Emerging chronic non-communicable diseases in rural communities of Northern Ethiopia: evidence using population-based verbal autopsy method in Kilite Awlaelo surveillance site

Cause-Specific Mortality Fraction (CSMF) of adult mortality in Butajira, South Central Ethiopia

Cause- and context-specific mortality data are imperative to understand the extent of health problems in low-income settings, where national death registration and cause of death identification systems are at a rudimentary stage. Aiming to estimate cause-specific mortality fractions, adult (15+ years) deaths between January 2008 and April 2020 were extracted from the Butajira health and demographic surveillance system electronic database. The physician review and a computerized algorithm, InterVA (Interpreting Verbal Autopsy), methods were used to assign the likely causes of death from January 2008 to April 2017 (the first) and May 2017 to April 2020 (the second) phase of the surveillance period, respectively. Initially, adult mortality rates per 1000py across sex and age were summarized. A total of 1,625 deaths were captured in 280, 461 person-years, with an overall mortality rate of 5.8 (95%CI: 5.5, 6.0) per 1000py. Principally, mortality fractions for each specific cause of death were estimated, and for 1,571 deaths, specific causes were determined. During the first phase, the leading cause of death was tuberculosis (13.6%), followed by hypertension (6.6%) and chronic liver disease (5.9%). During the second phase, digestive neoplasms (17.3%), tuberculosis (12.1%), and stroke (9.4%) were the leading causes of death, respectively. Moreover, tuberculosis was higher among persons aged 50+ (15.0%), males (13.8%), and in rural areas (14.1%) during the first phase. Hypertensive diseases were higher among females (7.9%) and in urbanities. In the second phase, digestive neoplasms were higher in the age group of 50-64 years (25.4%) and females (19.0%), and stroke was higher in older adults (65+) (10%) and marginally higher among males (9.7%). Our results showed that tuberculosis and digestive neoplasms were the most common causes of death. Hence, prevention, early detection, and management of cases at all levels of the existing healthcare system should be prioritized to avert premature mortality.

Patterns of Medical Admissions and Predictors of Mortality in Ayder Comprehensive Specialized Hospital, Northern Ethiopia: A Prospective Observational Study

Background

Previous works show that noncommunicable diseases (NCDs) are on the rise in developing nations, including Ethiopia, in the background of preexisting communicable diseases (CDs). Data on hospital admission in sub-Saharan Africa are scarce, particularly prospectively collected, and hence this study was done to close the gap in acquiring accurate diagnosis usually faced with retrospective data. We aimed to describe medical admission patterns, their outcomes and determinants at Ayder Comprehensive Specialized Hospital (ACSH) in Tigray, Ethiopia.

Methods

Data were collected prospectively from November 1, 2017 to October 31, 2018 for all medical admissions. Sociodemographic profiles, final diagnosis, outcome of hospitalization, and complications were recorded using a data-abstraction checklist. Data were analyzed using SPSS 26.

Results

There were 2084 medical admissions over 1 year. Median age was 45 years (IQR 31). A majority (1107, 53.1%) were male. The age-group 25-34 years had the most admissions (19.0%). NCDs constituted 68.2% of admissions. According to the International Classification of Diseases, patients were admitted most frequently due to disease of the circulatory system (36.7%) followed by infectious or parasitic diseases (24.1%). Of NCDs, cardiovascular diseases contributed to 53.9%, followed by cancers (8.6%). Of CDs, HIV/AIDS contributed to 31.3%, followed by tuberculosis (22.8%). A total of 1375 (66%) were discharged improved, while 311 (14.9%) died. On multivariate analysis, the in-hospital mortality was significantly higher (18.7%) for CDs than NCDs (13.2%, AOR 1.8, 95% CI 1.4-2.3; P<0.001). Bed occupancy of ACSH medical wards and ICU was 54%.

Conclusion

NCDs were leading causes of medical admissions in ACSH. The presence of CDs and the development of complications were associated with higher risk of death. Attention should be given by policy-makers to curb the higher morbidity from NCDs and mortality from CDs.

Foodscapes, finance, and faith: Multi-sectoral stakeholder perspectives on the local population health and wellbeing in an urbanizing area in Kenya

Introduction

Rapid urbanization (growth of cities) can upset the local population's health and wellbeing by creating obesogenic environments which increase the burden of non-communicable diseases (NCDs). It is important to understand how stakeholders perceive the impact of urbanizing interventions (such as the construction of a new hypermarket) on the health and wellbeing of local populations. Because low- and middle-income countries (LMICs) lack the reliable infrastructure to mitigate the effects of obesogenic environments, so engaging stakeholders who influence dietary habits is one population-level strategy for reducing the burden of NCDs caused by newly built developments.

Methods

We conducted key informant interviews with 36 stakeholders (25 regulatory and 11 local community stakeholders) from Kisumu and Homa Bay Counties of Western Kenya in June 2019. We collected stakeholders' perspectives on the impacts of a new Mall and supermarket in Kisumu, and existing supermarkets in Homa Bay on the health and wellbeing of local populations.

Results

Through thematic discourse analysis, we noted that some stakeholders thought supermarkets enabled access to unhealthy food items despite these outlets being also reliable food sources for discerning shoppers. Others linked the changing physical environment to both an increase in pollution and different types of diseases. Stakeholders were unsure if the pricing and convenience of supermarkets would stop local populations from buying from their usual small-scale food vendors. The key finding of this study was that engaging relevant stakeholders as part of population health impact assessments of new developments in cities are important as it directs focus on health equity and prevention in instances of resource constraints. The findings highlight, also, that community members have a strong awareness of the potential for interventions that would improve the health and wellbeing of local populations.

A qualitative study of the causes and circumstances of drowning in Uganda

Background

Drowning is a serious worldwide and preventable injury problem, especially in low- and middle-income countries (LMICs). The aim of this paper is to draw on the results of semi-structured interviews with witnesses, family members and friends of persons involved in fatal and nonfatal drowning incidents to describe the circumstances of drowning in both lakeside and non-lakeside districts and to identify potential contextually appropriate interventions for drowning prevention and surveillance in Uganda.

Methods

The findings presented in this study were based on data collected from study participants selected through purposive sampling comprising 324 individual face-to-face interviews with drowning witnesses, family members, friends of and survivors of drowning and ten (10) focus group discussions held with community members in 14 districts in Uganda. Data analysis was done using the Framework Analysis Approach with the aid of the Microsoft Atlas ti software (version 8) program.

Results

The study results reveal a range of circumstances under which drowning occurs in Uganda, poor record keeping of drowning incidents, fear of reporting drowning incidences to the authorities, challenges in preventing drowning and proposed strategies for mitigating the problem.

Conclusions

This study found that there is no specialized record keeping system for drowning cases in Uganda and where such records are kept, the system is entirely manual (in hard copy form) with no electronic storage of data. Secondly, the drowning cases reported to police posts and stations in various parts of the country are not transmitted to the district headquarters and national database. These and other conclusions not only provide valuable insights into understanding of drowning circumstances but also the key policy and programme interventions for water-based economic activities such as fishing and public water transportation in Uganda and other LMICs.

Causes of infant deaths and patterns of associated factors in Eastern Ethiopia: Results of verbal autopsy (InterVA-4) study

Background

In a range of setting, detecting and generate empirical information on the cause of infant death and contributing risk factors at population level is basically utmost essential to take evidence-based measures in reducing infant morbidity and mortality. An electronic verbal autopsy is suitable tool and best alternative solution to determine individuals’ cause of death in a setting where the majority of deaths occur at home and civil registration systems do not exist. The present study was undertaken to find out cause of infant death, applying computer-based probabilistic model (InterVA-4) and analyze the patterns of association factors of mother’s and the deceased infant’s characteristics to the leading cause-specific infant mortality in Eastern Ethiopia.

Methods

The study employed a community-based prospective longitudinal survey, which was conducted with routinely enumeration of reported infant deaths for a period of two years (from September 2016 to August 2018) in Eastern part of Ethiopia. Using the two-stage cluster sampling technique, the study was undertaken in four randomly selected districts of West Hararghe zone and two districts of zone 3 in Oromia and Afar regional state, respectively. The study included a total of 362 infants who were deceased during the study period. Data was collected by trained enumerators by interviewing the mothers or guardians of the deceased infant using a 2014 standardize World Health Organization (WHO) Verbal Autopsy questionnaire. InterVA-4 model were used for processing and interpreting verbal autopsy data in order to arrive at the most likely causes of infant death. SPSS version 23 was also used for statistical analysis of frequency distribution and logistic regression for the association between covariates and outcomes.

Findings

Of the overall (362) deceased infants’ during the study period, 53.0% of deaths occurred during neonatal time while 47.0% died in the post-neonatal period. Acute respiratory infection including neonatal and post-neonatal pneumonia (38.4%), birth asphyxia (16.4%), diarrheal diseases (16.3%), prematurity (7.4%) and malaria (4.3%) were found to be the leading causes of infant mortality in the study area. The independent factors strongly associated with probable ARI, including pneumonia related mortality as compared to all-causes of death were infants with maternal age lower than 20 years old (p = 0.001, AOR: 4.82, 95% CI: 1.88, 12.3) and infant being died outside of heath facilities (P = 0.007, AOR: 2.85, 95% CI: 1.33, 6.12). The post-neonatal period (P = 0.000, AOR: 15.5, 95% CI: 6.35, 37.8) and infant died in the wet season (P = 0.006, AOR: 2.38, 95% CI: 1.28, 4.44) had strong relationship with dying from diarrhea-related death than those infants died from all non-diarrhea. The death due to malaria robustly associated with infants whose mothers age between 20–35 years old (P = 0.024, AOR: 4.44, 95% CI: 1.22, 16.2) and infant who was dwelled in the districts of Afar region (P = 0.013, AOR: 4.08, 95% CI: 1.35, 12.4).

Conclusion

The highest cause of infant mortality was associated with disease of respiratory system, particularly acute respiratory infection, including both neonates and post-neonatal pneumonia. Most of the infant deaths existed are as a result of diseases and conditions that are readily preventable or treatable cause, similar to those reported in worldwide, which have needs of further attention. The patterns of significant associated factors across cause-specific mortality against all-cause of death were dissimilar. Therefore, strengthen maternal and child health program with effective preventive interventions emphasizing on the most common cause of infant deaths and those factors contributing in raising mortality risk are required.

Prevalence of chronic non-communicable diseases in Ethiopia: A systematic review and meta-analysis of evidence

Background

Non-communicable diseases (NCDs) are a growing global health challenge disproportionately impacting low- and middle-income settings, including Ethiopia. Currently, the body of evidence describing the burden of NCDs is fragmented, inconsistent, health facility- or institution-based, and out-dated in Ethiopia. We conducted a systematic review of the literature and meta-analysis of the prevalence of NCDs in community settings in Ethiopia.

Review methodology

Community-based quantitative studies published in English between January 1st, 2012, and June 30th, 2022, that reported on the prevalence of NCDs in Ethiopia were included. A systematic search of Medline, Embase, Scopus, CINAHL, and Global Health using pretested search terms related to NCDs was conducted, and data were extracted using a piloted data extraction proforma adapted from the Joanna Briggs Institute tool. Meta-analysis was performed using Stata 16. While the pooled prevalence of Diabetes Mellitus (DM) and undiagnosed (DM) was computed and presented using forest plots, then overall prevalence of NCDs and other various types of NCDs were narratively synthesized. I2 was used to assess heterogeneity. Studies that did not fulfill the criteria (used similar tool to measure the types of NCDs) for meta-analysis were narratively synthesized.

Results

Twenty-two studies met the inclusion criteria. Five studies measured the prevalence of NCDs (all NCDs together), ranging from 29 to 35% (prevalence estimates not pooled). The pooled prevalence of Diabetes Mellitus (DM) across ten studies was 5% (95% CI: 4–7%). Three studies each reported on the prevalence of undiagnosed DM (pooled prevalence 5%, 95% CI: 4–7%) and pre-DM (pooled prevalence 7%, 95% CI: 3–14%%). In a narrative analysis the prevalence of cardiovascular conditions ranged from 13.4 to 32.2% (n = 3 studies), cancer mortality ranged from 4 to 18% (n = 3 studies) and respiratory conditions ranged from 1 to 18% (n = 3 studies). Some studies have determined more than one NCDs and that is why the total number of studies are exceeding more than twenty studies.

Conclusion and recommendations

Our analysis found that approximately one-third of Ethiopians have an NCD, with cardiovascular diseases the most common of all NCDs. The prevalence of respiratory conditions also appears high, but there are insufficient data for a pooled estimate. Whilst the prevalence of DM appears relatively low, there is evidence that the magnitude is increasing. Public health actions to address the high burden of cardiovascular and respiratory diseases, as well as the increasing magnitude of DM in Ethiopia, must be prioritized.

Systematic review registration

PROSPERO [CRD42020196815].

Validity of InterVA model versus physician review of verbal autopsy for tracking tuberculosis-related mortality in Ethiopia

BACKGROUND

In most African countries where a legitimate vital registration system is lacking, physicians often review verbal autopsy (VA) data to determine the cause of death, while there are concerns about the routine practicality, accuracy, and reliability of this procedure. In Ethiopia where the burden of tuberculosis (TB) remains unacceptably high, reliable VA data are needed to guide intervention strategies. This study aimed to validate the InterVA model against the physician VA in tracking TB-related mortality in Ethiopia.

METHODS

From a sample of deaths in Addis Ababa, Ethiopia, VAs were conducted on TB-related mortality, physician-certified verbal autopsy (PCVA) through multiple steps to ascertain the causes of death. InterVA model was used to interpret the causes of death. Estimates of TB-related deaths between physician reviews and the InterVA model were compared using Cohen's Kappa (k), Receiver-operator characteristic (ROC) curve analysis, sensitivity, and specificity to compare agreement between PCVA and InterVA.

RESULTS

A total of 8952 completed PCVA were used. The InterVA model had an optimal likelihood cut-off point sensitivity of 0.64 (95% CI: 59.0-69.0) and specificity of 0.95 (95% CI: 94.9-95.8). The area under the ROC curve was 0.79 (95% CI: 0.78-0.81). The level of agreement between physician reviews and the InterVA model to identifying TB-related mortality was moderate (k = 0.59, 95% CI: 0.57-0.61).

CONCLUSION

The InterVA model is a viable alternative to physician review for tracking TB-related causes of death in Ethiopia. From a public health perspective, InterVA helps to analyze the underlying causes of TB-related deaths cost-effectively using routine survey data and translate to policies and strategies in resource-constrained countries.

Trends and causes of adult mortality from 2007 to 2017 using verbal autopsy method, Addis Ababa, Ethiopia

OBJECTIVES

We aim to analyse the trends and causes of mortality among adults in Addis Ababa.

SETTING

This analysis was conducted using verbal autopsy data from the Addis Ababa Mortality Surveillance in Addis Ababa, Ethiopia.

PARTICIPANTS

All deceased adults aged 15 years and above between 2007-2012 and 2015-2017 were included in the analysis.

OUTCOME MEASURES

We collected verbal autopsy and conducted physician review to ascertain cause of death.

RESULT

A total of 7911 data were included in this analysis. Non-communicable disease (NCD) accounted for 62.8% of adult mortality. Mortality from communicable diseases, maternal conditions and nutritional deficiencies followed this by accounting for 30.3% of total mortality. Injury accounted for 6.8% of total mortality. We have observed a significant decline in mortality attributed to group one cause of death (43.25% in 2007 to 12.34% in 2017, p<0.001). However, we observed a significant increase in mortality attributed to group II cause of death (from 49.95% in 2007 to 81.17% in 2017, p<0.001). The top five leading cause of death in 2017 were cerebrovascular disease (12.8%), diabetes mellitus (8.1%), chronic liver disease (6.3%), hypertension (5.7%), ischaemic heart disease (5.7%) and other specified neoplasm (5.2%).

CONCLUSION

We documented an epidemiological shift in cause of mortality from communicable diseases to NCD over 10 years. There is a great progress in reducing mortality due to communicable diseases over the past years. However, the burden of NCDs call for actions for improving access to quality health service, improved case detection and community education to increase awareness. Integrating NCD intervention in to a well-established and successful programme targeting communicable diseases in the country might be beneficial for improving provision of comprehensive healthcare.

The burden of cardiovascular diseases in Ethiopia from 1990 to 2017: evidence from the Global Burden of Disease Study

In Ethiopia, evidence on the national burden of cardiovascular diseases (CVDs) is limited. To address this gap, this systematic analysis estimated the burden of CVDs in Ethiopia using the Global Burden of Disease (GBD) 2017 study data. The age-standardized CVD prevalence, disability-adjusted life years (DALYs) and mortality rates in Ethiopia were 5534 (95% uncertainty interval [UI] 5310.09 - 5774.0), 3549.6 (95% UI 3229.0 - 3911.9) and 182.63 (95% UI 165.49 - 203.9) per 100 000 population, respectively. Compared with 1990, the age-standardized CVD prevalence rate in 2017 showed no change. But significant reductions were observed in CVD mortality (54.7%), CVD DALYs (57.7%) and all-cause mortality (53.4%). The top three prevalent CVDs were ischaemic heart disease, rheumatic heart disease and stroke in descending order. The reduction in the mortality rate due to CVDs is slower than for communicable, maternal, neonatal and nutritional disease mortalities. As a result, CVDs are the leading cause of mortality in Ethiopia. These findings urge Ethiopia to consider CVDs as a priority public health problem.

Epidemiology of hypertension in selected towns of Wollega zones, Western Ethiopia, 2019: A community-based cross-sectional study

Introduction:

Hypertension remains an emerging public health problem globally, particularly in developing countries. Age, income level, obesity, alcohol consumption, smoking, vegetables and fruit consumption, physical activity and chat chewing were some risk factors of hypertension. However, there are limited data on the epidemiology of hypertension in Ethiopia. This study aimed to assess Epidemiology of Hypertension among the community of selected towns of Wollega zones.

Methods:

A community-based cross-sectional study was conducted from 1 to 30 June 2019 in selected towns of Wollega zones. A multistage sampling technique was used to select 840 study participants. Data were collected using the WHO STEP wise approach. The data were coded and entered into EpiData 3, and exported to SPSS version 20.0 for analysis. Bivariate and multivariable logistic regression analyses were conducted. Statistical significance was declared at p-value < 0.05.

Results:

The study included a total of 838 respondents with a response rate of 99.7%. The prevalence of hypertension was found to be 189 (22.6%) (95% confidence interval = 19.9%–25.2%). Of this, 108 (12.9%) and 81 (9.7%) of female and male were hypertensive, respectively. Age groups of 30–44 years (adjusted odds ratio = 2.65 (1.43, 4.89)), 45–59 years (adjusted odds ratio = 3.55 (1.79, 7.04)), above 60 years (adjusted odds ratio = 2.97 (1.43, 6.18)), having history of alcohol consumption (adjusted odds ratio = 4.29 (2.4, 7.66)), involving in vigorous physical activity (adjusted odds ratio = 0.096 (0.028, 0.33)), not walking to and from the work (adjusted odds ratio = 13.12 (8.34, 20.67)), being overweight (adjusted odds ratio = 1.98 (1.21, 3.25)), inadequate fruits serving per day (adjusted odds ratio = 2.93 (1.75, 4.88)) were significantly associated with hypertension.

Conclusion:

The prevalence of hypertension was found to be high in the study area. Older age, alcohol consumption, not engaging in vigorous activity, physical inactivity, being overweight and inadequate intake of fruits were found to be risk factors for hypertension. Therefore, health care providers should provide extensive health education and promotion on recommended lifestyle modification to tackle the burden of hypertension.

What factors are associated with maternal undernutrition in eastern zone of Tigray, Ethiopia? Evidence for nutritional well-being of lactating mothers

Background

Maternal undernutrition is a pervasive health problem among Ethiopian mothers. This study aims at identifying the level of maternal undernutrition and its associated factors in Kilte Awaleo-Health and Demographic Surveillance Site (KA-HDSS), Tigray region, Ethiopia.

Methods

Nutritional status of 2260 lactating mothers was evaluated using the mid-upper-arm circumference (MUAC). Data from the vital events and verbal autopsy databases were linked to the survey and baseline recensus data to investigate the association of adult mortality from chronic causes of death (CoD) on maternal undernutrition. We employed a generalized log-binomial model to estimate the independent effects of the fitted covariates.

Results

The overall prevalence of maternal undernutrition based on MUAC < 23 cm was 38% (95% CI: 36.1, 40.1%). Recent occurrence of household morbidity (adjusted prevalence ratio (adjPR) = 1.49; 95%CI: 1.22, 1.81) was associated with increased risk of maternal undernutrition. In addition, there was a 28% higher risk (adjPR = 1.28; 95%CI: 0.98, 1.67) of maternal undernutrition for those mothers who lived in households with history of adult mortality from chronic diseases. Especially, its association with severe maternal undernutrition was strong (adjusted OR = 3.27; 95%CI: 1.48, 7.22). In contrast, good maternal health-seeking practice (adjPR = 0.86; 95%CI: 0.77, 0.96) and production of diverse food crops (adjPR = 0.72; 95%CI: 0.64, 0.81) were associated with a lower risk of maternal undernutrition. Relative to mothers with low scores of housing and environmental factors index (HAEFI), those with medium and higher scores of HAEFI had 0.81 (adjPR = 0.81; 95%CI: 0.69, 0.95) and 0.82 (adjPR = 0.82; 95%CI: 0.72, 0.95) times lower risk of maternal undernutrition, respectively.

Conclusions

Efforts to ameliorate maternal undernutrition need to consider the influence of the rising epidemiology of adult mortality from chronic diseases. Our data clearly indicate the need for channeling the integrated intervention power of nutrition-sensitive development programs with that of nutrition-specific sectoral services.

Injury related adult deaths in Addis Ababa, Ethiopia: analysis of data from verbal autopsy

Background

Injury related deaths are causing huge impact on families and communities throughout the world. Reports show that developing countries are highly affected by injury deaths. Ethiopia is among the countries that are highly affected by injury deaths especially road traffic accident. Previous studies in Ethiopia concerning injury deaths were mostly based on hospital records. However, in the context of Ethiopia, where majority of the deaths are happening outside health facilities, hospital-based studies cannot give the exact proportion of injury deaths. This study aimed to assess the proportion and types of injury deaths in Addis Ababa and the distribution with different socio-demographic characteristics using data from verbal autopsy.

Methods

We used verbal autopsy data of Addis Ababa Mortality Surveillance Program. The basic source of data for Addis Ababa Mortality Surveillance is burial surveillance from all cemeteries of Addis Ababa. We analyzed causes of injury mortality by different characteristics and tried to show the trends.

Results

Over the 8 years period of time injury has contributed about 7 % of the total deaths. Majority of injury related deaths were among males. Traffic accidents were the major injury related deaths for both sexes; intentional self-harm was highly observed among males compared with females. The findings of this study showed that the proportion of injury related deaths decreased with increasing age.

Conclusions

This study witnessed that deaths resulting from injuries are substantial health challenges in Addis Ababa. Road traffic accident is the most common cause of injury related deaths in the study area. The findings also indicated that males and the productive age groups are highly affected by injury deaths.

Drowning among fishing communities on the Tanzanian shore of lake Victoria: a mixed-methods study to examine incidence, risk factors and socioeconomic impact

OBJECTIVES

To estimate the incidence of unintentional fatal drowning and describe associated risk factors among Lake Victoria fishing communities, and to assess perceived social, financial and other impacts among families and colleagues of persons who drowned.

DESIGN

A retrospective, observational mixed-methods study, conducted between September 2017 and February 2018.

SETTING

Eight Tanzanian fishing communities on Lake Victoria.

PARTICIPANTS

Persons who drowned in the preceding 24 months were identified using an extensive community networking approach. Adult family members, colleagues or community members familiar with the habits and behaviours of people who drowned and/or circumstances of drowning incidents participated in surveys (n=44) and in-depth interviews (n=22).

MAIN OUTCOME MEASURES

Pooled drowning incidence, with sensitivity analyses allowing for uncertainties in population estimates. Risk factors were identified through the evaluation of behavioural characteristics of persons who drowned and circumstances of drowning incidents. Perceived socioeconomic impacts were assessed through semi-structured interviews with their family members and colleagues.

RESULTS

The estimated drowning incidence was 217/100 000 person-years (95% CI 118 to 425/100 000). Of 86 victims identified, 70 (81%) were fishermen (79% aged 18-40 years; all men) and 9 were children (all ≤10 years). All deaths occurred in the lake. Most adults (65/77; 84%) were fishing from a boat when they drowned; 57/77 (74%) died in the evening (from ~5 pm) or at night. Six children (67%) drowned while swimming/playing at the lakeshore unsupervised. Few victims (2/86; 2%) were wearing a life jacket at the time of death. Reported socioeconomic impacts of these deaths ranged from income loss to family break-up.

CONCLUSIONS

Drowning is a significant risk in Tanzanian lakeside fishing communities, with estimated mortality exceeding national incidence rates of fatal malaria, tuberculosis or HIV, but preventative strategies appear uncommon. Socioeconomic impact at the family level may be substantial. Intervention strategies are required to reduce the drowning burden among this neglected at-risk population.

Epidemiology, Risk Factors and Measures for Preventing Drowning in Africa: A Systematic Review

Background and Objectives: Drowning is a leading cause of unintentional injury related mortality worldwide, and accounts for roughly 320,000 deaths yearly. Over 90% of these deaths occur in low- and middle-income countries with inadequate prevention measures. The highest rates of drowning are observed in Africa. The aim of this review is to describe the epidemiology of drowning and identify the risk factors and strategies for prevention of drowning in Africa. Materials and Methods: A review of multiple databases (MEDLINE, CINAHL, PsycINFO, Scopus and Emcare) was conducted from inception of the databases to the 1st of April 2019 to identify studies investigating drowning in Africa. The preferred reporting items for systematic review and meta-analysis (PRISMA) was utilised. Results: Forty-two articles from 15 countries were included. Twelve articles explored drowning, while in 30 articles, drowning was reported as part of a wider study. The data sources were coronial, central registry, hospital record, sea rescue and self-generated data. Measures used to describe drowning were proportions and rates. There was a huge variation in the proportion and incidence rate of drowning reported by the studies included in the review. The potential risk factors for drowning included young age, male gender, ethnicity, alcohol, access to bodies of water, age and carrying capacity of the boat, weather and summer season. No study evaluated prevention strategies, however, strategies proposed were education, increased supervision and community awareness. Conclusions: There is a need to address the high rate of drowning in Africa. Good epidemiological studies across all African countries are needed to describe the patterns of drowning and understand risk factors. Further research is needed to investigate the risk factors and to evaluate prevention strategies.

Short-term clinical outcomes of patients admitted with chronic liver disease to selected teaching hospitals in Ethiopia

BACKGROUND

Chronic liver disease (CLD) is a progressive destruction of liver tissue with subsequent necrosis that persists for at least 6 months. In Ethiopia, despite the high burden report, data on CLD is limited. The objective of this study was to assess short-term clinical outcomes in patients admitted with chronic liver disease to three tertiary teaching hospitals in Ethiopia and to identify predictors of mortality.

METHODS

A cohort of 109 patients admitted with CLD to three tertiary teaching hospitals in Ethiopia, were prospectively followed from the time of admission to 30-days of hospital discharge. The study was conducted from April 1, 2018, to October 5, 2018. Kaplan-Maier curve was used to estimate survival and cox-regression analysis to identify predictors of mortality.

RESULT

A total of 109 patients (80% male) diagnosed with CLD were included. Median age of the participants was 38(IQR, 30-48). The overall median length of hospital stay was 7(IQR, 4-11) days. Of the total, 39(35.8%) patients were HBsAg positive, and 12(11%) patients were anti-HCV positive. The 30-day mortality was 38(34.9%), and most of the deaths, 31(81.6%) occurred before hospital discharge. Hepatic encephalopathy at admission; being with unidentified risk factor/etiologies of CLD and total bilirubin level were independent predictors of in-hospital mortality. Patients with hepatic encephalopathy at admission had approximately 11 times increased risk of death as compared to patients without hepatic encephalopathy at admission. Similarly, the hazard of mortality was 5.8 times higher in those patients with unidentified risk factor/etiology as compared to others. The risk of dying had also increased with an increase in bilirubin (1.188[95% CI, 1.0719-1.316]) level.

CONCLUSION

Approximately one-quarter of patients with CLD died during their hospital stay, and the risk of death continued after hospital discharge. Hepatic encephalopathy at admission, unidentified risk factor/etiology and increased level of total bilirubin are poor prognostic factors. Given that more than one third the patients had HBV-infection, access to antiviral drugs could help improve the prognosis of patients with end-stage liver disease in Ethiopia, as well as prevent the progression of the disease if initiated earlier.

Nutrition-specific and sensitive drivers of poor child nutrition in Kilte Awlaelo-Health and Demographic Surveillance Site, Tigray, Northern Ethiopia: implications for public health nutrition in resource-poor settings

Background: Child undernutrition is a prevalent health problem and poses various short and long-term consequences. Objective: This study seeks to investigate the burden of child undernutrition and its drivers in Kilte Awlaelo-Health and Demographic Surveillance Site, Tigray, northern Ethiopia. Methods: In 2015, cross-sectional data were collected from 1,525 children aged 6-23 months. Maternal and child nutritional status was assessed using the mid upper arm circumference. Child's dietary diversity score was calculated using 24-hours dietary recall method. Log-binomial regression and partial proportional odds model were fitted to examine the drivers of poor child nutrition and child dietary diversity (CDD), respectively. Results: The burden of undernutrition and inadequate CDD was 13.7% (95% CI: 12.1-15.5%) and 81.3% (95%CI: 79.2-83.1%), respectively. Maternal undernutrition (adjusted prevalence ratio, adjPR = 1.47; 95%CI: 1.14-1.89), low CDD (adjPR = 1.90; 95%CI: 1.22-2.97), and morbidity (adjPR = 1.83; 95%CI: 1.15-2.92) were the nutrition-specific drivers of child undernutrition. The nutrition-sensitive drivers were poverty (compared to the poorest, adjPR poor = 0.65 [95%CI:0.45-0.93], adjPR medium = 0.64 [95%CI: 0.44-0.93], adjPR wealthy = 0.46 [95%CI: 0.30-0.70], and adjPR wealthiest = 0.53 [95%CI: 0.34-0.82]), larger family size (adjPR = 1.10; 95%CI: 1.02-1.18), household head's employment insecurity (adjPR = 2.10; 95%CI: 1.43-3.09), and residing in highlands (adjPR = 1.93; 95%CI: 1.36-2.75). The data show that higher CDD was positively associated with wealth (OR wealthy = 3.06 [95%CI: 1.88-4.99], OR wealthiest = 2.57 [95%CI: 1.53-4.31]), but it was inversely associated with lack of diverse food crops production in highlands (OR = 0.23; 95%CI: 0.10-0.57]). Conclusions: Our findings suggest that the burden of poor child nutrition is very high in the study area. Multi-sectoral collaboration and cross-disciplinary interventions between agriculture, nutrition and health sectors are recommended to address child undernutrition in resource poor and food insecure rural communities of similar settings.

Unexplained chronic liver disease in Ethiopia: a cross-sectional study

BACKGROUND

Hepatitis B virus (HBV) infection is assumed to be the major cause of chronic liver disease (CLD) in sub-Saharan Africa. The contribution of other aetiological causes of CLD is less well documented and hence opportunities to modulate other potential risk factors are being lost. The aims of this study were to explore the aetiological spectrum of CLD in eastern Ethiopia and to identify plausible underlying risk factors for its development.

METHODS

A cross-sectional study was undertaken between April 2015 and April 2016 in two public hospitals in Harar, eastern Ethiopia. The study population comprised of consenting adults with clinical and radiological evidence of chronic liver disease. The baseline evaluation included: (i) a semi-structured interview designed to obtain information about the ingestion of alcohol, herbal medicines and local recreational drugs such as khat (Catha edulis); (ii) clinical examination; (iii) extensive laboratory testing; and, (iv) abdominal ultrasonography.

RESULTS

One-hundred-and-fifty patients with CLD (men 72.0%; median age 30 [interquartile range 25-40] years) were included. CLD was attributed to chronic HBV infection in 55 (36.7%) individuals; other aetiological agents were identified in a further 12 (8.0%). No aetiological factors were identified in the remaining 83 (55.3%) patients. The overall prevalence of daily khat use was 78.0%, while alcohol abuse, defined as > 20 g/day in women and > 30 g/day in men, was rare (2.0%). Histological features of toxic liver injury were observed in a subset of patients with unexplained liver injury who underwent liver biopsy.

CONCLUSION

The aetiology of CLD in eastern Ethiopia is largely unexplained. The widespread use of khat in the region, together with histopathological findings indicating toxic liver injury, suggests an association which warrants further investigation.

Reporting of ethics in peer-reviewed verbal autopsy studies: a systematic review

Introduction

Verbal autopsy (VA) is a method that determines the cause of death by interviewing a relative of the deceased about the events occurring before the death, in regions where medical certification of cause of death is incomplete. This paper aims to review the ethical standards reported in peer-reviewed VA studies.

Methods

A systematic review of Medline and Ovid was conducted by two independent researchers. Data were extracted and analysed for articles based on three key areas: Institutional Review Board (IRB) clearance and consenting process; data collection and management procedures, including: time between death and interview; training and education of interviewer, confidentiality of data and data security; and declarations of funding and conflict of interest.

Results

The review identified 802 articles, of which 288 were included. The review found that 48% all the studies reported having IRB clearance or obtaining consent of participants. The interviewer training and education levels were reported in 62% and 21% of the articles, respectively. Confidentiality of data was reported for 14% of all studies, 18% did not report the type of respondent interviewed and 51% reported time between death and the interview for the VA. Data security was reported in 8% of all studies. Funding was declared in 63% of all studies and conflict of interest in 42%. Reporting of all these variables increased over time.

Conclusions

The results of this systematic review show that although there has been an increase in ethical reporting for VA studies, there still remains a large gap in reporting.

Injury-related gaining momentum as external causes of deaths in Ethiopian health and demographic surveillance sites: evidence from verbal autopsy study

BACKGROUND

In Ethiopia, though all kinds of mortality due to external causes are an important component of overall mortality often not counted or documented on an individual basis.

OBJECTIVE

The aim of this study was to describe the patterns of mortality from external causes using verbal autopsy (VA) method at the Ethiopian HDSS Network sites.

METHODS

All deaths at Ethiopian HDSS sites were routinely registered and followed up with VA interviews. The VA forms comprised deaths up to 28 days, between four weeks and 14 years and 15 years and above. The cause of a death was ascertained based on an interview with next of families or other caregivers using a standardized questionnaire that draws information on signs, symptoms, medical history and circumstances preceding death after 45 days mourning period. Two physician assigned probable causes of death as underlying, immediate and contributing factors independently using information in VA forms based on the WHO ICD-10 and VA code system. Disagreed cases sent to third physician for independent review and diagnosis. The final cause of death considered when two of the three physicians assigned underlying cause of death; otherwise, labeled as undetermined.

RESULTS

In the period from 2009 to 2013, a total of 9719 deaths were registered. Of the total deaths, 623 (6.4%) were from external causes. Of these, accidental drowning and submersion, 136 (21.8%), accidental fall, 113 (18.1%) and transport-related accidents, 112 (18.0%) were the topmost three leading external causes of deaths. About 436 (70.0%) of deaths were from the age group above 15 years old. Drowning and submersion and transport-related accidents were high in age group between 5 and 14 years old.

CONCLUSION

In this study, external causes of death are significant public health problems and require attention as one of prior health agenda.

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.

National mortality burden due to communicable, non-communicable, and other diseases in Ethiopia, 1990-2015: findings from the Global Burden of Disease Study 2015

BACKGROUND

Ethiopia lacks a complete vital registration system that would assist in measuring disease burden and risk factors. We used the Global Burden of Diseases, Injuries, and Risk Factors Study 2015 (GBD 2015) estimates to describe the mortality burden from communicable, non-communicable, and other diseases in Ethiopia over the last 25 years.

METHODS

GBD 2015 mainly used cause of death ensemble modeling to measure causes of death by age, sex, and year for 195 countries. We report numbers of deaths and rates of years of life lost (YLL) for communicable, maternal, neonatal, and nutritional (CMNN) disorders, non-communicable diseases (NCDs), and injuries with 95% uncertainty intervals (UI) for Ethiopia from 1990 to 2015.

RESULTS

CMNN causes of death have declined by 65% in the last two-and-a-half decades. Injury-related causes of death have also decreased by 70%. Deaths due to NCDs declined by 37% during the same period. Ethiopia showed a faster decline in the burden of four out of the five leading causes of age-standardized premature mortality rates when compared to the overall sub-Saharan African region and the Eastern sub-Saharan African region: lower respiratory infections, tuberculosis, HIV/AIDS, and diarrheal diseases; however, the same could not be said for ischemic heart disease and other NCDs. Non-communicable diseases, together, were the leading causes of age-standardized mortality rates, whereas CMNN diseases were leading causes of premature mortality in 2015. Although lower respiratory infections, tuberculosis, and diarrheal disease were the leading causes of age-standardized death rates, they showed major declines from 1990 to 2015. Neonatal encephalopathy, iron-deficiency anemia, protein-energy malnutrition, and preterm birth complications also showed more than a 50% reduction in burden. HIV/AIDS-related deaths have also decreased by 70% since 2005. Ischemic heart disease, hemorrhagic stroke, and ischemic stroke were among the top causes of premature mortality and age-standardized death rates in Ethiopia in 2015.

CONCLUSIONS

Ethiopia has been successful in reducing deaths related to communicable, maternal, neonatal, and nutritional deficiency diseases and injuries by 65%, despite unacceptably high maternal and neonatal mortality rates. However, the country's performance regarding non-communicable diseases, including cardiovascular disease, diabetes, cancer, and chronic respiratory disease, was minimal, causing these diseases to join the leading causes of premature mortality and death rates in 2015. While the country is progressing toward universal health coverage, prevention and control strategies in Ethiopia should consider the double burden of common infectious diseases and non-communicable diseases: lower respiratory infections, diarrhea, tuberculosis, HIV/AIDS, cardiovascular disease, cancer, and diabetes. Prevention and control strategies should also pay special attention to the leading causes of premature mortality and death rates caused by non-communicable diseases: cardiovascular disease, cancer, and diabetes. Measuring further progress requires a data revolution in generating, managing, analyzing, and using data for decision-making and the creation of a full vital registration system in the country.

National disability-adjusted life years (DALYs) for 257 diseases and injuries in Ethiopia, 1990-2015: findings from the global burden of disease study 2015

BACKGROUND

Disability-adjusted life years (DALYs) provide a summary measure of health and can be a critical input to guide health systems, investments, and priority-setting in Ethiopia. We aimed to determine the leading causes of premature mortality and disability using DALYs and describe the relative burden of disease and injuries in Ethiopia.

METHODS

We used results from the Global Burden of Diseases, Injuries, and Risk Factors Study 2015 (GBD 2015) for non-fatal disease burden, cause-specific mortality, and all-cause mortality to derive age-standardized DALYs by sex for Ethiopia for each year. We calculated DALYs by summing years of life lost due to premature mortality (YLLs) and years lived with disability (YLDs) for each age group and sex. Causes of death by age, sex, and year were measured mainly using Causes of Death Ensemble modeling. To estimate YLDs, a Bayesian meta-regression method was used. We reported DALY rates per 100,000 for communicable, maternal, neonatal, and nutritional (CMNN) disorders, non-communicable diseases, and injuries, with 95% uncertainty intervals (UI) for Ethiopia.

RESULTS

Non-communicable diseases caused 23,118.1 (95% UI, 17,124.4-30,579.6), CMNN disorders resulted in 20,200.7 (95% UI, 16,532.2-24,917.9), and injuries caused 3781 (95% UI, 2642.9-5500.6) age-standardized DALYs per 100,000 in Ethiopia in 2015. Lower respiratory infections, diarrheal diseases, and tuberculosis were the top three leading causes of DALYs in 2015, accounting for 2998 (95% UI, 2173.7-4029), 2592.5 (95% UI, 1850.7-3495.1), and 2562.9 (95% UI, 1466.1-4220.7) DALYs per 100,000, respectively. Ischemic heart disease and cerebrovascular disease were the fourth and fifth leading causes of age-standardized DALYs, with rates of 2535.7 (95% UI, 1603.7-3843.2) and 2159.9 (95% UI, 1369.7-3216.3) per 100,000, respectively. The following causes showed a reduction of 60% or more over the last 25 years: lower respiratory infections, diarrheal diseases, tuberculosis, neonatal encephalopathy, preterm birth complications, meningitis, malaria, protein-energy malnutrition, iron-deficiency anemia, measles, war and legal intervention, and maternal hemorrhage.

CONCLUSIONS

Ethiopia has been successful in reducing age-standardized DALYs related to most communicable, maternal, neonatal, and nutritional deficiency diseases in the last 25 years, causing a major ranking shift to types of non-communicable disease. Lower respiratory infections, diarrheal disease, and tuberculosis continue to be leading causes of premature death, despite major declines in burden. Non-communicable diseases also showed reductions as premature mortality declined; however, disability outcomes for these causes did not show declines. Recently developed non-communicable disease strategies may need to be amended to focus on cardiovascular diseases, cancer, diabetes, and major depressive disorders. Increasing trends of disabilities due to neonatal encephalopathy, preterm birth complications, and neonatal disorders should be emphasized in the national newborn survival strategy. Generating quality data should be a priority through the development of new initiatives such as vital events registration, surveillance programs, and surveys to address gaps in data. Measuring disease burden at subnational regional state levels and identifying variations with urban and rural population health should be conducted to support health policy in Ethiopia.

Tuberculosis and HIV are the leading causes of adult death in northwest Ethiopia: evidence from verbal autopsy data of Dabat health and demographic surveillance system, 2007-2013

BACKGROUND

Reliable data on causes of death form the basis for building evidence on health policy, planning, monitoring, and evaluation. In Ethiopia, the majority of deaths occur at home and civil registration systems are not yet functional. The main objective of verbal autopsy (VA) is to describe the causes of death at the community or population level where civil registration and death certification systems are weak and where most people die at home without having had contact with the health system.

METHODS

Causes of death were classified and prepared based on the International Classification of Diseases (ICD-10). The cause of a death was ascertained based on an interview with next of kin or other caregivers using a standardized questionnaire that draws information on signs, symptoms, medical history, and circumstances preceding death. The cause of death, or the sequence of causes that led to death, is assigned based on the data collected by the questionnaire. The complete VA questionnaires were given to two blinded physicians and reviewed independently. A third physician was assigned to review the case when disagreements in diagnosis arose.

RESULTS

Communicable diseases (519 deaths [48.0%]), non-communicable diseases (377 deaths [34.8%]), and external causes (113 deaths [10.4%]) were the main causes of death between 2007 and 2013. Of communicable diseases, tuberculosis (207 deaths [19.7%]), HIV/AIDS (96 deaths [8.9%]) and meningitis (76 deaths [7.0%]) were the most common causes of death.

CONCLUSION

Tuberculosis, HIV/AIDS, and meningitis were the most common causes of deaths among adults. Death due to non-communicable diseases showed an increasing trend. Increasing community awareness of infections and their interrelationships, tuberculosis case finding, effective local TB programs, successful treatment, and interventions for HIV are supremely important.

Trend and causes of adult mortality in Kersa health and demographic surveillance system (Kersa HDSS), eastern Ethiopia: verbal autopsy method

Background

The health problems of adults have been neglected in many developing countries, yet many studies in these countries show high rates of premature mortality in adults. Measuring adult mortality and its cause through verbal autopsy (VA) methods is becoming an important process for mortality estimates and is a good indicator of the overall mortality rates in resource-limited settings. The objective of this analysis is to describe the levels, distribution, and trends of adult mortality over time (2008-2013) and causes of adult deaths using VA in Kersa Health and Demographic Surveillance System (Kersa HDSS).

Methods

Kersa HDSS is a demographic and health surveillance and research center established in 2007 in the eastern part of Ethiopia. This is a community-based longitudinal study where VA methods were used to assign probable cause of death. Two or three physicians independently assigned cause of death based on the completed VA forms in accordance with the World Health Organization’s International Classification of Diseases. In this analysis, the VA data considered were of all deaths of adults age 15 years and above, over a period of six years (2008–2013). The mortality fractions were determined and the causes of death analyzed. Analysis was done using STATA and graphs were designed using Microsoft Excel.

Results

A total of 1535 adult deaths occurred in the surveillance site during the study period and VA was completed for all these deaths. In general, the adult mortality rate over the six-year period was 8.5 per 1000 adult population, higher for males (9.6) and rural residents (8.6) than females (7.5) and urban residents (8.2). There is a general decrease in the mortality rates over the study period from 9.4 in 2008–2009 to 8.1 in 2012–2013. Out of the total deaths, about one-third (32.4%) occurred due to infectious and parasitic causes, and the second leading cause of death was diseases of circulatory system (11.4%), followed by gastrointestinal disorders (9.2%). Tuberculosis (TB) showed an increasing trend over the years and has been the leading cause of death in 2012 and 2013 for all adult age categories (15–49, 50–64, and 65 years and over). Chronic liver disease (CLD) was indicated as leading cause of death among adults in the age group 15–49 years.

Conclusion

The increasing TB-related mortality in the study years as well as the relative high mortality due to CLD among adults of age 15–49 years should be further investigated and triangulated with health service data to understand the root cause of death.

The epidemiology of drowning in low- and middle-income countries: a systematic review

Background

According to the World Health Organization, drowning is the 3rd leading cause of unintentional injury-related deaths worldwide, accounting for 370,000 annual deaths and 7% of all injury-related deaths. Low- and middle-income countries are the most affected, accounting for 91% of unintentional drowning deaths.

Methods

The authors performed a systematic review of literature indexed in EMBASE, PubMed, Web of Science, Cochrane Library, and Traumatology journals formerly indexed in PubMed in January 2014 and again in September 2016. Abstracts were limited to human studies in English, conducted in low- and middle-income countries, and containing quantitative data on drowning epidemiology.

Results

A total of 62 articles met inclusion criteria. The majority of articles originate from Asia (56%) and Africa (26%). Risk factors for drowning included young age (<17–20 years old), male gender (75% vs. 25% female), rural environment (84% vs. 16% urban), occurring in the daytime (95% vs. 5% night time), lack of adult supervision (76% vs. 18% supervised), and limited swimming ability (86% vs. 10% with swimming ability). There was almost equal risk of drowning in a small body of water versus a large body of water (42% ponds, ditches, streams, wells; 46% lakes, rivers, sea, ocean).

Conclusion

Drowning is a significant cause of injury-related deaths, especially in LMICs. Young males who are unsupervised in rural areas and have limited formal swimming instruction are at greatest risk of drowning in small bodies of water around their homes. Preventative strategies include covering wells and cisterns, fencing off ditches and small ponds, establishing community daycares, providing formal swimming lessons, and increasing awareness of the risks of drowning.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-017-4239-2) contains supplementary material, which is available to authorized users.

Causes of adult female deaths in Bangladesh: findings from two National Surveys

BACKGROUND

Assessment of causes of death and changes in pattern of causes of death over time are needed for programmatic purposes. Limited national level data exist on the adult female causes of death in Bangladesh.

METHOD

Using data from two nationally representation surveys, the 2001 and 2010 Bangladesh Maternal Mortality Surveys (BMMS), the paper examines the causes of adult female death, aged 15-49 years, and changes in the patterns of these deaths. In both surveys, all household deaths three years prior to the survey were identified. Adult female deaths were then followed by a verbal autopsy (VA) using the WHO structured questionnaire. Two physicians independently reviewed the VA forms to assign a cause of death using the ICD-10; in case of disagreement, a third physician made an independent review and assigned a cause of death.

RESULTS

The overall mortality rates for women aged 15-49 in 2001 and 2010 were 182 per 100,000 and 120 per 100,000 respectively. There is a shift in the pattern of causes of death during the period covered by the two surveys. In the 2001 survey, the main causes of death were maternal (20 %), followed by diseases of the circulatory system (15 %), malignancy (14 %) and infectious diseases (13 %). However, in the 2010 survey, malignancies were the leading cause (21 %), followed by diseases of the circulatory system (16 %), maternal causes (14 %) and infectious diseases (8 %). While maternal deaths remained the number one cause of death among 20-34 years old in both surveys, unnatural deaths were the main cause for teenage deaths, and malignancies were the main cause of death for older women. Although there is an increasing trend in the proportion of women who died in hospitals, in both surveys most women died at home (74 % in 2001 and 62 % in 2010).

CONCLUSION

The shift in the pattern of causes of adult female deaths is in agreement with the overall change in the disease pattern from communicable to non-communicable diseases in Bangladesh. Suicide and other violent deaths as the primary cause of deaths among teenage girls demands specific interventions to prevent such premature deaths. Prevention of deaths due to non-communicable diseases should also be a priority.

Infant mortality and causes of infant deaths in rural Ethiopia: a population-based cohort of 3684 births

Background

Ethiopia has made large-scale healthcare investments to improve child health and survival. However, there is insufficient population level data on the current estimates of infant mortality rate (IMR) in the country. The aim of this study was to measure infant mortality rate, investigate risk factors for infant deaths and identify causes of death in a rural population of northern Ethiopia.

Methods

Live births to a cohort of mothers under the Kilite Awlaelo Health and Demographic Surveillance System were followed up to their first birthday or death, between September 11, 2009 and September 10, 2013. Maternal and infant characteristics were collected at baseline and during the regular follow-up visit. Multiple-Cox regression was used to investigate risk factors for infant death. Causes of infant death were identified using physician review verbal autopsy method.

Results

Of the total 3684 infants followed, 174 of them died before their first birthday, yielding an IMR of 47 per 1000 live births (95 % CI: 41, 54) over the four years of follow-up. About 96 % of infants survived up to their first birthday, and 56 % of infant deaths occurred during the neonatal period. Infants born to mothers aged 15–19 years old had higher risk of death (HR = 2.68, 95 % CI: 1. 74, 4.87) than those born to 25–29 years old. Infants of mothers who attained a secondary school and above had 56 % lower risk of death (HR = 0.44, 95 % CI: 0.24, 0.81) compared to those whose mothers did not attend formal education. Sepsis, prematurity and asphyxia and acute lower respiratory tract infections were the commonest causes of death.

Conclusion

The IMR for the four-year period was lower than the national and regional estimates. Our findings suggest the need to improve the newborn care, and empower teenagers to delay teenage pregnancy and attain higher levels of education.

How much do the physician review and InterVA model agree in determining causes of death? A comparative analysis of deaths in rural Ethiopia

Background

Despite it is costly, slow and non-reproducible process, physician review (PR) is a commonly used method to interpret verbal autopsy data. However, there is a growing interest to adapt a new automated and internally consistent method called InterVA. This study evaluated the level of agreement in determining causes of death between PR and the InterVA model.

Methods

Verbal autopsy data for 434 cases collected between September 2009 and November 2012, were interpreted using both PR and the InterVA model. Cohen’s kappa statistic (κ) was used to compare the level of chance corrected case-by-case agreement in the diagnosis reached by the PR and InterVA model.

Results

Both methods gave comparable cause specific mortality fractions of communicable diseases (36.6 % by PR and 36.2 % by the model), non-communicable diseases (31.1 % by PR and 38.2 % by the model) and accidents/injuries (12.9 % by PR and 10.1 % by the model). The level of case-by-case chance corrected concordance between the two methods was 0.33 (95 % CI for κ = 0.29–0.34). The highest and lowest agreements were seen for accidents/injuries and non-communicable diseases; with κ = 0.75 and κ = 0.37, respectively.

Conclusion

If the InterVA were used in place of the existing PR process, the overall diagnosis would be fairly similar. The methods had better agreement in important public health diseases like; TB, perinatal causes, and pneumonia/sepsis; and lower in cardiovascular diseases and neoplasms. Therefore, both methods need to be validated against a gold-standard diagnosis of death.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-015-2032-7) contains supplementary material, which is available to authorized users.

Verbal Autopsy: Evaluation of Methods to Certify Causes of Death in Uganda

To assess different methods for determining cause of death from verbal autopsy (VA) questionnaire data, the intra-rater reliability of Physician-Certified Verbal Autopsy (PCVA) and the accuracy of PCVA, expert-derived (non-hierarchical) and data-driven (hierarchal) algorithms were assessed for determining common causes of death in Ugandan children. A verbal autopsy validation study was conducted from 2008-2009 in three different sites in Uganda. The dataset included 104 neonatal deaths (0-27 days) and 615 childhood deaths (1-59 months) with the cause(s) of death classified by PCVA and physician review of hospital medical records (the 'reference standard'). Of the original 719 questionnaires, 141 (20%) were selected for a second review by the same physicians; the repeat cause(s) of death were compared to the original,and agreement assessed using the Kappa statistic.Physician reviewers' refined non-hierarchical algorithms for common causes of death from existing expert algorithms, from which, hierarchal algorithms were developed. The accuracy of PCVA, non-hierarchical, and hierarchical algorithms for determining cause(s) of death from all 719 VA questionnaires was determined using the reference standard. Overall, intra-rater repeatability was high (83% agreement, Kappa 0.79 [95% CI 0.76-0.82]). PCVA performed well, with high specificity for determining cause of neonatal (>67%), and childhood (>83%) deaths, resulting in fairly accurate cause-specific mortality fraction (CSMF) estimates. For most causes of death in children, non-hierarchical algorithms had higher sensitivity, but correspondingly lower specificity, than PCVA and hierarchical algorithms, resulting in inaccurate CSMF estimates. Hierarchical algorithms were specific for most causes of death, and CSMF estimates were comparable to the reference standard and PCVA. Inter-rater reliability of PCVA was high, and overall PCVA performed well. Hierarchical algorithms performed better than non-hierarchical algorithms due to higher specificity and more accurate CSMF estimates. Use of PCVA to determine cause of death from VA questionnaire data is reasonable while automated data-driven algorithms are improved.

Poor linkages in maternal health care services-evidence on antenatal care and institutional delivery from a community-based longitudinal study in Tigray region, Ethiopia

Background

Progress towards attaining the maternal mortality and maternal health targets set by Millennium Development Goal 5 has been slow in most African countries. Assessing antenatal care and institutional delivery service utilization and their determinants is an important step towards improving maternal health care services.

Methods

Data were drawn from the longitudinal database of Kilite-Awlaelo Health and Demographic Surveillance System. A total of 2361 mothers who were pregnant and who gave birth between September 2009 and August 2013 were included in the analysis. Potential variables to explain antenatal care and institutional delivery service utilization were extracted, and descriptive statistics and logistic regression were used to determine the magnitude of maternal health care service utilization and associated factors, respectively.

Results

More than three-quarters, 76% [95% CI: 74.8%-78.2%] (n = 1806), of mothers had undergone at least one antenatal care visit during their previous pregnancy. However, only 27% [95% CI: 25.3%-28.9%] (n = 639) of mothers gave birth at a health institution. Older mothers, urban residents, mothers with higher education attainment, and farmer mothers were more likely to use antenatal care. Institutional delivery services were more likely to be used among older mothers, urban residents, women with secondary education, mothers who visited antenatal care, and mothers with lower parity.

Conclusions

Despite a relatively high proportion of mothers attending antenatal care services at least once, we found low levels of institutional delivery service utilization. Health service providers in Kilite-Awlaelo should be particularly vigilant regarding the additional maternal health needs of rural and less educated women with high parity.

Adult non-communicable disease mortality in Africa and Asia: evidence from INDEPTH Health and Demographic Surveillance System sites

Background

Mortality from non-communicable diseases (NCDs) is a major global issue, as other categories of mortality have diminished and life expectancy has increased. The World Health Organization's Member States have called for a 25% reduction in premature NCD mortality by 2025, which can only be achieved by substantial reductions in risk factors and improvements in the management of chronic conditions. A high burden of NCD mortality among much older people, who have survived other hazards, is inevitable. The INDEPTH Network collects detailed individual data within defined Health and Demographic Surveillance sites. By registering deaths and carrying out verbal autopsies to determine cause of death across many such sites, using standardised methods, the Network seeks to generate population-based mortality statistics that are not otherwise available.

Objective

To describe patterns of adult NCD mortality from INDEPTH Network sites across Africa and Asia, according to the WHO 2012 verbal autopsy (VA) cause categories, with separate consideration of premature (15–64 years) and older (65+ years) NCD mortality.

Design

All adult deaths at INDEPTH sites are routinely registered and followed up with VA interviews. For this study, VA archives were transformed into the WHO 2012 VA standard format and processed using the InterVA-4 model to assign cause of death. Routine surveillance data also provide person-time denominators for mortality rates.

Results

A total of 80,726 adult (over 15 years) deaths were documented over 7,423,497 person-years of observation. NCDs were attributed as the cause for 35.6% of these deaths. Slightly less than half of adult NCD deaths occurred in the 15–64 age group. Detailed results are presented by age and sex for leading causes of NCD mortality. Per-site rates of NCD mortality were significantly correlated with rates of HIV/AIDS-related mortality.

Conclusions

These findings present important evidence on the distribution of NCD mortality across a wide range of African and Asian settings. This comes against a background of global concern about the burden of NCD mortality, especially among adults aged under 70, and provides an important baseline for future work.

Mortality from external causes in Africa and Asia: evidence from INDEPTH Health and Demographic Surveillance System Sites

BACKGROUND

Mortality from external causes, of all kinds, is an important component of overall mortality on a global basis. However, these deaths, like others in Africa and Asia, are often not counted or documented on an individual basis. Overviews of the state of external cause mortality in Africa and Asia are therefore based on uncertain information. The INDEPTH Network maintains longitudinal surveillance, including cause of death, at population sites across Africa and Asia, which offers important opportunities to document external cause mortality at the population level across a range of settings.

OBJECTIVE

To describe patterns of mortality from external causes at INDEPTH Network sites across Africa and Asia, according to the WHO 2012 verbal autopsy (VA) cause categories.

DESIGN

All deaths at INDEPTH sites are routinely registered and followed up with VA interviews. For this study, VA archives were transformed into the WHO 2012 VA standard format and processed using the InterVA-4 model to assign cause of death. Routine surveillance data also provide person-time denominators for mortality rates.

RESULTS

A total of 5,884 deaths due to external causes were documented over 11,828,253 person-years. Approximately one-quarter of those deaths were to children younger than 15 years. Causes of death were dominated by childhood drowning in Bangladesh, and by transport-related deaths and intentional injuries elsewhere. Detailed mortality rates are presented by cause of death, age group, and sex.

CONCLUSIONS

The patterns of external cause mortality found here generally corresponded with expectations and other sources of information, but they fill some important gaps in population-based mortality data. They provide an important source of information to inform potentially preventive intervention designs.

Malaria mortality in Africa and Asia: evidence from INDEPTH health and demographic surveillance system sites

Background

Malaria continues to be a major cause of infectious disease mortality in tropical regions. However, deaths from malaria are most often not individually documented, and as a result overall understanding of malaria epidemiology is inadequate. INDEPTH Network members maintain population surveillance in Health and Demographic Surveillance System sites across Africa and Asia, in which individual deaths are followed up with verbal autopsies.

Objective

To present patterns of malaria mortality determined by verbal autopsy from INDEPTH sites across Africa and Asia, comparing these findings with other relevant information on malaria in the same regions.

Design

From a database covering 111,910 deaths over 12,204,043 person-years in 22 sites, in which verbal autopsy data were handled according to the WHO 2012 standard and processed using the InterVA-4 model, over 6,000 deaths were attributed to malaria. The overall period covered was 1992–2012, but two-thirds of the observations related to 2006–2012. These deaths were analysed by site, time period, age group and sex to investigate epidemiological differences in malaria mortality.

Results

Rates of malaria mortality varied by 1:10,000 across the sites, with generally low rates in Asia (one site recording no malaria deaths over 0.5 million person-years) and some of the highest rates in West Africa (Nouna, Burkina Faso: 2.47 per 1,000 person-years). Childhood malaria mortality rates were strongly correlated with Malaria Atlas Project estimates of Plasmodium falciparum parasite rates for the same locations. Adult malaria mortality rates, while lower than corresponding childhood rates, were strongly correlated with childhood rates at the site level.

Conclusions

The wide variations observed in malaria mortality, which were nevertheless consistent with various other estimates, suggest that population-based registration of deaths using verbal autopsy is a useful approach to understanding the details of malaria epidemiology.

HIV/AIDS-related mortality in Africa and Asia: evidence from INDEPTH health and demographic surveillance system sites

BACKGROUND

As the HIV/AIDS pandemic has evolved over recent decades, Africa has been the most affected region, even though a large proportion of HIV/AIDS deaths have not been documented at the individual level. Systematic application of verbal autopsy (VA) methods in defined populations provides an opportunity to assess the mortality burden of the pandemic from individual data.

OBJECTIVE

To present standardised comparisons of HIV/AIDS-related mortality at sites across Africa and Asia, including closely related causes of death such as pulmonary tuberculosis (PTB) and pneumonia.

DESIGN

Deaths related to HIV/AIDS were extracted from individual demographic and VA data from 22 INDEPTH sites across Africa and Asia. VA data were standardised to WHO 2012 standard causes of death assigned using the InterVA-4 model. Between-site comparisons of mortality rates were standardised using the INDEPTH 2013 standard population.

RESULTS

The dataset covered a total of 10,773 deaths attributed to HIV/AIDS, observed over 12,204,043 person-years. HIV/AIDS-related mortality fractions and mortality rates varied widely across Africa and Asia, with highest burdens in eastern and southern Africa, and lowest burdens in Asia. There was evidence of rapidly declining rates at the sites with the heaviest burdens. HIV/AIDS mortality was also strongly related to PTB mortality. On a country basis, there were strong similarities between HIV/AIDS mortality rates at INDEPTH sites and those derived from modelled estimates.

CONCLUSIONS

Measuring HIV/AIDS-related mortality continues to be a challenging issue, all the more so as anti-retroviral treatment programmes alleviate mortality risks. The congruence between these results and other estimates adds plausibility to both approaches. These data, covering some of the highest mortality observed during the pandemic, will be an important baseline for understanding the future decline of HIV/AIDS.

Applying the InterVA-4 model to determine causes of death in rural Ethiopia

BACKGROUND

In Ethiopia, most deaths take place at home and routine certification of cause of death by physicians is lacking. As a result, reliable cause of death (CoD) data are often not available. Recently, a computerized method for interpretation of verbal autopsy (VA) data, called InterVA, has been developed and used. It calculates the probability of a set of CoD given the presence of circumstances, signs, and symptoms reported during VA interviews. We applied the InterVA model to describe CoD in a rural population of Ethiopia.

OBJECTIVE

VA data for 436/599 (72.7%) deaths that occurred during 2010-2011 were included. InterVA-4 was used to interpret the VA data into probable cause of death. Cause-specific mortality fraction was used to describe frequency of occurrence of death from specific causes.

RESULTS

InterVA-4 was able to give likely cause(s) of death for 401/436 of the cases (92.0%). Overall, 35.0% of the total deaths were attributed to communicable diseases, and 30.7% to chronic non-communicable diseases. Tuberculosis (12.5%) and acute respiratory tract infections (10.4%) were the most frequent causes followed by neoplasms (9.6%) and diseases of circulatory system (7.2%).

CONCLUSION

InterVA-4 can produce plausible estimates of the major public health problems that can guide public health interventions. We encourage further validation studies, in local settings, so that InterVA can be integrated into national health surveys.

Cause-specific mortality in Africa and Asia: evidence from INDEPTH health and demographic surveillance system sites

BACKGROUND

Because most deaths in Africa and Asia are not well documented, estimates of mortality are often made using scanty data. The INDEPTH Network works to alleviate this problem by collating detailed individual data from defined Health and Demographic Surveillance sites. By registering all deaths over time and carrying out verbal autopsies to determine cause of death across many such sites, using standardised methods, the Network seeks to generate population-based mortality statistics that are not otherwise available.

OBJECTIVE

To build a large standardised mortality database from African and Asian sites, detailing the relevant methods, and use it to describe cause-specific mortality patterns.

DESIGN

Individual demographic and verbal autopsy (VA) data from 22 INDEPTH sites were collated into a standardised database. The INDEPTH 2013 population was used for standardisation. The WHO 2012 VA standard and the InterVA-4 model were used for assigning cause of death.

RESULTS

A total of 111,910 deaths occurring over 12,204,043 person-years (accumulated between 1992 and 2012) were registered across the 22 sites, and for 98,429 of these deaths (88.0%) verbal autopsies were successfully completed. There was considerable variation in all-cause mortality between sites, with most of the differences being accounted for by variations in infectious causes as a proportion of all deaths.

CONCLUSIONS

This dataset documents individual deaths across Africa and Asia in a standardised way, and on an unprecedented scale. While INDEPTH sites are not constructed to constitute a representative sample, and VA may not be the ideal method of determining cause of death, nevertheless these findings represent detailed mortality patterns for parts of the world that are severely under-served in terms of measuring mortality. Further papers explore details of mortality patterns among children and specifically for NCDs, external causes, pregnancy-related mortality, malaria, and HIV/AIDS. Comparisons will also be made where possible with other findings on mortality in the same regions. Findings presented here and in accompanying papers support the need for continued work towards much wider implementation of universal civil registration of deaths by cause on a worldwide basis.

Cause-specific childhood mortality in Africa and Asia: evidence from INDEPTH health and demographic surveillance system sites

Background

Childhood mortality, particularly in the first 5 years of life, is a major global concern and the target of Millennium Development Goal 4. Although the majority of childhood deaths occur in Africa and Asia, these are also the regions where such deaths are least likely to be registered. The INDEPTH Network works to alleviate this problem by collating detailed individual data from defined Health and Demographic Surveillance sites. By registering deaths and carrying out verbal autopsies to determine cause of death across many such sites, using standardised methods, the Network seeks to generate population-based mortality statistics that are not otherwise available.

Objective

To present a description of cause-specific mortality rates and fractions over the first 15 years of life as documented by INDEPTH Network sites in sub-Saharan Africa and south-east Asia.

Design

All childhood deaths at INDEPTH sites are routinely registered and followed up with verbal autopsy (VA) interviews. For this study, VA archives were transformed into the WHO 2012 VA standard format and processed using the InterVA-4 model to assign cause of death. Routine surveillance data also provided person-time denominators for mortality rates. Cause-specific mortality rates and cause-specific mortality fractions are presented according to WHO 2012 VA cause groups for neonatal, infant, 1–4 year and 5–14 year age groups.

Results

A total of 28,751 childhood deaths were documented during 4,387,824 person-years over 18 sites. Infant mortality ranged from 11 to 78 per 1,000 live births, with under-5 mortality from 15 to 152 per 1,000 live births. Sites in Vietnam and Kenya accounted for the lowest and highest mortality rates reported.

Conclusions

Many children continue to die from relatively preventable causes, particularly in areas with high rates of malaria and HIV/AIDS. Neonatal mortality persists at relatively high, and perhaps sometimes under-documented, rates. External causes of death are a significant childhood problem in some settings.

Causes of death among females-investigating beyond maternal causes: a community-based longitudinal study

Background

In developing countries, investigating mortality levels and causes of death among all age female population despite the childhood and maternal related deaths is important to design appropriate and tailored interventions and to improve survival of female residents.

Methods

Under Kilite-Awlealo Health and Demographic Surveillance System, we investigated mortality rates and causes of death in a cohort of female population from 1st of January 2010 to 31st of December 2012. At the baseline, 33,688 females were involved for the prospective follow-up study. Households under the study were updated every six months by fulltime surveillance data collectors to identify vital events, including deaths. Verbal Autopsy (VA) data were collected by separate trained data collectors for all identified deaths in the surveillance site. Trained physicians assigned underlining causes of death using the 10th edition of International Classification of Diseases (ICD). We assessed overall, age- and cause-specific mortality rates per 1000 person-years. Causes of death among all deceased females and by age groups were ranked based on cause specific mortality rates. Analysis was performed using Stata Version 11.1.

Results

During the follow-up period, 105,793.9 person-years of observation were generated, and 398 female deaths were recorded. This gave an overall mortality rate of 3.76 (95% confidence interval (CI): 3.41, 4.15) per 1,000 person-years. The top three broad causes of death were infectious and parasitic diseases (1.40 deaths per 1000 person-years), non-communicable diseases (0.98 deaths per 1000 person-years) and external causes (0.36 per 1000 person-years). Most deaths among reproductive age female were caused by Human Deficiency Virus/Acquired Immune Deficiency Virus (HIV/AIDS) and tuberculosis (0.14 per 1000 person-years for each cause). Pregnancy and childbirth related causes were responsible for few deaths among women of reproductive age—3 out of 73 deaths (4.1%) or 5.34 deaths per 1,000 person-years.

Conclusions

Communicable diseases are continued to be the leading causes of death among all age females. HIV/AIDS and tuberculosis were major causes of death among women of reproductive age. Together with existing efforts to prevent pregnancy and childbirth related deaths, public health and curative interventions on other causes, particularly on HIV/AIDS and tuberculosis, should be strengthened.

Causes of death among adults in northern Ethiopia: evidence from verbal autopsy data in health and demographic surveillance system

BACKGROUND

In countries where registration of vital events is lacking and the proportion of people who die at home without medical care is high, verbal autopsy is used to determine and estimate causes of death.

METHODS

We conducted 723 verbal autopsy interviews of adult (15 years of age and above) deaths from September 2009 to January 2013. Trained physicians interpreted the collected verbal autopsy data, and assigned causes of death according to the international classification of diseases (ICD-10). We did analysis of specific as well as broad causes of death (i.e. non-communicable diseases, communicable diseases and external causes of death) by sex and age using Stata version 11.1. We performed logistic regression to identify socio-demographic predictors using odds ratio with 95% confidence interval and a p-value of 0.05.

FINDINGS

Tuberculosis, cerebrovascular diseases and accidental falls were leading specific causes of death accounting for 15.9%, 7.3% and 3.9% of all deaths. Two hundred sixty three (36.4% [95% CI: 32.9, 39.9]), 252 (34.9% [95% CI: 31.4, 38.4]) and 89 (12.3% [95% CI: 10.1, 14.9]) deaths were due to non-communicable, communicable diseases, and external causes, respectively. Females had 1.5 times (AOR = 1.53 [95% CI: 1.10, 2.15]) higher odds of dying due to communicable diseases than males. The odds of dying due to external causes were 4 times higher among 15-49 years of age (AOR  = 4.02 [95% CI: 2.25, 7.18]) compared to older ages. Males also had 1.7 times (AOR = 1.70 [95% CI: 1.01, 2.85]) higher odds of dying due to external causes than females.

CONCLUSION

Tuberculosis, cerebrovascular diseases and accidental falls were the top three causes of death among adults. Efforts to prevent tuberculosis and cerebrovascular diseases related deaths should be improved and safety efforts to reduce accidents should also receive attention.

Mortality level and predictors in a rural Ethiopian population: community based longitudinal study

Background

Over the last fifty years the world has seen enormous decline in mortality rates. However, in low-income countries, where vital registration systems are absent, mortality statistics are not easily available. The recent economic growth of Ethiopia and the parallel large scale healthcare investments make investigating mortality figures worthwhile.

Methods

Longitudinal health and demographic surveillance data collected from September 11, 2009 to September 10, 2012 were analysed. We computed incidence of mortality, overall and stratified by background variables. Poisson regression was used to test for a linear trend in the standardized mortality rates. Cox-regression analysis was used to identify predictors of mortality. Households located at <2300 meter and ≥2300 meter altitude were defined to be midland and highland, respectively.

Results

An open cohort, with a baseline population of 66,438 individuals, was followed for three years to generate 194,083 person-years of observation. The crude mortality rate was 4.04 (95% CI: 3.77, 4.34) per 1,000 person-years. During the follow-up period, incidence of mortality significantly declined among under five (P<0.001) and 5–14 years old (P<0.001), whereas it increased among 65 years and above (P<0.001). Adjusted for other covariates, mortality was higher in males (hazard ratio (HR) = 1.42, 95% CI: 1.22, 1.66), rural population (HR = 1.74, 95% CI: 1.32, 2.31), highland (HR = 1.20, 95% CI: 1.03, 1.40) and among those widowed (HR = 2.25, 95% CI: 1.81, 2.80) and divorced (HR = 1.80, 95% CI: 1.30, 2.48).

Conclusions

Overall mortality rate was low. The level and patterns of mortality indicate changes in the epidemiology of major causes of death. Certain population groups had significantly higher mortality rates and further research is warranted to identify causes of higher mortality in those groups.