanswell 21032 7 15 0.49 0.19 0.97 17 0.44 0.17 0.86 Darragh 21033 9 11 0.86 0.38 1.58 12 0.77 0.34 1.41 Dromin 21034 12 15 0.84 0.42 1.41 17 0.75 0.37 1.26

25 Based on MWHB average rates Based on Irish average rates ED number observed expected SIR 95% confidence limits expected SIR 95% confidence limits cases cases of SIR cases of SIR ED name lower upper lower upper Emlygrennan 21035 23 20 1.16 0.72 1.72 22 1.03 0.64 1.54 Glenbrohane 21036 15 15 0.96 0.53 1.58 17 0.85 0.47 1.41 Griston 21037 9 9 1.02 0.45 1.86 10 0.91 0.40 1.65 Hospital 21038 46 36 1.27 0.93 1.69 40 1.14 0.83 1.51 Kilfinnane 21039 36 36 1.01 0.70 1.38 40 0.90 0.62 1.23 Kilflyn 21040 7 8 0.96 0.37 1.91 8 0.86 0.33 1.70 21041 69 62 1.11 0.86 1.40 69 0.99 0.77 1.25 Kilteely 21042 21 15 1.41 0.86 2.14 16 1.26 0.76 1.91 Knockainy 21043 24 21 1.15 0.72 1.69 23 1.03 0.64 1.51 Knocklong 21044 37 24 1.58 1.10 2.15 27 1.41 0.98 1.92 Particles 21045 7 7 1.03 0.40 2.05 8 0.92 0.35 1.82 Rockhill 21046 11 11 1.04 0.50 1.79 12 0.92 0.44 1.59 Tobernea 21047 19 18 1.07 0.63 1.66 20 0.96 0.56 1.48 Uregare 21048 23 18 1.25 0.78 1.86 20 1.12 0.69 1.66 Abington 21049 28 19 1.46 0.97 2.11 21 1.31 0.87 1.88 Ballybricken 21050 36 35 1.05 0.73 1.44 39 0.94 0.65 1.28 Ballycummin 21051 210 233 0.90 0.78 1.03 260 0.81 0.70 0.92 Ballysimon 21052 126 145 0.87 0.72 1.03 162 0.77 0.64 0.92 Ballyvarra 21053 76 62 1.22 0.96 1.52 69 1.10 0.86 1.37 Caherconlish East 21054 19 14 1.30 0.77 2.01 16 1.15 0.68 1.79 Caherconlish West 21055 25 34 0.72 0.46 1.05 39 0.65 0.41 0.94 Caherelly 21056 9 6 1.51 0.67 2.76 7 1.35 0.59 2.47 21057 46 37 1.25 0.91 1.66 41 1.12 0.81 1.49 Carrig 21058 18 13 1.31 0.76 2.07 15 1.18 0.69 1.85 21059 70 66 1.05 0.81 1.32 74 0.94 0.73 1.19 Clarina 21060 42 38 1.09 0.78 1.48 43 0.98 0.70 1.32 Clonkeen 21061 14 14 0.95 0.51 1.61 16 0.85 0.46 1.43 Doon West 21062 7 7 1.03 0.40 2.04 8 0.92 0.36 1.82 Glenstal 21063 21 21 0.98 0.60 1.49 24 0.88 0.53 1.33 Kilmurry 21064 24 24 0.98 0.61 1.43 27 0.87 0.55 1.28 Limerick North Rural 21065 112 125 0.90 0.74 1.08 139 0.81 0.67 0.97 Limerick South Rural 21066 18 22 0.82 0.48 1.29 24 0.73 0.42 1.15 Patrick’s Well 21067 49 36 1.37 1.01 1.81 40 1.24 0.91 1.62 Roxborough 21068 49 38 1.29 0.94 1.69 42 1.15 0.85 1.52 Anglesborough 21069 14 12 1.08 0.58 1.83 14 0.97 0.52 1.64 21070 16 19 0.84 0.47 1.36 21 0.75 0.42 1.21 Cullane 21071 16 10 1.49 0.84 2.43 12 1.33 0.75 2.17 Duntryleague 21072 12 12 1.08 0.54 1.81 13 0.96 0.48 1.61 Based on MWHB average rates Based on Irish average rates

26 ED number observed expected SIR 95% confidence limits expected SIR 95% confidence limits cases cases of SIR cases of SIR ED name lower upper lower upper Galbally 21073 17 16 1.02 0.58 1.62 18 0.91 0.52 1.45 Kilbeheny 21074 1 7 0.15 0.00 0.78 8 0.13 0.00 0.70 Kilglass 21075 0 7 0.00 0.00 0.52 8 0.00 0.00 0.47 Knocknascrow 21076 1 5 0.19 0.00 1.04 6 0.17 0.00 0.92 Riversdale 21077 3 7 0.43 0.08 1.20 8 0.38 0.07 1.06 21078 69 66 1.04 0.81 1.31 74 0.92 0.72 1.17 Ardagh 21079 26 29 0.90 0.57 1.30 32 0.80 0.51 1.16 Ballintober 21080 22 12 1.83 1.12 2.74 13 1.63 1.00 2.44 Ballynoe West 21081 2 9 0.23 0.03 0.80 10 0.21 0.02 0.72 Boola 21082 5 7 0.72 0.23 1.62 8 0.64 0.20 1.43 Broadford 21083 20 28 0.71 0.42 1.09 31 0.63 0.38 0.97 Caher 21084 16 11 1.41 0.79 2.29 12 1.25 0.70 2.04 Cleanglass 21085 10 11 0.97 0.45 1.72 12 0.87 0.40 1.53 Cloncagh 21086 9 9 1.08 0.47 1.97 10 0.96 0.42 1.76 Danganbeg 21087 16 12 1.26 0.71 2.05 14 1.13 0.63 1.84 Dromcolliher 21088 36 36 1.00 0.69 1.37 41 0.89 0.61 1.21 Dromtrasna 21089 24 25 0.96 0.60 1.41 28 0.85 0.53 1.25 Feenagh 21090 9 14 0.66 0.29 1.21 16 0.58 0.26 1.07 Garryduff 21091 9 7 1.25 0.55 2.28 8 1.12 0.49 2.05 Glenagower 21092 17 15 1.12 0.64 1.79 17 1.00 0.57 1.60 Glengort 21093 25 26 0.96 0.61 1.40 29 0.86 0.54 1.25 Glensharrold 21094 14 13 1.04 0.56 1.76 15 0.93 0.50 1.57 21095 19 13 1.46 0.86 2.27 14 1.30 0.77 2.02 21096 17 15 1.12 0.64 1.80 17 1.00 0.57 1.60 21097 12 13 0.93 0.46 1.56 15 0.83 0.41 1.39 Monagay 21098 24 30 0.80 0.50 1.18 33 0.71 0.45 1.05 Mountcollins 21099 28 19 1.49 0.99 2.14 21 1.32 0.88 1.90 Mountplummer 21100 9 11 0.83 0.37 1.53 13 0.74 0.33 1.35 Newcastle Rural 21101 31 33 0.93 0.63 1.31 37 0.83 0.56 1.18 Newcastle Urban 21102 111 119 0.93 0.77 1.12 134 0.83 0.68 1.00 Port 21103 16 15 1.04 0.58 1.69 17 0.92 0.52 1.50 Rathronan 21104 31 33 0.95 0.64 1.34 37 0.84 0.57 1.19 Rooskagh 21105 5 8 0.63 0.20 1.42 9 0.57 0.18 1.27 Templeglentan 21106 27 27 1.00 0.66 1.46 30 0.89 0.59 1.30 Askeaton East 21107 26 24 1.08 0.69 1.56 27 0.96 0.61 1.39 Askeaton West 21108 21 22 0.96 0.58 1.46 24 0.86 0.52 1.31 Aughinish 21109 6 6 1.11 0.39 2.32 6 0.99 0.35 2.07 Ballyallinan 21110 18 13 1.39 0.81 2.19 14 1.24 0.72 1.95 Based on MWHB average rates Based on Irish average rates ED number observed expected SIR 95% confidence limits expected SIR 95% confidence limits

27 cases cases of SIR cases of SIR ED name lower upper lower upper Ballynacarriga 21111 16 17 0.94 0.53 1.52 19 0.84 0.47 1.36 Castletown 21112 12 11 1.10 0.55 1.85 13 0.98 0.49 1.65 Craggs 21113 7 8 0.94 0.36 1.86 9 0.84 0.32 1.66 Croagh 21114 23 21 1.08 0.67 1.60 24 0.96 0.60 1.42 Dromard 21115 12 17 0.74 0.37 1.25 19 0.66 0.33 1.11 Dunmoylan East 21116 15 14 1.01 0.56 1.67 16 0.90 0.50 1.49 Dunmoylan West 21117 2 3 0.64 0.07 2.22 4 0.57 0.07 1.97 Iveruss 21118 10 11 0.91 0.42 1.62 13 0.81 0.37 1.43 Kilcornan 21119 18 19 0.95 0.55 1.50 21 0.85 0.49 1.34 Kildimo 21120 16 15 1.06 0.60 1.73 16 0.95 0.54 1.55 Kilscannell 21121 15 19 0.77 0.43 1.28 21 0.69 0.38 1.14 Lismakeery 21122 7 12 0.59 0.23 1.18 14 0.53 0.20 1.05 Loghill 21123 20 21 0.94 0.56 1.44 24 0.84 0.50 1.29 Mohernagh 21124 4 5 0.92 0.24 2.27 5 0.82 0.21 2.02 Nantinan 21125 16 19 0.84 0.47 1.37 21 0.75 0.42 1.22 Pallaskenry 21126 28 23 1.23 0.82 1.78 25 1.10 0.73 1.59 Rathkeale Rural 21127 10 10 1.03 0.47 1.82 11 0.92 0.42 1.62 Rathkeale Urban 21128 48 45 1.06 0.78 1.40 50 0.95 0.69 1.25 Riddlestown 21129 16 13 1.19 0.67 1.94 15 1.07 0.60 1.74 Shanagolden 21130 34 32 1.08 0.74 1.49 36 0.96 0.66 1.33 Shanid 21131 15 16 0.93 0.52 1.55 17 0.83 0.46 1.38 Bilboa 21132 15 12 1.24 0.68 2.05 13 1.10 0.61 1.82 Doon South 21133 47 40 1.17 0.86 1.55 45 1.04 0.76 1.38 Grean 21134 39 41 0.93 0.65 1.26 46 0.83 0.58 1.12 21135 39 34 1.12 0.78 1.52 38 1.00 0.70 1.36 Templebredon 21136 14 15 0.88 0.48 1.50 17 0.79 0.42 1.33

28

Based on MWHB average rates Based on Irish average rates ED number observed expected SIR 95% confidence limits expected SIR 95% confidence limits cases cases of SIR cases of SIR ED name lower upper lower upper Tipperary North Nenagh East Urban 22001 66 70 0.94 0.73 1.20 79 0.84 0.65 1.07 Nenagh West Urban 22002 97 113 0.86 0.70 1.05 127 0.77 0.62 0.93 Templemore 22003 82 68 1.21 0.96 1.49 77 1.07 0.85 1.33 Thurles Urban 22004 276 236 1.17 1.03 1.31 266 1.04 0.92 1.17 Aglishcloghane 22005 10 10 1.03 0.49 1.89 11 0.92 0.44 1.69 Ballingarry 22006 18 18 1.02 0.60 1.60 20 0.91 0.54 1.43 Ballylusky 22007 9 10 0.92 0.42 1.75 11 0.83 0.38 1.57 22008 41 43 0.97 0.69 1.31 48 0.86 0.61 1.16 Carrig 22009 0 6 0.00 0.00 0.58 7 0.00 0.00 0.52 Cloghjordan 22010 49 30 1.65 1.22 2.17 33 1.47 1.08 1.93 Cloghprior 22011 4 9 0.45 0.12 1.14 10 0.40 0.11 1.02 Clohaskin 22012 2 8 0.25 0.03 0.90 9 0.22 0.03 0.80 Finnoe 22013 3 6 0.47 0.10 1.37 7 0.42 0.09 1.22 Graigue 22014 11 12 0.96 0.48 1.70 13 0.84 0.42 1.50 Kilbarron 22015 25 21 1.19 0.77 1.76 24 1.06 0.69 1.56 East 22016 8 13 0.63 0.27 1.24 14 0.56 0.24 1.11 Lorrha West 22017 6 12 0.49 0.18 1.07 14 0.44 0.16 0.95 Mertonhall 22018 3 5 0.59 0.12 1.72 6 0.53 0.11 1.54 Rathcabban 22019 14 8 1.84 1.00 3.08 9 1.64 0.89 2.74 Redwood 22020 5 7 0.72 0.23 1.68 8 0.64 0.21 1.49 Riverstown 22021 1 13 0.08 0.00 0.44 14 0.07 0.00 0.39 22022 19 18 1.05 0.63 1.63 21 0.93 0.56 1.45 Uskane 22023 7 8 0.91 0.36 1.87 9 0.81 0.32 1.66 Abington 22024 15 16 0.92 0.51 1.51 18 0.82 0.46 1.35 Aghnameadle 22025 6 8 0.76 0.28 1.64 9 0.67 0.25 1.46 Ardcrony 22026 19 14 1.36 0.82 2.12 16 1.22 0.73 1.89 Ballina 22027 19 33 0.58 0.35 0.90 37 0.52 0.31 0.80 Ballygibbon 22028 17 15 1.14 0.66 1.82 17 1.02 0.59 1.63 Ballymackey 22029 13 15 0.88 0.47 1.50 17 0.78 0.42 1.34 Ballynaclogh 22030 10 16 0.64 0.31 1.17 18 0.57 0.27 1.05 Birdhill 22031 16 17 0.93 0.53 1.50 19 0.83 0.47 1.34 Burgesbeg 22032 13 12 1.09 0.58 1.86 13 0.97 0.52 1.66 Carrigatogher 22033 27 23 1.19 0.78 1.72 26 1.05 0.69 1.53 Castletown 22034 30 34 0.88 0.60 1.26 38 0.79 0.53 1.12 Derrycastle 22035 9 7 1.21 0.55 2.28 8 1.08 0.49 2.05 Dolla 22036 15 10 1.58 0.88 2.59 11 1.40 0.78 2.30 Greenhall 22037 Based on MWHB average rates Based on Irish average rates

29 ED number observed expected SIR 95% confidence limits expected SIR 95% confidence limits cases cases of SIR cases of SIR ED name lower upper lower upper Kilcomenty 22038 6 16 0.38 0.14 0.82 18 0.34 0.12 0.73 Kilkeary 22039 9 14 0.63 0.29 1.20 16 0.57 0.26 1.07 Killoscully 22040 5 8 0.63 0.20 1.46 9 0.56 0.18 1.31 Kilmore 22041 19 20 0.95 0.57 1.48 23 0.85 0.51 1.32 Kilnaneave 22042 17 13 1.34 0.78 2.15 14 1.20 0.70 1.92 Kilnarath 22043 7 9 0.75 0.30 1.54 11 0.67 0.27 1.37 Knigh 22044 9 18 0.51 0.23 0.96 20 0.45 0.21 0.86 Lackagh 22045 Greenhall/Lackagh 22037/22045 7 9 0.80 0.32 1.64 10 0.72 0.29 1.47 Latteragh 22046 19 19 0.99 0.59 1.54 22 0.88 0.53 1.37 Monsea 22047 12 17 0.70 0.36 1.23 19 0.63 0.32 1.09 Nenagh Rural 22048 51 43 1.19 0.88 1.56 48 1.06 0.79 1.39 Newport 22049 62 48 1.30 1.00 1.66 54 1.16 0.89 1.48 Templederry 22050 3 8 0.40 0.08 1.17 8 0.36 0.07 1.04 Youghalarra 22051 15 19 0.79 0.44 1.30 21 0.71 0.40 1.16 Borrisnafarney 22052 3 8 0.38 0.08 1.09 9 0.33 0.07 0.98 Borrisnoe 22053 2 3 0.59 0.07 2.11 4 0.52 0.06 1.87 Bourney East 22054 7 9 0.75 0.30 1.53 11 0.67 0.27 1.37 Bourney West 22055 13 12 1.10 0.59 1.88 13 0.99 0.52 1.68 Killavinoge 22056 13 13 1.00 0.53 1.70 15 0.89 0.47 1.52 Killea 22057 14 12 1.15 0.63 1.92 14 1.02 0.56 1.71 Rathnaveoge 22058 7 11 0.65 0.26 1.33 12 0.58 0.23 1.18 22059 181 165 1.09 0.94 1.27 185 0.98 0.84 1.13 Timoney 22060 10 9 1.09 0.52 1.99 10 0.97 0.46 1.77 Ballycahill 22061 23 15 1.58 1.00 2.36 16 1.40 0.89 2.10 Ballymurreen 22062 13 9 1.49 0.79 2.54 10 1.33 0.71 2.27 Borrisoleigh 22063 42 31 1.34 0.96 1.81 35 1.20 0.86 1.61 Drom 22064 18 27 0.68 0.40 1.07 30 0.60 0.36 0.95 Foilnaman 22065 20 12 1.71 1.04 2.63 13 1.52 0.92 2.34 Glenkeen 22066 7 15 0.46 0.18 0.94 17 0.40 0.16 0.83 Gortkelly 22067 13 15 0.88 0.47 1.51 17 0.79 0.42 1.34 Holycross 22068 44 43 1.02 0.74 1.37 48 0.91 0.66 1.22 Inch 22069 10 12 0.86 0.41 1.57 13 0.76 0.37 1.40 Kilrush 22070 9 12 0.73 0.34 1.39 14 0.65 0.30 1.24 Littleton 22071 34 32 1.08 0.74 1.50 36 0.96 0.66 1.34 Longfordpass 22072 3 8 0.36 0.07 1.04 10 0.32 0.06 0.92 Loughmoe 22073 13 17 0.78 0.41 1.33 19 0.69 0.37 1.18 Moyaliff 22074 19 13 1.49 0.90 2.33 14 1.33 0.80 2.07 Based on MWHB average rates Based on Irish average rates ED number observed expected SIR 95% confidence limits expected SIR 95% confidence limits

30 cases cases of SIR cases of SIR ED name lower upper lower upper Moycarky 22075 16 14 1.13 0.65 1.84 16 1.01 0.58 1.64 Moyne 22076 9 17 0.54 0.25 1.02 19 0.48 0.22 0.91 Rahelty 22077 14 19 0.76 0.41 1.26 21 0.68 0.37 1.13 Templetouhy 22078 20 28 0.71 0.44 1.10 32 0.64 0.39 0.98 Thurles Rural 22079 33 46 0.73 0.50 1.02 51 0.65 0.45 0.91 Twomileborris 22080 23 16 1.45 0.91 2.16 18 1.30 0.82 1.94 Upperchurch 22081 15 12 1.24 0.69 2.03 14 1.10 0.61 1.81

31