Evaluation of Country Dietary Habits Using Machine Learning Techniques in Relation to Deaths from COVID-19

COVID-19 disease has affected almost every country in the world. The large number of infected people and the different mortality rates between countries has given rise to many hypotheses about the key points that make the virus so lethal in some places. In this study, the eating habits of 170 countries were evaluated in order to find correlations between these habits and mortality rates caused by COVID-19 using machine learning techniques that group the countries together according to the different distribution of fat, energy, and protein across 23 different types of food, as well as the amount ingested in kilograms. Results shown how obesity and the high consumption of fats appear in countries with the highest death rates, whereas countries with a lower rate have a higher level of cereal consumption accompanied by a lower total average intake of kilocalories.

Deaths From Plasmodium knowlesi Malaria: Case Series and Systematic Review

BACKGROUND

Plasmodium knowlesi causes severe and fatal malaria, and incidence in Southeast Asia is increasing. Factors associated with death are not clearly defined.

METHODS

All malaria deaths in Sabah, Malaysia, from 2015 to 2017 were identified from mandatory reporting to the Sabah Department of Health. Case notes were reviewed, and a systematic review of these and all previously reported fatal P. knowlesi cases was conducted. Case fatality rates (CFRs) during 2010-2017 were calculated using incidence data from the Sabah Department of Health.

RESULTS

Six malaria deaths occurred in Sabah during 2015-2017, all from P. knowlesi. Median age was 40 (range, 23-58) years; 4 cases (67%) were male. Three (50%) had significant cardiovascular comorbidities and 1 was pregnant. Delays in administering appropriate therapy contributed to 3 (50%) deaths. An additional 26 fatal cases were included in the systematic review. Among all 32 cases, 18 (56%) were male; median age was 56 (range, 23-84) years. Cardiovascular-metabolic disease, microscopic misdiagnosis, and delay in commencing intravenous treatment were identified in 11 of 32 (34%), 26 of 29 (90%), and 11 of 31 (36%) cases, respectively. The overall CFR during 2010-2017 was 2.5/1000: 6.0/1000 for women and 1.7/1000 for men (P = .01). Independent risk factors for death included female sex (odds ratio, 2.6; P = .04), and age ≥45 years (odds ratio, 4.7; P < .01).

CONCLUSIONS

Earlier presentation, more rapid diagnosis, and administration of intravenous artesunate may avoid fatal outcomes, particularly in females, older adults, and patients with cardiovascular comorbidities.

Burden of Mesothelioma Deaths by National Income Category: Current Status and Future Implications

Background: This study compares estimates of the global-level mesothelioma burden with a focus on how existing national mortality data were utilized and further assesses the interrelationship of country-level mesothelioma burden and asbestos use with national income status. Methods: Country-level mesothelioma deaths in the WHO Mortality Database as of December 2019 were analyzed by national income category of countries in terms of data availability and reliability. Numbers of mesothelioma deaths from the study of Odgerel et al. were reanalyzed to assess country-level mesothelioma death burdens by national income status. Results: Among 80 high-income countries, 54 (68%) reported mesothelioma to the WHO and 26 (32%) did not, and among 60 upper middle-income countries, the respective numbers (proportions) were 39 (65%) countries and 21 (35%) countries, respectively. In contrast, among 78 low- and lower middle-income countries, only 11 (14%) reported mesothelioma deaths while 67 (86%) did not. Of the mesothelioma deaths, 29,854 (78%) were attributed to high- and upper middle-income countries, and 8534 (22%) were attributed to low- and lower middle- income countries. Conclusions: The global mesothelioma burden, based on reported numbers, is currently shouldered predominantly by high-income countries; however, mesothelioma burdens will likely manifest soon in upper middle-income and eventually in low and lower middle-income countries.

Implementation of the Perinatal Death Surveillance and Response guidelines: Lessons from annual health system strengthening interventions in the Rwenzori Sub-Region, Western Uganda

Aim

To determine the health facility-based perinatal mortality rate, its causes and avoidable factors using the perinatal mortality surveillance and response guidelines.

Design

This was an action study conducted in one of the districts in Western Uganda from 1 January-31 December 2019.

Methods

A total of 20 perinatal death cases were recruited consecutively. Data were collected using a Ministry of Health Perinatal Death Surveillance and Response (PDSR) questionnaire containing questions on pregnancy, delivery and immediate postnatal care. We used descriptive statistics to describe key data elements.

Results

We found a health facility-based perinatal mortality rate of 17.3 deaths per 1,000 live births. Birth asphyxia was the most common cause of perinatal deaths. Seven, three and ten mothers delayed seeking, reaching and receiving appropriate health care, respectively.

Improved outcome in early induction deaths in patients with acute promyelocytic leukemia after therapeutic and supportive interventions: a follow up study of seven-years' experience at a tertiary care center

INTRODUCTION AND OBJECTIVES

Acute promyelocytic leukemia (APL) is a unique subtype of acute myeloid leukemia with characteristic morphology and clinical features. Early mortality rate of 30% has been reported in developed countries despite prompt initiation of treatment. We have previously reported an early induction mortality of approximately 62% in our cohort. Based on this mortality rate, we made changes in our treatment protocol. The objective of this follow-up study was to report the early induction mortality and overall survival of patients with APL after incorporating changes in chemotherapy and supportive care regimen.

SUBJECTS AND METHODS

This was a prospective descriptive study conducted at Aga Khan University Karachi, Pakistan from October 2012 till October 2019. Data of patients included clinical features, morphological findings, cytogenetic and PCR studies, cytotoxic protocols, overall outcome and causes of early induction mortality. The changes in treatment protocol included prophylactic infusion of fresh frozen plasma, dexamethasone therapy and other changes in supportive care regimen. Results were recorded as frequencies and percentages. Statistical Package for the Social Sciences version 19.0 (SPSS Inc., Chicago, IL, USA) was used to analyze patient's data. Survival curves were calculated using the Kaplan-Meier method.

RESULTS

During the study period, total of 447 patients presented with acute myeloid leukemia at our institution out of which 40 patients were diagnosed with acute promyelocytic leukemia (9%). Out of these 40 patients 24 were males and 16 were females. The median age was 37 years. Twenty-five patients were in low risk group whereas 15 were high-risk. Differentiation syndrome was seen in 14 patients. As a part of induction chemotherapy, 13 patients received only ATRA because they were not eligible for chemotherapy and 17 patients received a combination of ATRA and anthracycline. Among the remaining patients, four received ATRA, arsenic and anthracycline while two received ATRA and arsenic only. Four patients did not receive any treatment because of rapid deterioration of clinical condition and death. The overall survival was 65% and early induction mortality was 30%.

CONCLUSION

The early induction mortality decreased to 30% from 62% in this study and the overall survival was 65%. With the introduction of prophylactic infusion of fresh frozen plasma, dexamethasone and appropriate supportive treatment during the induction chemotherapy, we were able to improve the induction mortality and overall survival of patients.

Social determinants of deaths from pneumonia and tuberculosis in children in Brazil: an ecological study

OBJECTIVE

To identify the risk areas of deaths due to unspecified pneumonia and tuberculosis (TB) in children, and to identify if there is a relationship between these events with higher TB incidence and social determinants.

METHODS

Ecological study carried out in Brazil. All cases of TB or unspecified pneumonia deaths in children under 5 years of age reported between 2006 and 2016 were included and collected through Department of Informatics of the Unified Health System (Brazil's electronic database). The Spatial Scan Statistics was used to identify areas at higher risk of dying from this event. The spatial association was verified through the Getis-Ord techniques. The Bivariate Moran Global Index was used to verify the spatial autocorrelation between the two events. To identify the association of TB and pneumonia deaths with endemic areas of pulmonary TB and social determinants, four explanatory statistical models were identified.

RESULTS

A total of 21 391 cases of pneumonia and 238 cases of TB were identified. Spatial scanning analysis enabled the detection of four clusters of risk for TB (relative risk, RR, between 3.30 and 18.18) and 22 clusters for pneumonia (RR between 1.38 and 5.24). The spatial association of the events was confirmed (z-score 3.74 and 64.34) and spatial autocorrelation between events (Moran Index:0.031 (p=0.001)). The zero-inflated negative binomial distribution was chosen, and an association for both events was identified with the TB incidence rate (OR 5.3, 95% CI 2.85 to 9.84; OR 6.63, 95% CI 5.62 to 7.81), with the Gini Index (OR 1.78, 95% CI 1.12 to 2.82; OR 4.22, 95% CI 3.63 to4.92). Primary care coverage showed an inverse association for both events (OR 0.10, 95% CI 0.67 to 0.17; OR 0.18, 95% CI 0.15 to 0.21) for pneumonia). Finally, a family that benefited from the Bolsa Família Programme had an inverse association for deaths from pneumonia (OR 0.81, 95% CI 0.52 to 1.25).

CONCLUSIONS

The results do not just contribute to reduce mortality in children, but mainly contribute to prevent premature deaths through identification of critical areas in Brazil, which is crucial to qualify health surveillance services.

Mortality Attributed to COVID-19 in High-Altitude Populations

Woolcott, Orison O., and Richard N. Bergman. Mortality attributed to COVID-19 in high-altitude populations. High Alt Med Biol. 21:409-416, 2020. Background: Since partial oxygen pressure decreases as altitude increases, environmental hypoxia could worsen Coronavirus Disease 2019 (COVID-19) patient's hypoxemia. We compared COVID-19 mortality at different altitudes. Methods: Retrospective analysis of population-level data on COVID-19 deaths was conducted in the United States (1,016 counties) and Mexico (567 municipalities). Mixed-model Poisson regression analysis of the association between altitude and COVID-19 mortality was conducted using individual-level data from 40,168 Mexican subjects with COVID-19, adjusting for multiple covariates. Results: Between January 20 and April 13, 2020, mortality rates were higher in U.S. counties located at ≥2,000 m elevation versus those located <1,500 m (12.3 vs. 3.2 per 100,000; p < 0.001). In Mexico, between March 13 and May 13, 2020, mortality rates were higher in municipalities located at ≥2,000 m versus those located <1,500 m (5.3 vs. 3.9 per 100,000; p < 0.001). Among Mexican subjects younger than 65 years, the risk of death was 36% higher in those living at ≥2,000 m versus those living at <1,500 m (adjusted incidence rate ratio [IRR]: 1.36; confidence interval [95% CI], 1.05-1.78; p = 0.022). Among Mexican men, the risk of death was 31% higher at ≥2,000 m versus that at <1,500 m (adjusted IRR: 1.31; 95% CI, 1.03-1.66; p = 0.025). No association between altitude and COVID-19 mortality was found among Mexican women or among Mexican subjects 65 years of age and older. Conclusions: Altitude is associated with COVID-19 mortality in men younger than 65 years.

Call for proper documentation of COVID-19 deaths in poor resource setting: a necessity for management of future occurrences

INTRODUCTION

A Pandemic is an epidemic at a global scale. The word 'epidemic' has the potential to lead to chaotic, unreasoned responses to health problems, especially when used by journalists. Nigeria like other poor resource countries is equally affected by the current coronavirus disease 2019 (COVID-19) pandemic. Standardization and proper documentation of the mortality of the COVID-19 in the poor-resource countries will help in managing other disease outbreaks in future. This paper calls for improvement in capturing of these data for better planning in the future.

AREAS COVERED

Quality data is very essential for policy makers to appreciate any disease condition. In order to present a comprehensive picture of COVID-19 mortality, the deaths were broadly grouped into two as follows: direct and indirect COVID-19 deaths. Most of the current reported deaths seem to be direct deaths.

EXPERT OPINION

We propose that for better estimation and standardization, verbal autopsy could be used to differentiate direct/indirect COVID deaths. At full development, this model could be applied to other diseases, outbreaks, or pandemics. The disease surveillance officers, and other health workers can be trained in this regard as well as scaling up the e-surveillance of the DSNOs.

Trends in Disease Burden Attributable to Tobacco in China, 1990-2017: Findings From the Global Burden of Disease Study 2017

In 2018, there were more than 371 million cigarette smokers and 12. 6 million electronic cigarette users, with 340.2 million non-smokers exposed to secondhand smoke (SHS) in China, which resulted in heavy tobacco-attributable disease burden. According to the definition by the Global Burden of Disease Study 2017 (GBD 2017), tobacco is a level 2 risk factor that consists of three sublevel risk factors, namely, smoking, SHS, and chewing tobacco. In this study, we aimed to evaluate the trends in deaths and disability-adjusted life years (DALYs) attributable to tobacco, smoking, SHS, and chewing tobacco by sex in China from 1990 to 2017 and to explore the leading causes of tobacco-attributable deaths and DALYs using data from the GBD 2017. From 1990 to 2017, the tobacco-attributable death rates per 100,000 people decreased from 75.65 [95% uncertainty interval (95% UI) = 56.23-97.74] to 70.90 (95% UI = 59.67-83.72) in females and increased from 198.83 (95% UI = 181.39-217.47) to 292.39 (95% UI = 271.28-313.76) in males. From 1990 to 2017, the tobacco-attributable DALY rates decreased from 2209.11 (95% UI = 1678.63-2791.91) to 1489.05 (95% UI = 1237.65-1752.57) in females and increased from 5650.42 (95% UI = 5070.06-6264.39) to 6994.02 (95% UI = 6489.84-7558.41) in males. In 2017, the tobacco-attributable deaths in China were concentrated on chronic obstructive pulmonary disease, ischemic heart disease, lung cancer, and stroke. The focus of tobacco control for females was SHS in 1990, whereas smoking and SHS were equally important for tobacco control in females in 2017. Increasing tobacco taxes and prices may be the most effective and feasible measure to reduce tobacco-attributable disease burdens.

Victims of road accidents with serious injuries and dependence on some individual, climatic and infrastructure factors on federal highways in Brazil

Road or urban traffic accidents in Brazil have a large presence in external causes of mortality. The main goal of this study is to discover significant factors in the incidence of accidents on Brazilian highways based on a database with information on each person injured on federal highways in Brazil reported by the Federal Highway Police. Some factors are considered in the study as cause of the accident, type of accident, stage of the day, weather condition, highway type, highway facility, age of the victim, gender of the victim and type of vehicle. From the obtained results of chi-square tests and logistic regression models, it was observed statistical dependence (p < 0.05) of the occurrence of injured people with serious injuries and the factors cause of the accident, type of accident, day, highway type and vehicle type. Considering the dead victims, the covariates age, time of day, highway type, highway facility, gender and type of vehicle showed significance (p < 0.05). These results are of great interest for authorities to increase road enforcement, improve highway facilities and target the production of vehicles with better safety standards.

Estimating the Risk of COVID-19 Death During the Course of the Outbreak in Korea, February-May 2020

BACKGROUND

In Korea, a total of 10,840 confirmed cases of COVID-19 including 256 deaths have been recorded as of May 9, 2020. The time-delay adjusted case fatality risk (CFR) of COVID-19 in Korea is yet to be estimated.

METHODS

We obtained the daily series of confirmed cases and deaths in Korea reported prior to May 9, 2020. Using statistical methods, we estimated the time-delay adjusted risk for death from COVID-19 in Daegu, Gyeongsangbuk-do, other regions in Korea, as well as the entire country.

RESULTS

Our model-based crude CFR fitted the observed data well throughout the course of the epidemic except for the very early stage in Gyeongsangbuk-do; this was partially due to the reporting delay. Our estimates of the risk of death in Gyeongsangbuk-do reached 25.9% (95% Credible Interval (CrI): 19.6%-33.6%), 20.8% (95% CrI: 18.1%-24.0%) in Daegu, and 1.7% (95% CrI: 1.1%-2.5%) in other regions, whereas the national estimate was 10.2% (95% CrI: 9.0%-11.5%).

CONCLUSIONS

The latest estimates of CFR of COVID-19 in Korea are considerably high, even with the early implementation of public health interventions including widespread testing, social distancing, and delayed school openings. Geographic differences in the CFR are likely influenced by clusters tied to hospitals and nursing homes.

Estimating the Risk of COVID-19 Death During the Course of the Outbreak in Korea, February-May 2020

BACKGROUND

In Korea, a total of 10,840 confirmed cases of COVID-19 including 256 deaths have been recorded as of May 9, 2020. The time-delay adjusted case fatality risk (CFR) of COVID-19 in Korea is yet to be estimated.

METHODS

We obtained the daily series of confirmed cases and deaths in Korea reported prior to May 9, 2020. Using statistical methods, we estimated the time-delay adjusted risk for death from COVID-19 in Daegu, Gyeongsangbuk-do, other regions in Korea, as well as the entire country.

RESULTS

Our model-based crude CFR fitted the observed data well throughout the course of the epidemic except for the very early stage in Gyeongsangbuk-do; this was partially due to the reporting delay. Our estimates of the risk of death in Gyeongsangbuk-do reached 25.9% (95% Credible Interval (CrI): 19.6%-33.6%), 20.8% (95% CrI: 18.1%-24.0%) in Daegu, and 1.7% (95% CrI: 1.1%-2.5%) in other regions, whereas the national estimate was 10.2% (95% CrI: 9.0%-11.5%).

CONCLUSIONS

The latest estimates of CFR of COVID-19 in Korea are considerably high, even with the early implementation of public health interventions including widespread testing, social distancing, and delayed school openings. Geographic differences in the CFR are likely influenced by clusters tied to hospitals and nursing homes.

Global Burden of Chronic Respiratory Diseases

Background: Noncommunicable diseases (NCDs) and chronic respiratory diseases (CRDs) are the main causes of mortality and morbidity worldwide. Methods: The main evidences about the NCDs and CRDs burden and related risk factors, from updated international reports and results of original researches, were collected and described in this review. Results: Most recent evidence is available from the Global Burden of Diseases Study (GBD) 2017 reports. There were 3.2 million deaths due to chronic obstructive pulmonary disease (COPD) and 495,000 deaths due to asthma. COPD was the seventh leading cause of years of life lost (YLLs). Overall, prevalent cases of CRDs were 545 million: about 50% for COPD and 50% for asthma. Incident cases of CRDs were 62 million, mostly due to asthma (69%) and COPD (29%). COPD accounted for 81.6 million disability-adjusted life years, asthma for 22.8 million. COPD prevalence of 9.1% has been found in a recent general population sample of North-Eastern Italy, while in Central Italy a 25-year follow-up of a general population sample has shown an increased prevalence of COPD and asthma up to 6.8% and 7.8%, respectively. In Central Italy, a COPD incidence of 8% and an asthma incidence of 3.2% have been found in adult subjects at an 18-year follow-up. Among the risk factors, a relevant role is played by smoking and high body mass index for asthma, while smoking, particulate matter pollution, ambient ozone pollution, occupational exposure to particulate matter, gases and fumes, as well as second-hand smoke, play an important role for COPD. Forecasting the YLLs by 2040 indicates a rising toll from several NCDs due to population growth and aging, with COPD expected to reach the fourth leading cause. Conclusions: Several recent studies and international reports highlighted the huge global health burden of CRDs and other major NCDs, pointing out the need for implementing international collaborations to fight this epidemic trend.

Pediatric Palliative Care During End of Life: A Privilege of a Few in a Tertiary Referral Hospital From Colombia

BACKGROUND

We aim to describe the access to palliative care (PC) in hospitalized children during end-of-life care and compare the circumstances surrounding the deaths of hospitalized children as a basis for implementing a pediatric PC program at our institution.

METHODS

We performed a retrospective chart review of deceased pediatric patients at a tertiary referral hospital in Colombia. The study group was selected by randomly drawing a sample of 100 observations from the 737 deceased children from 2013 to 2016. A 1:1 propensity score (PS) matching was performed to compare the characteristics and outcomes between PC and non-PC treated patients.

RESULTS

We included 87 patients. After PS matching, we found that patients under the care of non-PC physicians were more likely to die in the pediatric intensive care unit (non-PC: 6/10 vs PC: 1/10; P = .02), to be on vasopressor agents and mechanical ventilation (non-PC: 7/10 vs PC: 1/10; P = .02), and to receive cardiopulmonary resuscitation at the end of life (non-PC: 5/10 vs PC: 0/10; P = .03). In contrast, a significantly higher proportion of patients under the care of the pediatric PC team died with comfort measures (non-PC: 2/10 vs 8/10; P = .02) and nonescalation of care in physician orders (non-PC: 5/10 vs PC: 10/10; 0.03).

CONCLUSION

In this study, only 10 of 87 patients were treated by the pediatric PC team at the end of life. The latter finding is concerning and is a call to action to improve access to pediatric PC at our institution.

Effectiveness of influenza vaccine in reducing influenza-associated hospitalizations and deaths among the elderly population; Lazio region, Italy, season 2016-2017

BACKGROUND

This study aimed to estimate influenza vaccine effectiveness (VE) in preventing influenza-related deaths and hospitalizations in the elderly population.

METHODS

We retrospectively analyzed the cohort of 1,251,218 elderly aged ≥65 years who were residing in the Lazio region in 2016-2017. We estimated influenza VE using the Cox proportional hazards model, adjusting for demographic characteristics, preexisting health-risk conditions, and prior vaccinations.

RESULTS

Estimated VE was 14% (95% confidence interval (CI): 11 to 17); 26% (95%CI: 19 to 33) in preventing influenza-related deaths and 13% (95%CI: 10 to 16) in preventing influenza-related hospitalizations. Seasonal VE was higher in the elderly vaccinated in prior seasons (VE = 20%, 95%CI: 17 to 23). We found no significant differences in effectiveness by vaccine type, although the MF59-adjuvanted vaccine appeared more effective than other vaccines in individuals aged ≥75 years, particularly in those aged ≥90 years (VE = 18%, 95%CI: 9 to 26).

CONCLUSIONS

Although VE was low, vaccination still provided benefits in preventing influenza-related hospitalizations and deaths in the elderly, particularly among those vaccinated in prior seasons. Efforts should therefore be made to improve vaccine uptake and the utilization of vaccines with greater effectiveness in the oldest elderly (e.g. high-dose and adjuvanted cell-based vaccines).

Birth incidence, deaths and hospitalisations of children and young people with Down syndrome, 1990-2015: birth cohort study

OBJECTIVE

To investigate current Down syndrome live birth and death rates, and childhood hospitalisations, compared with peers.

SETTING

General community.

PARTICIPANTS

All live births with Down syndrome, 1990-2015, identified via Scottish regional cytogenetic laboratories, each age-sex-neighbourhood deprivation matched with five non-Down syndrome controls. Record linkage to Scotland's hospital admissions and death data.

PRIMARY OUTCOME

HRs comparing risk of first hospitalisation (any and emergency), readmission for children with Down syndrome and matched controls were calculated using stratified Cox proportional hazards (PH) model, and length of hospital stay was calculated using a conditional log-linear regression model.

RESULTS

689/1479 (46.6%) female and 769/1479 (51.9%) male children/young people with Down syndrome were identified (1.0/1000 births, with no reduction over time); 1235 were matched. 92/1235 (7.4%) died during the period, 18.5 times more than controls. More of the Down syndrome group had at least one admission (incidence rate ratio(IRR) 72.89 (68.72-77.32) vs 40.51 (39.15-41.92); adjusted HR=1.84 (1.68, 2.01)) and readmissions (IRR 54.85 (51.46-58.46) vs 15.06 (14.36-15.80); adjusted HR=2.56 (2.08, 3.14)). More of their admissions were emergencies (IRR 56.78 (53.13-60.72) vs 28.88 (27.73-30.07); first emergency admission adjusted HR=2.87 (2.61, 3.15)). Children with Down syndrome had 28% longer first admission after birth. Admission rate increased from 1990-2003 to 2004-2014 for the Down syndrome group (from 90.7% to 92.2%) and decreased for controls (from 63.3% to 44.8%).

CONCLUSIONS

We provide contemporaneous statistics on the live birth rate of babies with Down syndrome, and their childhood death rate. They require more hospital admissions, readmissions emergency admissions and longer lengths of stays than their peers, which has received scant research attention in the past. This demonstrates the importance of statutory planning as well as informal support to families to avoid added problems in child development and family bonding over and above that brought by the intellectual disabilities associated with Down syndrome.

Estimates of healthcare utilisation and deaths from waterborne pathogen exposure in Ontario, Canada

Burden of disease analyses can quantify the relative impact of different exposures on population health outcomes. Gastroenteritis where the causative pathogen was not determined and respiratory illness resulting from exposure to opportunistic pathogens transmitted by water aerosols have not always been considered in waterborne burden of disease estimates. We estimated the disease burden attributable to nine enteric pathogens, unspecified pathogens leading to gastroenteritis, and three opportunistic pathogens leading primarily to respiratory illness, in Ontario, Canada (population ~14 million). Employing a burden of disease framework, we attributed a fraction of annual (year 2016) emergency department (ED) visits, hospitalisations and deaths to waterborne transmission. Attributable fractions were developed from the literature and clinical input, and unattributed disease counts were obtained using administrative data. Our Monte Carlo simulation reflected uncertainty in the inputs. The estimated mean annual attributable rates for waterborne diseases were (per 100 000 population): 69 ED visits, 12 hospitalisations and 0.52 deaths. The corresponding 5th–95th percentile estimates were (per 100 000 population): 13–158 ED visits, 5–22 hospitalisations and 0.29–0.83 deaths. The burden of disease due to unspecified pathogens dominated these rates: 99% for ED visits, 63% for hospitalisations and 40% for deaths. However, when a causative pathogen was specified, the majority of hospitalisations (83%) and deaths (97%) resulted from exposure to the opportunistic pathogens Legionella spp., non-tuberculous mycobacteria and Pseudomonas spp. The waterborne disease burden in Ontario indicates the importance of gastroenteritis not traced back to a particular pathogen and of opportunistic pathogens transmitted primarily through contact with water aerosols.

How deaths can help clinicians and policy-makers understand the risks of novel psychoactive substances

Novel psychoactive substances (NPS), especially those newly created, are largely an unknown quantity, particularly in terms of their potential serious adverse effects. This means that policy-makers and clinicians are under-informed about appropriate responses. Collation of detailed information on deaths related to NPS use can help in providing knowledge and understanding these aspects of the NPS phenomenon. The purpose of this review is to outline the role(s) which such evidence-based data can play in this respect. UK NPS-related cases demonstrate differences in definitions used by the General Mortality Registers, and differences between countries, not only in terms of the type of NPS implicated in deaths, but the number and extent of such deaths over time. NPS deaths are continuing to increase numerically and as a proportion of all drug-poisoning deaths. In order to better understand how specific molecules contribute to and/or cause death, detailed information collected by Special Mortality Registers can provide examples of substances' modes of action, adverse effects, symptomatology, treatment interventions, mechanisms of death, etc. This information can provide clinicians and policy-makers with objective information on the serious harms from such emerging molecules. Such evidence-based advice informs public health interventions, service provision and policy decisions on regulation and control of NPS. However, without reliable, accurate and complete information that is correctly collated, scientifically analysed and disseminated in a timely manner, an understanding of the phenomenon of what deaths can be ascribed to NPS, their characteristics and nature will remain unachieved, and thus limit what can be done to reduce them.

Accidental adult deaths involving ladders: A forensic perspective

A retrospective study was undertaken of autopsy cases at the Forensic Science South Australia state mortuary over a 20-year period from January 1999 to December 2018 for all cases aged ≥18 years where a ladder was mentioned in the death scene description and/or police reports. Twelve cases were identified, all of whom were male, with an average age of 56 years (range 21–83 years). The most frequent cause of death was a fall from a ladder ( n = 8; 66%), followed by electrocution ( n = 4; 33%). The falls were associated with deaths from blunt injuries, impalement and laceration. The age range of those who fell was 47–83 years (average 66 years). The three of the four deaths associated with electrocutions involved contact with power lines or live electrical wires; the remaining case involved a sharp metal ladder base cutting through a live power lead. The age range of those who were electrocuted was 21–43 years (average 35 years) – significantly younger than those who had died from falls ( p < 0.05). The increase in mean age of the population with increasing popularity of home maintenance activities may result in more cases of lethal falls involving ladders presenting for forensic assessment.

Particulate matter pollution and the COVID-19 outbreak: results from Italian regions and provinces

INTRODUCTION

Particulate matter exposure has been associated with the appearance and severity of several diseases, including viral infections. The aim of this study was to investigate whether coronavirus disease 2019 (COVID-19) cases and deaths across Italian regions and provinces in March 2020 were linked to past exposure to fine and coarse particulate matter (namely, PM_2.5 and PM₁₀, respectively).

MATERIAL AND METHODS

Geographical distributions of COVID-19 cases and deaths (105,792 and 12,428, respectively, up to 31^st March 2020), PM_2.5 and PM₁₀ exposure, and demographic characteristics were extracted from publicly accessible databases. Adjusted regression models were performed to test the association between particulate matter exposure in different Italian regions and provinces and COVID-19 incidence proportions and death rates.

RESULTS

A heterogeneous distribution of COVID-19 cases/deaths and particulate matter exposure was observed in Italy, with the highest numbers in Northern Italy regions and provinces. Independent associations between regional PM_2.5/PM₁₀ exposure and COVID-19 incidence proportion and death rate were observed (COVID-19 incidence proportion: β = 0.71, p = 0.003, β = 0.61, p = 0.031, respectively; COVID-19 death rate: β = 0.68, p = 0.004 and β = 0.61, p = 0.029, respectively). Similarly, PM_2.5/PM₁₀ exposures were independently associated with COVID-19 incidence proportion (β = 0.26, p = 0.024 and β = 0.27, p = 0.006, respectively) at the provincial level. The number of days exceeding the provincial limit value of exposure to PM₁₀ (50 µg/m³) was also independently associated with the COVID-19 incidence proportion (β = 0.30, p = 0.008).

CONCLUSIONS

Exposure to PM_2.5 and PM₁₀ is associated with COVID-19 cases and deaths, suggesting that particulate matter pollution may play a role in the COVID-19 outbreak and explain the heterogeneous distribution of COVID-19 in Italian regions and provinces.

Unexplained periods of higher deaths contribute to marginal changes in health care demand and health insurance costs: International perspectives

Sudden and unexplained increases in hospital medical admissions and population total deaths have been characterized in the United Kingdom. These sudden increases appear to endure for around 1 to 3 years before they abate. This study demonstrates that the sudden increases in deaths also occur in 125 countries and occur at subnational geographies. The magnitude of the sudden increase diminishes as a power law function up to around 10 000 deaths. Above 10 000 deaths, there is only a small decline with increasing size (deaths). At around 10 000 deaths, a 10% maximum sudden increase applies across many countries or subnational regions. The nearness to death effect, where around half of a person's lifetime hospital admissions occurs in the last 6 months of life, results in higher associated increases in medical admissions. This paper confirms that the use of calendar year data can be misleading. Periods of unexplained higher deaths appear to occur in bursts across multiple countries and appear to show spatial spread within the neighbourhoods which constitute the whole country.

Bold actions needed to improve civil registration data for road traffic deaths

Persisting problems of underreporting and poor quality of road traffic mortality data exist. Bold and sustained actions need to be undertaken by countries to improve civil registration data collection and reporting. Countries need to implement three specific actions to improve civil registration and vital statistics data systems and/or road traffic injury data collection:Ensure that civil registration and vital statistics systems produce high-quality cause of death data by working with the health sector to improve medical certification of cause of death and statistical coding in line with the International Classification of Diseases.Adopt a consistent definition of a road traffic death for use in police databases, particularly in countries with incomplete civil registration and vital statistics data, where police data are the most reliable source of informationLink data sources - including civil registration records, police data, health records, insurance data - to improve official road traffic fatality estimates while ensuring the privacy of individual identification.

Evaluation of fatal diving accidents in Turkey

In any kind of diving there is a risk of accidents, as the move from the topside environment to underwater can affect a diver’s physiological and psychological condition. It is important to investigate dive accidents to clarify the causative factors and determine preventive measures. In this study, autopsy files of fatal dive accident cases were reviewed to evaluate demographic data, type of diving, purpose of dive, seasonal distribution, autopsy findings, and causes of death. We reviewed 56 fatal dive accident files from autopsy units in cities where dive activities are concentrated and from the archive of the Turkish Underwater Federation. Four cases were excluded from the study since we were unable to obtain autopsy reports. Of 52 cases there were 20 scuba divers, two surface-supplied divers and 30 breath-hold divers. The majority of cases involved males (94%). The average age of 50 cases was 38.6; age estimation for two cases could not be determined due to advanced putrefaction. Of these fatal dive accidents 75% took place over a period of six months between May and October. Drowning was recorded as the primary cause of death in these cases. X-ray imaging was used in four (8%) cases. A special autopsy technique was used for nine (17%) cases, to detect possible pulmonary barotrauma and arterial gas embolism. The forensic specialist who is planning to conduct the autopsy for a dive fatality should have knowledge and experience about dive physics and physiology as well as physiopathology of dysbaric injuries.

Crew and passenger deaths from vessel accidents in United Kingdom passenger ships since 1900

BACKGROUND

There is very limited systematic analysis of the causes and consequences of maritime accidents across the whole passenger sector during the twentieth century either in United Kingdom (UK) or in other maritime nations, but some of the larger events have been the subject of detailed investigations that led to improved safety measures. In recent years, there has been increased attention to the analysis of passenger ship accidents, especially in relation to the two now dominant markets: vehicle/passenger ferries and cruise ships.

MATERIALS AND METHODS

Long-term trends since 1900 in passenger and crew deaths on UK seagoing pas- senger ships that have sustained a maritime accident, as defined by Lloyds Register, have been collated and analysed.

RESULTS

Over the course of the 20th century, there has been a continuous fall in the number of incidents and in their severity. This may be a reflection of improved vessel safety, however the scale and nature of UK passenger shipping has also changed markedly over the period.

CONCLUSIONS

In addition to the reducing frequency of deaths it is apparent that the majority of fatalities in both crew and passengers came from a very small number of major events during the study period. Altho- ugh there has been no major disaster involving a UK passenger ship in the last 30 years, major casualties with heavy loss of life continue in the world passenger fleet, in recent years involving flags such as Greece, Indonesia, Italy, Panama and The Philippines.

Medical encounters, cardiac arrests and deaths during a 109 km community-based mass-participation cycling event: a 3-year study in 102 251 race starters-SAFER IX

BACKGROUND

There are few data on medical encounters, including deaths during mass-participation cycling events.

OBJECTIVE

To determine the incidence and nature of medical encounters during a community-based mass-participation cycling event.

DESIGN

Cross-sectional study across three annual events.

SETTING

2012-2014 Cape Town Cycle Tour (109 km), South Africa.

PARTICIPANTS

102 251 race starters (male=80 354, female=21 897).

METHODS

Medical encounters (moderate, serious life-threatening, sudden cardiac arrest/death), using the 2019 international consensus definitions, were recorded on race day for 3 years as incidence rates (IR per 1000 starters; 95% CI). Overall illness-related (by organ system) or injury-related (by anatomical region) encounters, and severity were recorded.

RESULTS

We recorded 539 medical encounters (IR 5.3; 4.8 to 5.7). The IR was 3.2 for injuries (2.9 to 3.6), 2.1 for illnesses (1.0 to 2.4) and 0.5 for serious life-threatening medical encounters (0.4 to 0.7). In the 3-year study, we encountered three cardiac arrests and one death (2.9 and 1.0 per 100 000 starters, respectively). Injury IRs included upper limb (1.9; 1.6 to 2.1), lower limb (1.0; 0.8 to 1.0) and head/neck (0.8; 0.6 to 1.0). Illness IRs included fluid/electrolyte abnormalities (0.6; 0.5 to 0.8) and the cardiovascular system (0.5; 0.4 to 0.6).

CONCLUSION

In a 109 km community-based mass-participation cycling event, medical encounters (moderate to severe) occurred in about 1 in 200 cyclists. Injury-related (1/300 cyclists) encounters were higher than illness-related medical encounters (1 in about 500). Serious life-threatening medical encounters occurred in 1/2000 cyclists. These data allow race organisers to anticipate the medical services required and the approximate extent of demand.

Mortality trends in Erbil, Iraq, 2007-2011

BACKGROUND

Reliable and valid information on trends of mortality and common causes of death is essential to guide priorities for the allocation of resources within the health sector in order to improve health services for the population, increase longevity and improve quality of life.

AIMS

This study aimed to determine crude, gender, age and cause specific death rates and to examine mortality trends in a five-year period between 2007 and 2011 in Erbil City, Iraq.

METHODS

This study researched 16 780 deaths registered at the statistical unit of the Directorate of Health, Irbil City. Data were reviewed and cleared for the purpose of analysis. Causes of deaths were classified according to body systems.

RESULTS

The average crude death rate was 3.1 per 1000 population with male predominance over females in all the years of study (3.5 and. 2.7, respectively). The age-specific death rates were high in the old and middle age groups in addition to the under 5 years age group. Accidents and circulatory diseases were the leading causes of deaths with rates of 65.2 and 58.3/100 000 population, respectively.

CONCLUSIONS

An accurate identification of cause of death suggests that the only use of the death certificate in Erbil is for the purpose of burial and legal issues, and therefore it is imperative for educational efforts to achieve a complete and comprehensive death registration.

Root Causes of Appalachia's Deaths of Despair

The U.S. is experiencing a decline in life expectancy, particularly among rural white males in their most productive years. Appalachia is disproportionally represented in mortality rates, accounting for 30% of the U.S. population, but 50% of the excess mortality attributed to the "deaths of despair": drug overdose, suicide, and alcoholic cirrhosis. A substantial proportion of that excess mortality is related to the current opioid crisis we are experiencing. We have data on evidence-based solutions to the treatment of addiction, but little information on prevention of addiction as well as the other deaths of despair, likely with the same etiologic agent. We must focus on finding the root cause of the current epidemic, so that we can prevent this devastating mortality.

Causes of death among persons diagnosed with hepatitis C infection in the pre- and post-DAA era in England: A record linkage study

Through record linkage, we describe the causes of death among persons with diagnosis of hepatitis C virus (HCV) in England. Persons ≥1 year with anti-HCV/HCV-PCR tests reported to PHE sentinel surveillance during 2002-2016 were linked to death registrations from the Office for National Statistics during 2008-2016. We found that 8.6% of the 204 265 with evidence of HCV during the study period died. Among them, external causes (accidental poisoning from drugs) and liver disease (end-stage liver disease, liver cancer, hepatitis, alcohol- and non-alcohol-related) were the leading underlying causes of death (18% and 34.5%, respectively); the latter increased to 49.2% if reported anywhere on the death certificate. Median age of death was lower in persons with evidence of HCV than the general population (53 years vs 81 years). A higher proportion of persons with HCV died of external causes, liver disease and HIV compared to the general population (P < 0.001). Potential impact of new HCV treatments was observed as a relative reduction in liver-related deaths in 2016 compared with 2015. Recording of HCV as a contributory cause of death was 28.4% for all underlying causes, but 58.8% among the subgroup who died of liver disease. Data linkage between laboratory diagnosis and deaths data is an important tool for monitoring all-cause mortality among those with HCV and quantifying under-reporting of HCV in death registrations. Changes in mortality trends (causes and prematurity) in people with HCV can help evaluate the impact in the UK of HCV treatment scale-up and other interventions to achieve HCV elimination.

Demographic Seasonality

The seasonality of demographic data has been of great interest. It depends mainly on the climatic conditions, and the findings may vary from study to study. Commonly, the studies are based on monthly data. The population at risk plays a central role. For births or deaths over short periods, the population at risk is proportional to the lengths of the months. Hence, one must analyze the number of births (and deaths) per day. If one studies the seasonality of multiple maternities, the population at risk is the total monthly number of confinements and the number of multiple maternities in a given month must be compared with the monthly number of all maternities. Consequently, when one considers the monthly rates of multiple maternities, the monthly number of births is eliminated and one obtains an unaffected seasonality measure of the rates. In general, comparisons between the seasonality of different data sets presuppose standardization of the data to indices with common means, mainly 100. If one assumes seasonality as 'non-flatness' throughout a year, a chi-squared test would be an option, but this test calculates only the heterogeneity and the same test statistic can be obtained for data sets with extreme values occurring in consecutive months or in separate months. Hence, chi-squared tests for seasonality are weak because of this arbitrariness and cannot be considered a model test. When seasonal models are applied, one must pay special attention to how well the applied model fits the data. If the goodness of fit is poor, nonsignificant models obtained can erroneously lead to statements that the seasonality is slight, although the observed seasonal fluctuations are marked. In this study, we investigate how the application of seasonal models can be applied to different demographic variables.

Health insurance and opioid deaths: Evidence from the Affordable Care Act young adult provision

The concurrence of health insurance expansion under the Affordable Care Act (ACA) and increasing opioid-related mortality has led to debate whether insurance increases or decreases opioid deaths. I use the introduction of the ACA young adult (YA) provision as a quasi-experiment and utilize the resulting policy-induced variation across states over time in YA access to insurance to study the effect of coverage on opioid-related mortality. I rely on the share of state populations which stood to gain insurance before the ACA to perform a dose-response analysis, and find that the YA provision reduced opioid-related mortality. The analysis suggests that 1 percentage point more coverage reduced opioid mortality among YA by 2.5/100,000 or 19.8%.

Causes of deaths in the intensives care unit of Sylvanus Olympio Teaching Hospital, Lomé, Togo

To analyze the causes of deaths in the intensive care unit (ICU) at the CHU Sylvanus Olympio (CHU SO) teaching hospital of Lomé. This retrospective study examined the files of patients who died in the ICU of CHU SO, during the 12-month period from November 2012 to October 2013. Of 732 patients admitted to the ICU, 237 died, for a mortality rate of 32.38%. Men accounted for 163 (68.8%) of the deaths, and women 74 (31.2%), for a M/F ratio of 2.2. The average age of patients who died was 41.7 years; the age group 21-30 years comprised 16% of the deaths, that 31-40 years 19.8%, and 41-50 years 17.7%. Trauma (50.64%) dominated the causes of death, including especially severe traumatic brain injury (34.18%), followed by postoperative intensive care (25.32%), including peritonitis (8%). Medical diseases accounted for 18.14% of ICU admissions. More than half the deaths (55.7%) took place in the 72 hours after ICU entry. Mortality in the ICU at CHU SO of Lomé remains very high. It affects young patients, mainly with traumatic and surgery-related pathologies.

Use of Verbal Autopsy to Determine Underlying Cause of Death during Treatment of Multidrug-Resistant Tuberculosis, India

Of patients with multidrug-resistant tuberculosis (MDR TB), <50% complete treatment. Most treatment failures for patients with MDR TB are due to death during TB treatment. We sought to determine the proportion of deaths during MDR TB treatment attributable to TB itself. We used a structured verbal autopsy tool to interview family members of patients who died during MDR TB treatment in India during January-December 2016. A committee triangulated information from verbal autopsy, death certificate, or other medical records available with the family members to ascertain the underlying cause of death. For 66% of patient deaths (47/71), TB was the underlying cause of death. We assigned TB as the underlying cause of death for an additional 6 patients who died of suicide and 2 of pulmonary embolism. Deaths during TB treatment signify program failure; accurately determining the cause of death is the first step to designing appropriate, timely interventions to prevent premature deaths.

Waist Circumference and All-Cause Mortality among Older Adults in Rural Indonesia

Waist circumference, a measure of abdominal obesity, is associated with all-cause mortality in general adult population. However, the link between abdominal obesity with all-cause mortality in the studies of older adults is unclear. This study aims to determine the association between waist circumference and all-cause mortality in older adults in Indonesia. The association between waist circumference and all-cause mortality was examined in 10,997 men and women aged 50 years and older, in the World Health Organization (WHO) and International Network of field sites for continuous Demographic Evaluation of Populations and their Health in developing countries (INDEPTH) collaboration Study on global AGEing and adult health (SAGE) in Purworejo District Central Java, Indonesia during 2007⁻2010. Multivariate Cox regression analysis with restricted cubic splines was used to assess the non-linear association between waist circumference and all-cause mortality. During the 3-year follow-up, a total of 511 men and 470 women died. The hazard ratio plot shows a pattern of U-shape relationship between waist circumference and all-cause mortality among rich women, though the result was significant only for women in the lower end of waist circumference distribution (p < 0.05). Poor men with a low waist circumference (5th percentile) have a two times higher mortality risk (HR = 2.1; 95% CI = 1.3, 3.3) relative to those with a waist circumference of 90 cm. Poor women with a low waist circumference (25th percentile) have a 1.4 times higher mortality risk (HR = 1.4; 95% CI = 1.1, 1.8) relative to those with a waist circumference of 80 cm. This study shows a significant association between low waist circumference measure and mortality, particularly among poor men and women. Though the association between large waist circumference and mortality was not significant, we observed a trend of higher mortality risk particularly among rich women with large waist circumference measure. Public health intervention should include efforts to improve nutritional status among older people and promoting healthy lifestyle behaviours including healthy food and active lifestyle.

Trends in Infectious Disease Mortality, South Korea, 1983-2015

We used national statistics from 1983-2015 to evaluate trends in mortality caused by infectious diseases in South Korea. Age-standardized mortality from infectious disease decreased from 43.5/100,000 population in 1983 to 16.5/100,000 in 1996, and then increased to 44.6/100,000 in 2015. Tuberculosis was the most common cause of death in 1983 and respiratory tract infections in 2015. We observed a significant decline in infant deaths caused by infectious diseases, but mortality in persons age >65 years increased from 135 deaths/100,000 population in 1996 to 307/100,000 in 2015. The relative inequality indices for respiratory tract infections, sepsis, and tuberculosis tended to increase over time. Although substantial progress has been achieved in terms of infant mortality, death rates from infectious disease has not decreased overall. Elderly populations with lower education levels and subgroups susceptible to respiratory infections and sepsis should be the focus of preventive policies.

National Pediatric Palliative Care Needs from Hospital Deaths

OBJECTIVE

The objective of this study was to estimate palliative care needs and to describe the cohort of children with life-limiting illnesses (LLI) dying in hospitals.

DESIGN

This study was a retrospective cohort study. The national hospital admissions database was reviewed and children who had died who had life-limiting illnesses were identified.

SETTING

This study was conducted at Ministry of Health hospitals, Malaysia.

PATIENTS

Children aged 18 years and below who had died between January 1, 2012 and December 31, 2014.

MAIN OUTCOME MEASURES

Life-limiting diagnoses based on Hain et al.'s directory of LLI or the ACT/RCPCH categories of life-limiting disease trajectories.

RESULTS

There were 8907 deaths and 3958 (44.4%) were that of children with LLI. The majority, 2531 (63.9%) of children with LLI were neonates, and the most common diagnosis was extreme prematurity <28 weeks with 676 children (26.7%). For the nonneonatal age group, the median age at admission was 42 months (1-216 months). A majority, 456 (32.0%) had diagnoses from the ICD-10 chapter "Neoplasms" followed by 360 (25.3%) who had a diagnoses from "Congenital malformations, deformations, and chromosomal abnormalities" and 139 (9.7%) with diagnoses from "Disease of the nervous system." While a majority of the terminal admissions were to the general ward, there were children from the nonneonatal age group, 202 (14.2%) who died in nonpediatric wards.

CONCLUSION

Understanding the characteristics of children with LLI who die in hospitals could contribute toward a more efficient pediatric palliative care (PPC) service development. PPC service should include perinatal and neonatal palliative care. Palliative care education needs to extend to nonpediatric healthcare providers who also have to manage children with LLI.

The opioid crisis in Canada: a national perspective

INTRODUCTION

This review provides a national summary of what is currently known about the Canadian opioid crisis with respect to opioid-related deaths and harms and potential risk factors as of December 2017.

METHODS

We reviewed all public-facing opioid-related surveillance or epidemiological reports published by provincial and territorial ministries of health and chief coroners' or medical examiners' offices. In addition, we reviewed publications from federal partners and reports and articles published prior to December 2017. We synthesized the evidence by comparing provincial and territorial opioid-related mortality and morbidity rates with the national rates to look for regional trends.

RESULTS

The opioid crisis has affected every region of the country, although some jurisdictions have been impacted more than others. As of 2016, apparent opioid-related deaths and hospitalization rates were highest in the western provinces of British Columbia and Alberta and in both Yukon and the Northwest Territories. Nationally, most apparent opioid-related deaths occurred among males; individuals between 30 and 39 years of age accounted for the greatest proportion. Current evidence suggests regional age and sex differences with respect to health outcomes, especially when synthetic opioids are involved. However, differences between data collection methods and reporting requirements may impact the interpretation and comparability of reported data.

CONCLUSION

This report identifies gaps in evidence and areas for further investigation to improve our understanding of the national opioid crisis. The Public Health Agency of Canada will continue to work closely with the provinces, territories and national partners to further refine and standardize national data collection, conduct special studies and expand information-sharing to improve the evidence needed to inform public health action and prevent opioid-related deaths and harms.

Moderate and severe household food insecurity predicts stunting and severe stunting among Rwanda children aged 6-59 months residing in Gicumbi district

Household food insecurity (HFI) plays an important role in child malnutrition in many low-income countries. We determined the association between HFI and stunting and severe stunting among Rwandan children from the Gicumbi district, aged 6-59 months using a cross-sectional study of 2,222 children. HFI factor was calculated by summing all seven HFI (access) frequency questions and was categorised into food security, mildly food insecurity, moderately food insecurity, and severe food insecurity. The association between stunting, severe stunting, and HFI was determined using the multiple logistic regression analyses that adjust for clustering and sampling weights. The odds of moderate and severe HFI were significantly higher among stunted children aged 6-59 months than those who were not stunted (adjusted odds ratio [AOR] = 1.43; 95% confidence interval [CI] [1.11, 1.84] and AOR = 1.35; 95% CI [1.08, 1.69], respectively). Children from households with moderate food insecurity were 2.47 times more likely to be severely stunted (AOR = 2.47; 95% CI [1.77, 3.46]), and those from households with severe food insecurity were more likely to be severely stunted (AOR = 1.82; 95% CI [1.34, 2.48]), compared with children aged 6-59 months from households with food security. Other factors included male children and children who did not attend monthly growth monitoring sessions. This study showed that moderate and severe HFI correlated with stunting and severe stunting. Interventions to improve stunting in Gicumbi children should also focus on male children, children who did not attend monthly growth monitoring sessions, and households with moderate and severe food insecurity.

Historical Earthquakes and Their Socioeconomic Consequences in China: 1950⁻2017

Understanding the spatiotemporal pattern of historical earthquake disasters and resultant socioeconomic consequences is essential for designing effective disaster risk reduction measures. Based on historical earthquake disaster records, this study compiles a Chinese earthquake disaster catalog (CH-CAT) that includes records of 722 earthquake disasters that occurred during 1950⁻2017 in the mainland of China. This catalog includes more complete data records than other existing global earthquake databases for China as a whole. Statistical results demonstrate that the number of earthquake disasters and the resultant direct economic losses (DELs) exhibit significant increasing trends (p < 0.01) over the studied 68-year period. Earthquake-induced deaths vary greatly between individual years and exhibit no significant trend. The Qinghai-Tibet seismic zone is the area with the highest frequency of earthquake disasters and the largest accumulated DELs, whereas the North China seismic zone is associated with the highest number of deaths. Among the 722 earthquake disasters, nearly 99.0% of deaths and 95.0% of DELs are attributable to 1.8% and 3.9% of the earthquake disasters, respectively. Approximately 54.2% of recorded earthquake disasters have earthquake magnitude (Ms) values between 5.0 and 5.9, while earthquake disasters with Ms greater than or equal to 7.0 account for 88.5% of DELs and 98.8% of deaths. On average, earthquake-induced DELs and deaths increase nonlinearly with increasing Ms per earthquake. DELs have a positive correlation with deaths and casualties on a logarithmic scale. This study further discusses that during different stages of socioeconomic development, changes in both exposure and vulnerability may be the major factors leading to change differences in earthquake-induced socioeconomic consequences. This study is a beneficial supplement to the global earthquake database and is useful for calibrating global or regional empirical loss models.

Can a Village Headman Use an Electronic Village Register and a Simplified Community-Based Verbal Autopsy Tool to Record Numbers and Causes of Death in Rural Malawi?

Introduction: Most people in Africa die without appearing in official vital statistics records. To improve this situation, Malawi has introduced solar-powered electronic village registers (EVR), managed by village headmen, to record birth and death information for production of vital statistics. The EVR is deployed in 83 villages in Traditional Authority Mtema, Lilongwe, which is an area without electricity. In 17 villages, village headmen were also trained to use a simple verbal autopsy (VA) tool adapted from one developed by the World Health Organization (WHO). Study objectives were to (i) document numbers and causes of death occurring in 17 villages between April 2016 and September 2017, and (ii) assess percentage measures of agreement on causes of death as recorded by village headmen using a simple VA tool and by a team of health surveillance assistant (HSA)/medical doctor using the WHO VA tool. Methods: The study was in two-parts: (i) a cross-sectional study using secondary data from the EVR; (ii) primary data collection study comparing causes of death obtained by village headmen using a simple VA tool and by HSA/medical doctor using the WHO VA tool. Results: Over 18 months, 120 deaths were recorded by EVR in 14,264 residents - crude annual death rate 5.6/1,000 population. Median age at death was 43 years with 69 (58%) deaths being in males. Death occurred at home (75%) and at health facility (25%). Malaria, diarrhoeal disease, pulmonary tuberculosis, acute respiratory infection, and stroke accounted for 56% of deaths recorded by village headmen using the simple VA tool. Causes of death between village headmen and the HSA/medical doctor team were compared for 107 deaths. There was full agreement in causes of death in 33 (31%) deaths, mostly for malaria, severe anemia, intentional self-harm, cancer, and epilepsy. Unknown-sudden death and sepsis recorded by the HSA/medical doctor team were responsible for most disagreements. Conclusion: It is feasible for village headmen in rural Malawi to use an EVR and simple VA tool to document numbers and causes of deaths. More work is needed to improve accuracy of causes of death by village headmen.

Hospitalizations and Deaths Associated with Diarrhea and Respiratory Diseases among Children Aged 0⁻5 Years in a Referral Hospital of Mauritania

Diarrhea and respiratory diseases are the leading causes of morbidity and mortality among <5-year-olds worldwide, but systematic data are not available from Mauritania. We conducted a hospital-based retrospective study. Data on admissions to Mauritania's National Referral Hospital (the main pediatric referral center in the country), due to diarrhea and respiratory diseases, during 2011⁻2014, were analyzed. A total of 3695 children <5 years were hospitalized during this period; 665 (18.0%) due to respiratory diseases, and 829 (22.4%) due to diarrhea. Case fatality rates in the respiratory diseases and diarrhea groups were 18.0% (120/665) and 14.1% (117/829), respectively. The highest frequency of deaths due to diarrhea occurred in the age group 2⁻5 years (16/76; 21.0%), and due to respiratory diseases in the age group 6⁻12 months (32/141; 22.6%). We conclude that case fatality rates caused by respiratory diseases and diarrhea are extremely high in children hospitalized at the National Referral Hospital. These data call for intensified efforts to reduce deaths among hospitalized Mauritanian children, and also for integrated control measures to prevent and reduce the burden of both diseases. Additional studies are needed to show the effectiveness of the introduction of vaccination programs for pneumococcal diseases and rotavirus infection in the child population, which were launched in November 2013 and December 2014, respectively.

Causes of Morbidity and Mortality among Neonates and Children in Post-Conflict Burundi: A Cross-Sectional Retrospective Study

The risk of a child dying before age five in Burundi is almost 1.6 times higher than that in the World Health Organization (WHO) African region. However, variations in the all-cause mortality rates across Burundi have not yet been measured directly at subnational levels, age group and by gender. The objective of this study was to describe the main causes of hospitalization and mortality in children during the neonatal period and at ages 1 to 59 months, for boys and girls, and to assess the total annual (2010) burden of under-five morbidity and mortality in hospitals using hospitalization records from 21 district hospitals. We found variation in the gender and regional distribution of the five leading causes of hospitalization and death of children under five. Although the five causes accounted for 89% (468/523) of all neonatal hospitalizations, three causes accounted for 93% (10,851/11,632) of all-cause hospitalizations for children ages 1 to 59 months (malaria, lung disease, and acute diarrhea), malaria accounted for 69% (1086/1566) of all deaths at ages 1 to 59 months. In Burundi, human malarial infections continue to be the main cause of hospitalization and mortality among under-five children.

Investigation of Canine-Mediated Human Rabies Death, Haiti, 2015

In Haiti, an investigation occurred after the death of a 4-year-old girl with suspected rabies. With tips provided by community members, the investigation led to the identification of 2 probable rabies-related deaths and 16 persons bitten by rabid dogs, 75% of which chose postexposure prophylaxis. Community engagement can bolster rabies control.

Scaling up electronic village registers for measuring vital statistics in rural villages in Malawi

Setting: Eighty-three villages without electricity in Mtema Traditional Authority, Lilongwe District, Malawi. Objectives: To describe 1) the expansion of the electronic village register (EVR) to 83 villages in Mtema Traditional Authority, 2) the challenges encountered and changes made to render the system robust and user-friendly, 3) the value propositions developed to increase the system's desirability, and 4) the results of the village register. Design: Descriptive study. Results: After the deployment of the EVR in one village in 2013, the system was extended to 83 villages with modifications to render it more robust and user-friendly. These changes included modifications to the power, connectivity and work stations, better battery security and a single modular electronics panel. Value propositions of the EVR for the village headmen included daily postings of news/sports items and sockets for charging mobile phones and lanterns. Of the 47 559 residents registered, 48% were male, 14% were aged 0-4 years, 43% were aged 15-44 years and 4% were aged ⩾65 years. Between 1 April 2016 and 31 March 2017, 976 births and 177 deaths were recorded. The total equipment cost per village was US$2430. Conclusion: An electronic village birth and death registration system can function in an area with no communication or electricity infrastructure.

Towards elimination of HIV transmission, AIDS and HIV-related deaths in the UK

OBJECTIVES

Our objective was to present recent trends in the UK HIV epidemic (2007-2016) and the public health response.

METHODS

HIV diagnoses and clinical markers were extracted from the HIV and AIDS Reporting System; HIV testing data in sexual health services (SHS) were taken from GUMCAD STI Surveillance System. HIV data were modelled to estimate the incidence in men who have sex with men (MSM) and post-migration HIV acquisition in heterosexuals. Office for National Statistics (ONS) data enabled mortality rates to be calculated.

RESULTS

New HIV diagnoses have declined in heterosexuals as a result of decreasing numbers of migrants from high HIV prevalence countries entering the UK. Among MSM, the number of HIV diagnoses fell from 3570 in 2015 to 2810 in 2016 (and from 1554 to 1096 in London). Preceding the decline in HIV diagnoses, modelled estimates indicate that transmission began to fall in 2012, from 2800 [credible interval (CrI) 2300-3200] to 1700 (CrI 900-2700) in 2016. The crude mortality rate among people promptly diagnosed with HIV infection was comparable to that in the general population (1.22 vs. 1.39 per 1000 aged 15-59 years, respectively). The number of MSM tested for HIV at SHS increased annually; 28% of MSM who were tested in 2016 had been tested in the preceding year. In 2016, 76% of people started antiretroviral therapy within 90 days of diagnosis (33% in 2007).

CONCLUSIONS

The dual successes of the HIV transmission decline in MSM and reduced mortality are attributable to frequent HIV testing and prompt treatment (combination prevention). Progress towards the elimination of HIV transmission, AIDS and HIV-related deaths could be achieved if combination prevention, including pre-exposure prophylaxis, is replicated for all populations.

Diabetes hospitalizations and deaths in a cohort of treatment-seeking illicit drug users

Background:

Studies on diabetes among illicit drug users are scarce in Finland. This study aimed to describe hospitalization and death due to diabetes among treatment-seeking illicit drug users.

Methods:

Information of 4817 treatment-seeking drug users (3365 men and 1452 women) aged 11–65 years (mean 24.5 years) was linked to the Finnish national hospital discharge register and the national death registry to identify those clients who were hospitalized or died from diabetes mellitus during 1997–2013.

Results:

Fifty-three persons (42 men and 11 women) had primary diagnoses of diabetes, with a total of 146 hospitalizations (121 among men and 25 among women). The total length of stay among men (1183 days) far exceeded those of women (138 days). Overall, type 1 diabetes was the main contributor to hospitalizations (67%, n = 98/146). The proportion of Type 1 diabetes with complications was 31% in men (n = 37/121) and 44% in women (n = 11/25). All cases of deaths due to diabetes (n = 7) occurred in men.

Conclusion:

Diabetes hospitalizations were mainly due to Type 1 diabetes. Longer length of hospital stay was observed in men, and all diabetes deaths occurred among men. Male drug users and drug users in general would require more support to reduce morbidity and mortality due to diabetes.

Trends in Deaths from Rheumatic Heart Disease in the Eastern Mediterranean Region: Burden and Challenges

Rheumatic heart disease (RHD) is a preventable disease that is prevalent in developing regions of the world. Its eradication from most of the developed world indicates that this disease can be controlled and eliminated. Aim: To conduct an in-depth analysis of the trends and challenges of controlling RHD in the Eastern Mediterranean region (EMR). Methodology: Global data from the World Health Organization (WHO) data banks were retrieved for total deaths and age standardized death rate per 100,000 (ASDR) by age group, sex, and year (from 2000 to 2015). The data was compared with the five other WHO regions of the world. We also performed in-depth analysis by socio-economic groups in relation to other attributes in the region related to population growth, illiteracy, and nutritional status. Indicators of service delivery were correlated with ASDR from RHD. Findings: Prevalence of RHD in 2015 in the EMR region was one-third of that of the total deaths reported in the Asian and West Pacific regions. The total deaths for the region peaked twice: in early adulthood and again later in old age, and was higher in females than in males. There was a rising trend in deaths from RHD from 2000 to 2015. The highest total deaths were reported from Egypt, Pakistan, Iran, Afghanistan, and Yemen, representing 80% of the total death rates for the region (35,248). The highest ASDR was Afghanistan (27.5), followed by Yemen (18.78) and Egypt (15.59). The ASDR for RHD was highest in low income countries. It correlated highly, in all income groups, with anemia during pregnancy. Conclusions: Trends and patterns of deaths from RHD in the EMR have shifted to a later age group and are linked with poverty related to inequalities in development and service delivery for certain age groups and gender.

Risk profile for drowning deaths in children in the Indian state of Bihar: results from a population-based study

BACKGROUND

We report on incidence of drowning deaths and related contextual factors in children from a population-based study in the Indian state of Bihar which estimated the causes of death using verbal autopsy (VA).

METHODS

Interviews were conducted for deaths in 1-14 years population that occurred from January 2012 to March 2014 in 109 689 households (87.1% participation) in 1017 clusters representative of the state. The Population Health Metrics Research Consortium shortened VA questionnaire was used for interview and cause of death was assigned using the SmartVA automated algorithm. The annualised unintentional drowning death incidence, activity prior to drowning, the body of water where drowning death had occurred and contextual information are reported.

FINDINGS

The survey covered 224 077 children aged 1-14 years. Drowning deaths accounted for 7.2%, 12.5% and 5.8% of all deaths in 1-4, 5-9 and 10-14 years age groups, respectively. The adjusted incidence of drowning deaths was 14.3 (95% CI 14.0 to 14.7) per 100 000 children, with it being higher in urban (16.1, 95% CI 14.8 to 17.3) areas. Nearly half of the children drowned in a river (5.9, 95% CI 5.6 to 6.1) followed by in a pond (2.8, 95% CI 2.6 to 2.9). Drowning death incidence was the highest while playing (5.1, 95% CI 4.9 to 5.4) and bathing (4.0, 95% CI 3.8 to 4.2) with the former accounting for more deaths in 1-4 years age group. Sixty per cent of children were already dead when found. None of these deaths were reported to the civil registration system to obtain death certificate.

INTERPRETATION

The findings from this large representative sample of children document the magnitude of and variations in unintentional drowning deaths in Bihar. Urgent targeted drowning interventions are needed to address the risk in children. Gross under-reporting of drowning deaths in children in India needs attention.

Predictors of mortality in adults on treatment for human immunodeficiency virus-associated tuberculosis in Botswana: A retrospective cohort study

Mortality in patients with human immunodeficiency virus (HIV)-associated tuberculosis (TB) is high, particularly in sub-Saharan Africa. This study aimed to compare mortality and predictors of mortality in those who were antiretroviral therapy (ART) naïve to those with prior ART exposure.This retrospective cohort study was conducted in Serowe/Palapye District, Botswana, a predominantly urban district with a large burden of HIV-associated TB with a high case fatality. Between January 1, 2013 and December 31, 2013, patients confirmed with HIV-associated TB were enrolled and followed up. Kaplan-Meier and Cox proportional hazard modeling was undertaken to identify predictors of mortality, with ART initiation included as time-updated variable.Among the 300 patients enrolled in the study, 131 had started ART before TB diagnosis (44%). There were 45 deaths. There was no difference in mortality between ART-naïve patients and those with prior ART exposure. In the multivariate analysis, no ART use during TB treatment (hazard ratio [HR] = 5.6, 95% confidence interval [CI] = 2.9-11; P < .001), opportunistic infections other than TB (HR = 8.5, 95% CI = 4-18.4; P = .013), age ≥60 years (HR = 4.8, 95% CI = 1.8-13; P = .002), hemoglobin <10 g/dL (HR = 2.4, 95% CI = 1.3-4.5) and hepatotoxicity (HR = 5, 95% CI = 1.6-17; P = .007) were associated with increased mortality. In the subgroup analysis, among ART-naïve patients, no ART use during TB treatment (HR = 8.1, 95% CI = 3.4-19.4; P < .001), opportunistic infections other than TB (HR = 16, 95% CI = 6.2-42; P < .001), and hepatotoxicity (HR = 8.3, 95% CI = 2.6-27; P < .001) were associated with mortality. Among patients with prior ART exposure, opportunistic infections other than TB (HR = 6, 95% CI = 2.6-27; P < .001) were associated with mortality.Mortality in patients with HIV-associated TB is still high. To reduce mortality, close clinical monitoring of patients together with initiation of ART during TB treatment is indicated.

An Analysis of The Morbidity and Mortality of Diabetes Mellitus in a Forensic Context

To investigate the spectrum of diseases seen in diabetes mellitus in a forensic context, all autopsy reports of diabetic individuals who presented to Forensic Science, South Australia (FSSA), over a 5-year period from 2005 to 2009 were studied. The leading cause of death was cardiovascular disease (55.0%), followed by unnatural deaths (15.4%) and infections (9.4%). In type 1 diabetics, principal causes of death included cardiovascular disease (44.7%), acute metabolic complications (18.7%), unnatural deaths (17.9%), and infections (8.9%). However, frequencies of these diseases differed in type 2 diabetics, with cardiovascular events responsible for 56.6% of cases, followed by unnatural deaths (15.0%) and infections (10.9%). A larger number of male deaths were seen in all disease categories, except respiratory and gastrointestinal where the frequencies were similar to females. Cardiovascular disease was the leading overall cause of death across all ages except in those under the age of 30 where metabolic complications were more common.