Adult mortality in sub-saharan Africa, Zambia: Where do adults die?

An assessment of excess mortality during the COVID-19 pandemic, a retrospective post-mortem surveillance in 12 districts - Zambia, 2020-2022

BACKGROUND

The number of COVID-19 deaths reported in Zambia (N = 4069) is most likely an underestimate due to limited testing, incomplete death registration and inability to account for indirect deaths due to socioeconomic disruption during the pandemic. We sought to assess excess mortality during the COVID-19 pandemic in Zambia.

METHODS

We conducted a retrospective analysis of monthly-death-counts (2017-2022) and individual-daily-deaths (2020-2022) of all reported health facility and community deaths at district referral health facility mortuaries in 12 districts in Zambia. We defined COVID-19 wave periods based on a sustained nationally reported SARS-CoV-2 test positivity of greater than 5%. Excess mortality was calculated as the difference between observed monthly death counts during the pandemic (2020-2022) and the median monthly death counts from the pre-pandemic period (2017-2019), which served as the expected number of deaths. This calculation was conducted using a Microsoft Excel-based tool. We compared median daily death counts, median age at death, and the proportion of deaths by place of death (health facility vs. community) by wave period using the Mann-Whitney-U test and chi-square test respectively in R.

RESULTS

A total of 112,768 deaths were reported in the 12 districts between 2020 and 2022, of which 17,111 (15.2%) were excess. Wave periods had higher median daily death counts than non-wave periods (median [IQR], 107 [95-126] versus 96 [85-107], p < 0.001). The median age at death during wave periods was older than non-wave periods (44.0 [25.0-67.0] versus 41.0 [22.0-63.0] years, p < 0.001). Approximately half of all reported deaths occurred in the community, with an even greater proportion during wave periods (50.6% versus 53.1%, p < 0.001), respectively.

CONCLUSION

There was excess mortality during the COVID-19 pandemic in Zambia, with more deaths occurring within the community during wave periods. This analysis suggests more COVID-19 deaths likely occurred in Zambia than suggested by officially reported numbers. Mortality surveillance can provide important information to monitor population health and inform public health programming during pandemics.

Characteristics of cases and deaths arising from SARS-CoV-2 infection in Zambia: March 2020 to April 2021

Introduction

since March 2020, Zambia has been experiencing a SARS-CoV-2 epidemic. Little data has been reported on cases and deaths arising from COVID-19 in Africa. We described the demographic characteristics of these cases and deaths in Zambia.

Methods

we analyzed data on all persons testing positive for SARS-CoV-2 from 18th March 2020 to 25th April 2021 in Zambia. COVID-19 cases were identified through port-of-entry surveillance, contact-tracing, health-care-worker testing, health-facility-based and community-based screening and community-death screening. All diagnoses were confirmed using real-time-polymerase-chain-reaction and rapid-antigen-test-kits of nasopharyngeal specimens. We analyzed age, sex, and date-of-reporting according to whether the cases or deaths occurred during the first wave (1st July to 15th September 2020) or the second wave (15th December 2020 to 10th April 2021). We computed Mann-Whitney-U-test to compare medians of continuous variables and chi-square tests to compare differences between proportions using R.

Results

a total 1,246 (1.36%) deaths were recorded among 91,378 confirmed cases during March 2020-April 2021 in Zambia. Persons who died were older than those who did not (median age 50 years versus 32.0 years, p< 0.001). Although only 4.7% of cases were among persons aged >60 years, most deaths (31.6%) occurred in this age group (p<0.001). More deaths (83.5%) occurred in the community than in health facilities (p<0.001).

Conclusion

during the SARS-CoV-2 epidemic in Zambia, most deaths occurred in the community, indicating potential gaps in public health messaging about COVID-19. Improving health-seeking behaviors for COVID-19 through public messaging campaigns and engaging key community stakeholders in Zambia might reduce avoidable mortality. As the group most impacted by COVID-19 mortality, older persons might need enhanced outreach and linkage to care.

Obstructive sleep apnea and excessive daytime sleepiness among commercial motor vehicle drivers in Lusaka, Zambia

STUDY OBJECTIVES

Obstructive sleep apnea (OSA) is a risk factor for a major public health problem, car crashes, due to excessive daytime sleepiness (EDS). Commercial vehicle driving (CVD) is a hazardous occupation, having a high fatality rate worldwide. There have been no studies on EDS and OSA in Zambia despite the high rate of annual road traffic accidents (RTAs). We aim to determine the prevalence of EDS and OSA risk among CVDs in Lusaka, Zambia, to assess the impact of OSA on high RTA rates.

METHODS

This was a cross-sectional study. The STOP BANG questionnaire and the Epworth Sleepiness Scale were used. Consecutive sampling of drivers was done who were divided into low and high risk of OSA (HROSA). The risk factors associated with OSA in the bivariate analyses were subjected to a multivariate logistic regression model.

RESULTS

One hundred thirty-six drivers participated in the study (all male) with a mean age of 48 ± 5 years. The prevalence of HROSA was 22.8% out of whom 67.7% also had a EDS. Only 9.6% of the total cohort had EDS without HROSA. Using Fisher's exact test, HROSA was significantly associated with older age (> 50 years, P < .001), obesity (body mass index >30, P < .001), neck circumference of > 40 cm (P = .032), and hypertension (P < .001). Snoring and EDS were significantly associated with RTAs (P < .0001 and P = .007, respectively).

CONCLUSIONS

High risk of OSA and EDS are common among CMV drivers in Zambia and underdiagnosed. The risk factors for OSA are amenable to preventive interventions.

CITATION

Simpamba K, May JL, Waghat A, Attarian H, Mateyo K. Obstructive sleep apnea and excessive daytime sleepiness among commercial motor vehicle drivers in Lusaka, Zambia. J Clin Sleep Med. 2023;19(7):1191-1198.

Collecting mortality data via mobile phone surveys: A non-inferiority randomized trial in Malawi

Despite the urgent need for timely mortality data in low-income and lower-middle-income countries, mobile phone surveys rarely include questions about recent deaths. Such questions might a) be too sensitive, b) take too long to ask and/or c) generate unreliable data. We assessed the feasibility of mortality data collection using mobile phone surveys in Malawi. We conducted a non-inferiority trial among a random sample of mobile phone users. Participants were allocated to an interview about their recent economic activity or recent deaths in their family. In the group that was asked mortality-related questions, half of the respondents completed an abridged questionnaire, focused on information necessary to calculate recent mortality rates, whereas the other half completed an extended questionnaire that also included questions about symptoms and healthcare. The primary trial outcome was the cooperation rate, i.e., the number of completed interviews divided by the number of mobile subscribers invited to participate. Secondary outcomes included self-reports of negative feelings and stated intentions to participate in future interviews. We called more than 7,000 unique numbers and reached 3,054 mobile subscribers. In total, 1,683 mobile users were invited to participate. The difference in cooperation rates between those asked to complete a mortality-related interview and those asked to answer questions about economic activity was 0.9 percentage points (95% CI = -2.3, 4.1), which satisfied the non-inferiority criterion. The mortality questionnaire was non-inferior to the economic questionnaire on all secondary outcomes. Collecting mortality data required 2 to 4 additional minutes per reported death, depending on the inclusion of questions about symptoms and healthcare. More than half of recent deaths elicited during mobile phone interviews had not been registered with the National Registration Bureau. Including mortality-related questions in mobile phone surveys is feasible. It might help strengthen the surveillance of mortality in countries with deficient civil registration systems. Registration: AEA RCT Registry, #0008065 (14 September 2021).

Trends and risk factors for non-communicable diseases mortality in Nairobi slums (2008-2017)

INTRODUCTION

Tracking progress in reaching global targets for reducing premature mortality from non-communicable diseases (NCDs) requires accurately collected population based longitudinal data. However, most African countries lack such data because of weak or non-existent civil registration systems. We used data from the Nairobi Urban Health and Demographic Surveillance System (NUDSS) to estimate NCD mortality trends over time and to explore the determinants of NCD mortality.

METHODS

Deaths identified in the NUHDSS were followed up with a verbal autopsy to determine the signs and symptoms preceding the death. Causes of death were then assigned using InSilicoVA algorithm. We calculated the rates of NCD mortality in the whole NUHDSS population between 2008 and 2017, looking at how these changed over time. We then merged NCD survey data collected in 2008, which contains information on potential determinants of NCD mortality in a sub-sample of the NUHDSS population, with follow up information from the full NUHDSS including whether any of the participants died of an NCD or non-NCD cause. Poisson regression models were used to identify independent risk factors (broadly categorized as socio-demographic, behavioural and physiological) for NCD mortality, as well as non-NCD mortality.

RESULTS

In the total NUHDSS population of adults age 18 and over, 23% were assigned an NCD as the most likely cause of death. There was evidence that NCD mortality decreased over the study period, with rates of NCD mortality dropping from 1.32 per 1000 person years in 2008-10 (95% CI: 1.13-1.54) to 0.93 per 1000 person years in 2014-17 (95% CI: 0.80-1.08). Of 5115 individuals who participated in the NCD survey in 2008, 421 died during the follow-up period of which 43% were attributed to NCDs. Increasing age, lower education levels, ever smoking and having high blood pressure were identified as independent determinants of NCD mortality in multivariate analyses.

CONCLUSION

We found that NCDs account for one-quarter of mortality in Nairobi slums, although we document a reduction in the rate of NCD mortality over time. This may be attributed to increased surveillance and introduction of population-wide NCD interventions and health system improvements from research activities in the slums. To achieve further decline there is a need to strengthen health systems to respond to NCD care and prevention along with addressing social factors such as education.

Approaches to integrating palliative care into African health systems: a qualitative systematic review

Africa is characterized by a high burden of disease and health system deficits, with an overwhelming and increasing demand for palliative care (PC). Yet only one African country is currently considered to have advanced integration of palliative care into medical services and generalized PC is said to be available in only a handful of others. The integration of PC into all levels of a health system has been called for to increase access to PC and to strengthen health systems. Contextually appropriate evidence to guide integration is vital yet limited. This qualitative systematic review analyses interventions to integrate PC into African health systems to provide insight into the 'how' of PC integration. Forty articles were identified, describing 51 different interventions. This study found that a variety of integration models are being applied, with limited best practices being evaluated and repeated in other contexts. Interventions typically focused on integrating specialized PC services into individual or multiple health facilities, with only a few examples of PC integrated at a population level. Four identified issues could either promote integration (by being present) or block integration (by their absence). These include the provision of PC at all levels of the health system alongside curative care; the development and presence of sustainable partnerships; health systems and workers that can support integration; and lastly, placing the client, their family and community at the centre of integration. These echo the broader literature on integration of health services generally. There is currently a strong suggestion that the integration of PC contributes to health system strengthening; however, this is not well evidenced in the literature and future interventions would benefit from placing health systems strengthening at the forefront, as well as situating their work within the context of integration of health services more generally.

What socio-economic factors determine place of death for people with life-limiting illness? A systematic review and appraisal of methodological rigour

BACKGROUND

Socio-economic factors play important roles in place of death. However, up-to-date knowledge on socio-economic determinants for place of death is warranted including analysis of collinearity between socio-economic determinants.

AIM

To examine associations between socio-economic determinants (social class, deprivation level in area of residence, income, education, occupation, urbanisation) and place of death among adult patients with life-limiting illnesses. Furthermore, to describe how these factors are operationalised and examined for collinearity.

DESIGN

A systematic review was performed (PROSPERO, record: CRD42018091218) and quality was assessed using the Newcastle-Ottawa Scale.

DATA SOURCES

A comprehensive search of PubMed, Embase, CINAHL, Scopus and PsycINFO was conducted for studies published from 1 January 2008 until the date of the search (23 March 2018) in English or Scandinavian languages.

RESULTS

Of the 1599 unique citations identified, 34 studies were eligible. Dying at home was to a high degree associated with better financial situation and living in rural areas. Furthermore, hospital death was associated with a high level of deprivation in the area of residence and being employed. Regarding educational level, we found mixed and inconclusive results.

CONCLUSION

Inequalities concerning place of death were found, and attention towards socio-economic inequality concerning place of death is necessary, especially in patients with a poor financial status, patients living in deprived and metropolitan areas and patients who are employed. Furthermore, we found a low degree of assessment for collinearity and adjustment of socio-economic variables. These issues should be considered in planning of future studies of socio-economic determinants for place of death.

A Prospective Cohort Study of Factors Associated With Place of Death Among Patients With Late-Stage Cancer in Southern Africa

CONTEXT

Identifying factors that affect terminally ill patients' preferences for and actual place of death may assist patients to die wherever they wish.

OBJECTIVE

The objective of this study was to investigate factors associated with preferred and actual place of death for cancer patients in Johannesburg, South Africa.

METHODS

In a prospective cohort study at a tertiary hospital in Johannesburg, South Africa, adult patients with advanced cancer and their caregivers were enrolled from 2016 to 2018. Study nurses interviewed the patients at enrollment and conducted postmortem interviews with the caregivers.

RESULTS

Of 324 patients enrolled, 191 died during follow-up. Preferred place of death was home for 127 (66.4%) and a facility for 64 (33.5%) patients; 91 (47.6%) patients died in their preferred setting, with a kappa value of congruence of 0.016 (95% CI = -0.107, 0.139). Factors associated with congruence were increasing age (odds ratio [OR]: 1.03, 95% CI: 1.00-1.05), use of morphine (OR: 1.87, 95% CI: 1.04-3.36), and wanting to die at home (OR: 0.44, 95% CI: 0.24-0.82). Dying at home was associated with increasing age (OR 1.03, 95% CI 1.00-1.05) and with the patient wishing to have family and/or friends present at death (OR 6.73, 95% CI 2.97-15.30).

CONCLUSION

Most patients preferred to die at home, but most died in hospital and fewer than half died in their preferred setting. Further research on modifiable factors, such as effective communication, access to palliative care and morphine, may ensure that more cancer patients in South Africa die wherever they wish.

Organizing palliative care in the rural areas of Iran: are family physician-based approaches suitable?

INTRODUCTION

The provision of palliative end-of-life care (P/EOLc) for patients, wherever they live, is an increasingly important service, particularly given the increasing rates of cancer and other life-threatening diseases in Iran. However, unfortunately, those living in the rural areas of Iran are greatly disadvantaged with respect to this type of care. Therefore, the present study explored the feasibility of organizing P/EOLc in the rural areas of Iran.

METHODS

In this qualitative study, two focus group (FG) discussions were held in Tabriz (Iran) with rural family physicians (FPs, n=23) and key P/EOLc stakeholders (n=13). The FG sessions were recorded, transcribed, and the transcriptions checked by participants before the data were subjected to content analysis.

RESULTS

While most FPs indicated that they did not have sufficient involvement in providing P/EOLc, they emphasized the necessity of providing P/EOLc through four main themes and 25 subthemes. The four main themes were labeled as "structures and procedures," "health care provider teams," "obstacles," and "strategies or solutions." Furthermore, according to the main themes and subthemes identified here, the key stakeholders believed that the Iranian health system and the FPs' team have the potential to provide P/EOLc services in rural areas.

CONCLUSION

The most feasible strategy for providing P/EOLc in Iranian rural areas would be to use the current health care framework and base the process around the FP.

Differences in barriers to birth and death registration in Guinea-Bissau: implications for monitoring national and global health objectives

OBJECTIVE

Improving civil registration and vital statistics (CRVS) systems is essential to monitoring health objectives locally and globally. The barriers to birth and particularly death registration in low- and middle-income countries are however poorly understood.

METHODS

We conducted a survey among women of reproductive age in Bissau, the capital of Guinea-Bissau. We asked women with a birth in the past two years whether their child had been registered and had obtained a birth certificate. We elicited the sources of information about birth registration and asked respondents to list their reasons for (not) registering a birth. If their child had died, we asked similar questions about death registration.

RESULTS

Most women (86%) had received messages about birth registration, but few women whose child had died had heard about the need to register deaths (22%). The primary sources of information about birth registration were messages broadcast on the radio or displayed at health facilities. Information about death registration was primarily obtained through informal social networks. Only 16% of births, and 2% of deaths, had been registered. The main barriers to birth registration were administrative pre-requisites and paternal absence. The main reasons for not registering a death were lack of knowledge about death registration and lack of perceived benefits.

CONCLUSION

Strengthening CRVS systems requires addressing the specific barriers preventing birth and death registration. In Bissau, interventions to improve knowledge about death registration are needed. Simplifying registration procedures, as well as providing additional incentives, might help improve the coverage of birth registration.

Returning home to die or leaving home to seek health care? Location of death of urban and rural residents in Burkina Faso and Senegal

Background: In sub-Saharan Africa, the literature on end of life is limited and focuses on place of death as an indicator of access and utilization of health-care resources. Little is known about population mobility at the end of life.

Objective: To document the magnitude, motivations and associated factors of short-term mobility before death among adults over 15 years of age in Burkina Faso and Senegal.

Methods: The study was based on deaths of adult residents reported in three Health and Demographic Surveillance System (HDSS) sites in urban (Ouagadougou) and semi-rural areas (Kaya) of Burkina Faso, and rural areas of Senegal (Mlomp). After excluding deaths from external causes, the analysis covered, respectively, 536 and 695 deaths recorded during the period 2012–2015 in Ouagadougou and Kaya. The period was extended to 2000–2015 in Mlomp, with a sample of 708 deaths. Binary logistic regressions were used to examine the effects of socio-demographic characteristics on place of death (health facility or not) and location of death (within or outside the HDSS).

Results: In Mlomp, Kaya and Ouagadougou, respectively 20.6%, 5.3% and 5.9% of adults died outside the HDSS site. In Mlomp and Kaya, these deaths were more likely to occur in a health facility than deaths that occurred within the site. The reverse situation was found in Ouagadougou. Age is the strongest determinant of mobility before death in Mlomp and Kaya. In Mlomp, young adults (15–39) were 10 times more likely to die outside the site than adults in the 60–79 age group. In Ouagadougou, non-natives were three times more likely to die outside the city than natives.

Conclusions: At the end of life, some rural residents move to urban areas for medical treatment while some urban dwellers return to their village for supportive care. These movements of dying individuals may affect the estimation of urban/rural mortality differentials.

Pattern of all-causes and cause-specific mortality in an area with progressively declining malaria burden in Korogwe district, north-eastern Tanzania

BACKGROUND

Although death records are useful for planning and monitoring health interventions, such information is limited in most developing countries. Verbal autopsy (VA) interviews are alternatively used to determine causes of death in places without or with incomplete hospital records. This study was conducted to determine all causes and cause-specific mortality in Korogwe health and demographic surveillance system (HDSS) undertaken in Korogwe district, northeastern Tanzania.

METHODS

The study was conducted from January 2006 to December 2012 in 14 villages under Korogwe HDSS. Vital events such as births, deaths and migrations were routinely updated quarterly. A standard VA questionnaire was administered to parents/close relatives of the deceased to determine cause of death.

RESULTS

Overall, 1325 deaths of individuals with median age of 46 years were recorded in a population with 170,471.4 person years observed (PY). Crude mortality rate was 7.8 per 1000 PY (95% CI 7.2-8.4) and the highest rate was observed in infants (77.9 per 1000 PY; 95% CI 67.4-90.0). The overall mortality increased between 2006 and 2007, followed by a slight decline up to 2011, with the highest decrease observed in 2012. Causes of deaths were established in 942 (71.1%) deaths and malaria (198 deaths, 21.0%) was the leading cause of death in all age groups except adults (15-59 years). HIV/AIDS (17.6%, n = 365) was the leading cause of death in individuals aged 15-59 years followed by malaria (13.9%) and tuberculosis. Non-communicable diseases (NCDs) including stroke, hypertension, cancer, and cardiac failure caused majority of deaths in elderly (60 years and above) accounting for 37.1% (n = 348) of all deaths, although malaria was the single leading cause of death in this group (16.6%).

CONCLUSION

The study showed a significant decline of deaths in the Korogwe HDSS site and malaria was the main cause of death in all age groups (except adults, aged 15-59 years) while HIV/AIDS and NCDs were the main causes in adults and elderly, respectively. Further surveillance is required to monitor and document changes in cause-specific mortality as malaria transmission continues to decline in this and other parts of Tanzania.

Social determinants of adult mortality from non-communicable diseases in northern Ethiopia, 2009-2015: Evidence from health and demographic surveillance site

INTRODUCTION

In developing countries, mortality and disability from non-communicable diseases (NCDs) is rising considerably. The effect of social determinants of NCDs-attributed mortality, from the context of developing countries, is poorly understood. This study examines the burden and socio-economic determinants of adult mortality attributed to NCDs in eastern Tigray, Ethiopia.

METHODS

We followed 45,982 adults implementing a community based dynamic cohort design recording mortality events from September 2009 to April 2015. A physician review based Verbal autopsy was used to identify the most probable causes of death. Multivariable Cox proportional hazards regression was performed to identify social determinants of NCD mortality.

RESULTS

Across the 193,758.7 person-years, we recorded 1,091 adult deaths. Compared to communicable diseases, NCDs accounted for a slightly higher proportion of adult deaths; 33% vs 34.5% respectively. The incidence density rate (IDR) of NCD attributed mortality was 194.1 deaths (IDR = 194.1; 95% CI = 175.4, 214.7) per 100,000 person-years. One hundred fifty-seven (41.8%), 68 (18.1%) and 34 (9%) of the 376 NCD deaths were due to cardiovascular disease, cancer and renal failure, respectively. In the multivariable analysis, age per 5-year increase (HR = 1.35; 95% CI: 1.30, 1.41), and extended family and non-family household members (HR = 2.86; 95% CI: 2.05, 3.98) compared to household heads were associated with a significantly increased hazard of NCD mortality. Although the difference was not statistically significant, compared to poor adults, those who were wealthy had a 15% (HR = 0.85; 95% CI: 0.65, 1.11) lower hazard of mortality from NCDs. On the other hand, literate adults (HR = 0.35; 95% CI: 0.13, 0.9) had a significantly decreased hazard of NCD attributed mortality compared to those adults who were unable to read and write. The effect of literacy was modified by age and its effect reduced by 18% for every 5-year increase of age among literate adults.

CONCLUSION

In summary, the study indicates that double mortality burden from both NCDs and communicable diseases was evident in northern rural Ethiopia. Public health intervention measures that prioritise disadvantaged NCD patients such as those who are unable to read and write, the elders, the extended family and non-family household co-residents could significantly reduce NCD mortality among the adult population.