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Assefa N, Scott A, Madrid L, Dheresa M, Mengesha G, Mahdi S, Mahtab S, Dangor Z, Myburgh N, Mothibi LK, Sow SO, Kotloff KL, Tapia MD, Onwuchekwa UU, Djiteye M, Varo R, Mandomando I, Nhacolo A, Sacoor C, Xerinda E, Ogbuanu I, Samura S, Duduyemi B, Swaray-Deen A, Bah A, El Arifeen S, Gurley ES, Hossain MZ, Rahman A, Chowdhury AI, Quique B, Mutevedzi P, Cunningham SA, Blau D, Whitney C. Comparison of causes of stillbirth and child deaths as determined by verbal autopsy and minimally invasive tissue sampling. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0003065. [PMID: 39074089 DOI: 10.1371/journal.pgph.0003065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Accepted: 07/02/2024] [Indexed: 07/31/2024]
Abstract
In resource-limited settings where vital registration and medical death certificates are unavailable or incomplete, verbal autopsy (VA) is often used to attribute causes of death (CoD) and prioritize resource allocation and interventions. We aimed to determine the CoD concordance between InterVA and CHAMPS's method. The causes of death (CoDs) of children <5 were determined by two methods using data from seven low- and middle-income countries (LMICs) enrolled in the Child Health and Mortality Prevention Surveillance (CHAMPS) network. The first CoD method was from the DeCoDe panel using data from Minimally Invasive Tissue Sampling (MITS), whereas the second method used Verbal Autopsy (VA), which utilizes the InterVA software. This analysis evaluated the agreement between the two using Lin's concordance correlation coefficient. The overall concordance of InterVA4 and DeCoDe in assigning causes of death across surveillance sites, age groups, and causes of death was poor (0.75 with 95% CI: 0.73-0.76) and lacked precision. We found substantial differences in agreement by surveillance site, with Mali showing the lowest and Mozambique and Ethiopia the highest concordance. The InterVA4 assigned CoD agrees poorly in assigning causes of death for U5s and stillbirths. Because VA methods are relatively easy to implement, such systems could be more useful if algorithms were improved to more accurately reflect causes of death, for example, by calibrating algorithms to information from programs that used detailed diagnostic testing to improve the accuracy of COD determination.
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Affiliation(s)
- Nega Assefa
- College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Anthony Scott
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Lola Madrid
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Merga Dheresa
- College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Gezahegn Mengesha
- College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Shabir Mahdi
- South African Medical Research Council Vaccines and Infectious Diseases Analytics Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Sana Mahtab
- South African Medical Research Council Vaccines and Infectious Diseases Analytics Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Ziyaad Dangor
- South African Medical Research Council Vaccines and Infectious Diseases Analytics Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Nellie Myburgh
- Centre pour le Développement des Vaccins), Ministère de la Santé, Bamako, Mali
| | | | - Samba O Sow
- Centre pour le Développement des Vaccins), Ministère de la Santé, Bamako, Mali
| | - Karen L Kotloff
- Department of Pediatrics, Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
| | - Milagritos D Tapia
- Department of Pediatrics, Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
| | - Uma U Onwuchekwa
- Centre pour le Développement des Vaccins), Ministère de la Santé, Bamako, Mali
| | - Mahamane Djiteye
- Centre pour le Développement des Vaccins), Ministère de la Santé, Bamako, Mali
| | - Rosauro Varo
- ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique
| | - Inacio Mandomando
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique
- Instituto Nacional de Saude, Ministerio de Saude, Maputo, Mozambique
| | - Ariel Nhacolo
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique
| | | | - Elisio Xerinda
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique
| | | | | | | | | | | | - Shams El Arifeen
- Maternal and Child Health Division, International Centre for Diarrhoeal Disease Research Bangladesh, Dhaka, Bangladesh
| | - Emily S Gurley
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
| | | | - Afruna Rahman
- Program for Emerging Infections, Infectious Disease Division, International Centre for Diarrhoeal Disease Research Bangladesh b, Dhaka, Bangladesh
| | | | - Bassat Quique
- ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique
- Instituto Nacional de Saude, Ministerio de Saude, Maputo, Mozambique
| | - Portia Mutevedzi
- Global Health Institute, Emory University, Atlanta, Georgia, United States of America
| | - Solveig A Cunningham
- Global Health Center, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Dianna Blau
- Global Health Center, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Cyndy Whitney
- Global Health Institute, Emory University, Atlanta, Georgia, United States of America
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Fenta EH, Sisay BG, Gebreyesus SH, Endris BS. Trends and causes of adult mortality from 2007 to 2017 using verbal autopsy method, Addis Ababa, Ethiopia. BMJ Open 2021; 11:e047095. [PMID: 34785542 PMCID: PMC8596056 DOI: 10.1136/bmjopen-2020-047095] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 10/28/2021] [Indexed: 11/22/2022] Open
Abstract
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.
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Affiliation(s)
- Esete Habtemariam Fenta
- Department of Nutrition and Dietetics, Addis Ababa University College of Health Sciences, Addis Ababa, Ethiopia
| | - Binyam Girma Sisay
- Department of Nutrition and Dietetics, Addis Ababa University College of Health Sciences, Addis Ababa, Ethiopia
| | - Seifu H Gebreyesus
- Department of Nutrition and Dietetics, Addis Ababa University, Addis Ababa, Ethiopia
| | - Bilal Shikur Endris
- Department of Nutrition and Dietetics, Addis Ababa University, Addis Ababa, Ethiopia
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Idicula-Thomas S, Gawde U, Jha P. Comparison of machine learning algorithms applied to symptoms to determine infectious causes of death in children: national survey of 18,000 verbal autopsies in the Million Death Study in India. BMC Public Health 2021; 21:1787. [PMID: 34607591 PMCID: PMC8488544 DOI: 10.1186/s12889-021-11829-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 09/15/2021] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Machine learning (ML) algorithms have been successfully employed for prediction of outcomes in clinical research. In this study, we have explored the application of ML-based algorithms to predict cause of death (CoD) from verbal autopsy records available through the Million Death Study (MDS). METHODS From MDS, 18826 unique childhood deaths at ages 1-59 months during the time period 2004-13 were selected for generating the prediction models of which over 70% of deaths were caused by six infectious diseases (pneumonia, diarrhoeal diseases, malaria, fever of unknown origin, meningitis/encephalitis, and measles). Six popular ML-based algorithms such as support vector machine, gradient boosting modeling, C5.0, artificial neural network, k-nearest neighbor, classification and regression tree were used for building the CoD prediction models. RESULTS SVM algorithm was the best performer with a prediction accuracy of over 0.8. The highest accuracy was found for diarrhoeal diseases (accuracy = 0.97) and the lowest was for meningitis/encephalitis (accuracy = 0.80). The top signs/symptoms for classification of these CoDs were also extracted for each of the diseases. A combination of signs/symptoms presented by the deceased individual can effectively lead to the CoD diagnosis. CONCLUSIONS Overall, this study affirms that verbal autopsy tools are efficient in CoD diagnosis and that automated classification parameters captured through ML could be added to verbal autopsies to improve classification of causes of death.
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Affiliation(s)
- Susan Idicula-Thomas
- Biomedical Informatics Centre, Indian Council of Medical Research-National Institute for Research in Reproductive Health, Mumbai, 400012, India.
- Centre for Global Health Research, St. Michael's Hospital, Unity Health Toronto, and Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.
| | - Ulka Gawde
- Biomedical Informatics Centre, Indian Council of Medical Research-National Institute for Research in Reproductive Health, Mumbai, 400012, India
| | - Prabhat Jha
- Centre for Global Health Research, St. Michael's Hospital, Unity Health Toronto, and Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.
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Rai RK, Barik A, Mazumdar S, Chatterjee K, Kalkonde YV, Mathur P, Chowdhury A, Fawzi WW. Non-communicable diseases are the leading cause of mortality in rural Birbhum, West Bengal, India: a sex-stratified analysis of verbal autopsies from a prospective cohort, 2012-2017. BMJ Open 2020; 10:e036578. [PMID: 33099492 PMCID: PMC7590361 DOI: 10.1136/bmjopen-2019-036578] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVES There is a dearth of data on causes of death in rural India, which impedes identification of public health priorities to guide health interventions. This study aims to offer insights from verbal autopsies, to understand the pattern and distribution of causes of death in a rural area of Birbhum District, West Bengal, India. DESIGN Causes of death data were retrieved from a prospective vital event surveillance system. SETTING The Birbhum Population Project, a Health and Demographic Surveillance System, West Bengal, India. PARTICIPANTS Between January 2012 and December 2017, all deaths were recorded. MAIN OUTCOME MEASURES Trained Surveyors tracked all deaths prospectively and used a previously validated verbal autopsy (VA) tool to record causes of death. Experienced physicians reviewed completed VA forms, and assigned cause of death using the 10th version of International Classification of Diseases. In addition to cause-specific mortality fraction, cause-specific crude death rate (CDR) among males and females were estimated. RESULTS A total of 2320 deaths (1348 males and 972 females) were recorded. An estimated CDR was 708/100 000. Over half of all deaths (1176 deaths, 50.7%) were attributed to non-communicable diseases (NCDs), with nearly 30% of all deaths attributed to circulatory system disorders; whereas 24.2% and 3.9% deaths were due to cerebrovascular diseases and ischaemic heart disease, respectively. Equal percent (13%) of males died from external causes and from infectious and parasitic diseases, and 11% died from respiratory system-related diseases. Among females, 12% died from infectious and parasitic diseases. Among children aged 0-4 years, 50% of all male deaths and 45% of all female deaths were attributed to conditions in the perinatal period. CONCLUSIONS NCDs are the leading cause of death among adults in a select population of rural Birbhum, India. Health programmes for rural India should prioritise plans to mitigate deaths due to NCDs.
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Affiliation(s)
- Rajesh Kumar Rai
- Society for Health and Demographic Surveillance, Suri, West Bengal, India
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, Massachusetts, United States
- Department of Economics, University of Göttingen, Göttingen, Germany
- Centre for Modern Indian Studies, University of Göttingen, Göttingen, Germany
| | - Anamitra Barik
- Society for Health and Demographic Surveillance, Suri, West Bengal, India
- Chest Clinic, DTC District Hospital and Niramoy TB Sanatorium, Birbhum, West Bengal, India
| | - Saibal Mazumdar
- Society for Health and Demographic Surveillance, Suri, West Bengal, India
| | - Kajal Chatterjee
- Society for Health and Demographic Surveillance, Suri, West Bengal, India
| | - Yogeshwar V Kalkonde
- Rural NCDs and Tribal Health Programme, Society for Education Action and Research in Community Health, Gadchiroli, Maharashtra, India
| | - Prashant Mathur
- Indian Council of Medical Research-National Centre for Disease Informatics and Research, Bengaluru, Karnataka, India
| | - Abhijit Chowdhury
- Society for Health and Demographic Surveillance, Suri, West Bengal, India
- Department of Hepatology, School of Digestive and Liver Diseases, Institute of Post Graduate Medical Education and Research, Kolkata, West Bengal, India
- Indian Institute of Liver and Digestive Sciences, Kolkata, West Bengal, India
| | - Wafaie W Fawzi
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, Massachusetts, United States
- Department of Epidemiology, Harvard T H Chan School of Public Health, Boston, Massachusetts, United States
- Department of Nutrition, Harvard T H Chan School of Public Health, Boston, Massachusetts, United States
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Uneke CJ, Uro-Chukwu HC, Chukwu OE. Validation of verbal autopsy methods for assessment of child mortality in sub-Saharan Africa and the policy implication: a rapid review. Pan Afr Med J 2019; 33:318. [PMID: 31692720 PMCID: PMC6815483 DOI: 10.11604/pamj.2019.33.318.16405] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Accepted: 08/12/2019] [Indexed: 12/31/2022] Open
Abstract
Reliable data on the cause of child death is the cornerstone for evidence-informed health policy making towards improving child health outcomes. Unfortunately, accurate data on cause of death is essentially lacking in most countries of sub-Saharan Africa due to the widespread absence of functional Civil Registration and Vital Statistics (CRVS) systems. To address this problem, verbal autopsy (VA) has gained prominence as a strategy for obtaining Cause of Death (COD) information in populations where CRVS are absent. This study reviewed publications that investigated the validation of VA methods for assessment of COD. A MEDLINE PubMed search was undertaken in June 2018 for studies published in English that investigated the validation of VA methods in sub-Saharan Africa from 1990-2018. Of the 17 studies identified, 9 fulfilled the study inclusion criteria from which additional five relevant studies were found by reviewing their references. The result showed that Physician-Certified Verbal Autopsy (PCVA) was the most widely used VA method. Validation studies comparing PCVA to hospital records, expert algorithm and InterVA demonstrated mixed and highly varied outcomes. The accuracy and reliability of the VA methods depended on level of healthcare the respondents have access to and the knowledge of the physicians on the local disease aetiology and epidemiology. As the countries in sub-Saharan Africa continue to battle with dysfunctional CRVS system, VA will remain the only viable option for the supply of child mortality data necessary for policy making.
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Affiliation(s)
- Chigozie Jesse Uneke
- African Institute for Health Policy and Health Systems, Ebonyi State University, PMB 053 Abakaliki, Nigeria
| | | | - Onyedikachi Echefu Chukwu
- African Institute for Health Policy and Health Systems, Ebonyi State University, PMB 053 Abakaliki, Nigeria
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Jha P, Kumar D, Dikshit R, Budukh A, Begum R, Sati P, Kolpak P, Wen R, Raithatha SJ, Shah U, Li ZR, Aleksandrowicz L, Shah P, Piyasena K, McCormick TH, Gelband H, Clark SJ. Automated versus physician assignment of cause of death for verbal autopsies: randomized trial of 9374 deaths in 117 villages in India. BMC Med 2019; 17:116. [PMID: 31242925 PMCID: PMC6595581 DOI: 10.1186/s12916-019-1353-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Accepted: 05/28/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Verbal autopsies with physician assignment of cause of death (COD) are commonly used in settings where medical certification of deaths is uncommon. It remains unanswered if automated algorithms can replace physician assignment. METHODS We randomized verbal autopsy interviews for deaths in 117 villages in rural India to either physician or automated COD assignment. Twenty-four trained lay (non-medical) surveyors applied the allocated method using a laptop-based electronic system. Two of 25 physicians were allocated randomly to independently code the deaths in the physician assignment arm. Six algorithms (Naïve Bayes Classifier (NBC), King-Lu, InSilicoVA, InSilicoVA-NT, InterVA-4, and SmartVA) coded each death in the automated arm. The primary outcome was concordance with the COD distribution in the standard physician-assigned arm. Four thousand six hundred fifty-one (4651) deaths were allocated to physician (standard), and 4723 to automated arms. RESULTS The two arms were nearly identical in demographics and key symptom patterns. The average concordances of automated algorithms with the standard were 62%, 56%, and 59% for adult, child, and neonatal deaths, respectively. Automated algorithms showed inconsistent results, even for causes that are relatively easy to identify such as road traffic injuries. Automated algorithms underestimated the number of cancer and suicide deaths in adults and overestimated other injuries in adults and children. Across all ages, average weighted concordance with the standard was 62% (range 79-45%) with the best to worst ranking automated algorithms being InterVA-4, InSilicoVA-NT, InSilicoVA, SmartVA, NBC, and King-Lu. Individual-level sensitivity for causes of adult deaths in the automated arm was low between the algorithms but high between two independent physicians in the physician arm. CONCLUSIONS While desirable, automated algorithms require further development and rigorous evaluation. Lay reporting of deaths paired with physician COD assignment of verbal autopsies, despite some limitations, remains a practicable method to document the patterns of mortality reliably for unattended deaths. TRIAL REGISTRATION ClinicalTrials.gov , NCT02810366. Submitted on 11 April 2016.
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Affiliation(s)
- Prabhat Jha
- Centre for Global Health Research, St Michael's Hospital and Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.
| | - Dinesh Kumar
- Department of Community Medicine, Pramukhswami Medical College, Anand, Gujarat, India
| | - Rajesh Dikshit
- Centre for Cancer Epidemiology, Tata Memorial Centre, Mumbai, India
| | - Atul Budukh
- Centre for Cancer Epidemiology, Tata Memorial Centre, Mumbai, India
| | - Rehana Begum
- Centre for Global Health Research, St Michael's Hospital and Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Prabha Sati
- Centre for Global Health Research, St Michael's Hospital and Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Patrycja Kolpak
- Centre for Global Health Research, St Michael's Hospital and Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Richard Wen
- Centre for Global Health Research, St Michael's Hospital and Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | | | - Utkarsh Shah
- Department of Community Medicine, Pramukhswami Medical College, Anand, Gujarat, India
| | | | | | - Prakash Shah
- Centre for Global Health Research, St Michael's Hospital and Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Kapila Piyasena
- Centre for Global Health Research, St Michael's Hospital and Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Tyler H McCormick
- Department of Statistics, University of Washington, Seattle, USA.,Department of Sociology, University of Washington, Seattle, USA
| | - Hellen Gelband
- Centre for Global Health Research, St Michael's Hospital and Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Samuel J Clark
- London School of Hygiene & Tropical Medicine, London, UK.,Department of Sociology, Ohio State University, Columbus, USA
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Omar A, Ganapathy SS, Anuar MFM, Khoo YY, Jeevananthan C, Maria Awaluddin S, Yn JLM, Rao C. Cause-specific mortality estimates for Malaysia in 2013: results from a national sample verification study using medical record review and verbal autopsy. BMC Public Health 2019; 19:110. [PMID: 30678685 PMCID: PMC6345029 DOI: 10.1186/s12889-018-6384-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Accepted: 12/28/2018] [Indexed: 01/17/2023] Open
Abstract
Background Mortality indicators are essential for monitoring population health. Although Malaysia has a functional death registration system, the quality of information on causes of death still needs improvement, since approximately 30% of deaths are classified to poorly defined causes. This study was conducted to verify registered causes in a sample of deaths in 2013 and utilise the findings to estimate cause-specific mortality indicators for Malaysia in 2013. Methods This is a cross-sectional study involving a nationally representative sample of 14,497 deaths distributed across 19 districts. Registered causes of deaths were verified using standard medical record review protocols for hospital deaths, and locally adapted international standard verbal autopsy procedures for deaths outside hospitals. The findings were used to measure the validity and reliability of the registration data, as well as to establish plausible cause-specific mortality fractions for hospital and non-hospital deaths, which were subsequently used as the basis for estimating national cause-specific mortality indicators. Results The overall response rate for the study was 67%. Verified causes of 5041 hospital deaths and 3724 deaths outside hospitals were used to derive national mortality estimates for 2013 by age, sex and cause. The study was able to reclassify most of the ill-defined deaths to a specific cause. The leading causes of deaths for males were Ischaemic Heart Disease (15.4%), Cerebrovascular diseases (13.7%), Chronic Obstructive Pulmonary Disease (8.5%) and Road Traffic Accident (8.0%). Among females, the leading causes were Cerebrovascular diseases (18.3%), Ischaemic Heart Disease (12.7%), Lower Respiratory Infections (11.5%) and Diabetes Mellitus (7.2%). Conclusions Investigation of registered causes of death using verbal autopsy and medical record review yielded adequate information to enable estimation of cause-specific mortality indicators in Malaysia. Strengthening the national mortality statistics system must be made a priority as it is a core data source for policy and evaluation of the public health and healthcare sectors in Malaysia.
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Affiliation(s)
- Azahadi Omar
- Institute for Public Health, Ministry of Health Malaysia, Jalan Bangsar, 50590, Kuala Lumpur, Malaysia.
| | - Shubash Shander Ganapathy
- Institute for Public Health, Ministry of Health Malaysia, Jalan Bangsar, 50590, Kuala Lumpur, Malaysia
| | | | - Yi Yi Khoo
- Department of Social and Preventive Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Chandrika Jeevananthan
- Institute for Public Health, Ministry of Health Malaysia, Jalan Bangsar, 50590, Kuala Lumpur, Malaysia
| | - S Maria Awaluddin
- Institute for Public Health, Ministry of Health Malaysia, Jalan Bangsar, 50590, Kuala Lumpur, Malaysia
| | - Jane Ling Miaw Yn
- Institute for Public Health, Ministry of Health Malaysia, Jalan Bangsar, 50590, Kuala Lumpur, Malaysia
| | - Chalapati Rao
- Department of Global Health, Research School of Population Health, Australian National University, Canberra, Australia
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Munthali CVT, Kang'oma S, Nasasara K, Zaina LM, Lupafya C, Mziya J, Harries AD, Takarinda KC, Kwataine M, Dambula I, Yosefe S. Can a Village Headman Use an Electronic Village Register and a Simplified Community-Based Verbal Autopsy Tool to Record Numbers and Causes of Death in Rural Malawi? Front Public Health 2018; 6:246. [PMID: 30234090 PMCID: PMC6131634 DOI: 10.3389/fpubh.2018.00246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 08/15/2018] [Indexed: 10/28/2022] Open
Abstract
Introduction: Most people in Africa die without appearing in official vital statistics records. To improve this situation, Malawi has introduced solar-powered electronic village registers (EVR), managed by village headmen, to record birth and death information for production of vital statistics. The EVR is deployed in 83 villages in Traditional Authority Mtema, Lilongwe, which is an area without electricity. In 17 villages, village headmen were also trained to use a simple verbal autopsy (VA) tool adapted from one developed by the World Health Organization (WHO). Study objectives were to (i) document numbers and causes of death occurring in 17 villages between April 2016 and September 2017, and (ii) assess percentage measures of agreement on causes of death as recorded by village headmen using a simple VA tool and by a team of health surveillance assistant (HSA)/medical doctor using the WHO VA tool. Methods: The study was in two-parts: (i) a cross-sectional study using secondary data from the EVR; (ii) primary data collection study comparing causes of death obtained by village headmen using a simple VA tool and by HSA/medical doctor using the WHO VA tool. Results: Over 18 months, 120 deaths were recorded by EVR in 14,264 residents - crude annual death rate 5.6/1,000 population. Median age at death was 43 years with 69 (58%) deaths being in males. Death occurred at home (75%) and at health facility (25%). Malaria, diarrhoeal disease, pulmonary tuberculosis, acute respiratory infection, and stroke accounted for 56% of deaths recorded by village headmen using the simple VA tool. Causes of death between village headmen and the HSA/medical doctor team were compared for 107 deaths. There was full agreement in causes of death in 33 (31%) deaths, mostly for malaria, severe anemia, intentional self-harm, cancer, and epilepsy. Unknown-sudden death and sepsis recorded by the HSA/medical doctor team were responsible for most disagreements. Conclusion: It is feasible for village headmen in rural Malawi to use an EVR and simple VA tool to document numbers and causes of deaths. More work is needed to improve accuracy of causes of death by village headmen.
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Affiliation(s)
| | - Sophie Kang'oma
- Ministry of Home Affairs and Internal Security, National Registration Bureau, Lilongwe, Malawi
| | | | | | | | | | - Anthony D Harries
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | | | - Isaac Dambula
- Central Monitoring and Evaluation Division, Ministry of Health, Lilongwe, Malawi
| | - Simeon Yosefe
- Central Monitoring and Evaluation Division, Ministry of Health, Lilongwe, Malawi
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Dedefo M, Zelalem D, Eskinder B, Assefa N, Ashenafi W, Baraki N, Damena Tesfatsion M, Oljira L, Haile A. Causes of Death among Children Aged 5 to 14 Years Old from 2008 to 2013 in Kersa Health and Demographic Surveillance System (Kersa HDSS), Ethiopia. PLoS One 2016; 11:e0151929. [PMID: 27304832 PMCID: PMC4909200 DOI: 10.1371/journal.pone.0151929] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Accepted: 03/07/2016] [Indexed: 11/04/2022] Open
Abstract
Background The global burden of mortality among children is still very huge though its trend has started declining following the improvements in the living standard. It presents serious challenges to the well-being of children in many African countries. Today, Sub-Saharan Africa alone accounts for about 50% of global child mortality. The overall objective of this study was to determine the magnitude and distribution of causes of death among children aged 5 to 14 year olds in the population of Kersa HDSS using verbal autopsy method for the period 2008 to 2013. Methods Kersa Health and Demographic Surveillance System(Kersa HDSS) was established in September 2007. The center consists of 10 rural and 2 urban kebeles which were selected randomly from 38 kebeles in the district. Thus this study was conducted in Kersa HDSS and data was taken from Kersa HDSS database. The study population included all children aged 5 to 14 years registered during the period of 2008 to 2013 in Kersa HDSS using age specific VA questionnaires. Data were extracted from SPSS database and analyzed using STATA. Results A total of 229 deaths were recorded over the period of six years with a crude death rate of 219.6 per 100,000 population of this age group over the study period. This death rate was 217.5 and 221.5 per 100,000 populations for females and males, respectively. 75% of deaths took place at home. The study identified severe malnutrition(33.9%), intestinal infectious diseases(13.8%) and acute lower respiratory infections(9.2%) to be the three most leading causes of death. In broad causes of death classification, injuries have been found to be the second most cause of death next to communicable diseases(56.3%) attributing to 13.1% of the total deaths. Conclusion and Recommendation In specific causes of death classification severe malnutrition, intestinal infectious diseases and acute lower respiratory infections were the three leading causes of death where, in broad causes of death communicable diseases and injuries were among the leading causes of death. Hence, concerned bodies should take measures to avert the situation of mortality from these causes of death and further inferential analysis into the prevention and management of infectious diseases should also be taken.
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Affiliation(s)
- Melkamu Dedefo
- Kersa Health and Demographic Surveillance System (Kersa HDSS), Harar Ethiopia
- Haramaya University, College of Computing and Informatics, Department of Statistics, Dire Dawa, Ethiopia
- * E-mail:
| | - Desalew Zelalem
- Kersa Health and Demographic Surveillance System (Kersa HDSS), Harar Ethiopia
- Haramaya University, College of Health and Medical Sciences, Harar, Ethiopia
| | - Biniyam Eskinder
- Centers for Disease Control and Prevention (CDC-Eth), Addis Ababa, Ethiopia
| | - Nega Assefa
- Kersa Health and Demographic Surveillance System (Kersa HDSS), Harar Ethiopia
- Haramaya University, College of Health and Medical Sciences, Harar, Ethiopia
| | - Wondimye Ashenafi
- Kersa Health and Demographic Surveillance System (Kersa HDSS), Harar Ethiopia
- Haramaya University, College of Health and Medical Sciences, Harar, Ethiopia
| | - Negga Baraki
- Kersa Health and Demographic Surveillance System (Kersa HDSS), Harar Ethiopia
- Haramaya University, College of Health and Medical Sciences, Harar, Ethiopia
| | - Melake Damena Tesfatsion
- Kersa Health and Demographic Surveillance System (Kersa HDSS), Harar Ethiopia
- Haramaya University, College of Health and Medical Sciences, Harar, Ethiopia
| | - Lemessa Oljira
- Kersa Health and Demographic Surveillance System (Kersa HDSS), Harar Ethiopia
- Haramaya University, College of Health and Medical Sciences, Harar, Ethiopia
| | - Ashenafi Haile
- Centers for Disease Control and Prevention (CDC-Eth), Addis Ababa, Ethiopia
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King C, Zamawe C, Banda M, Bar-Zeev N, Beard J, Bird J, Costello A, Kazembe P, Osrin D, Fottrell E. The quality and diagnostic value of open narratives in verbal autopsy: a mixed-methods analysis of partnered interviews from Malawi. BMC Med Res Methodol 2016; 16:13. [PMID: 26830814 PMCID: PMC4736636 DOI: 10.1186/s12874-016-0115-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Accepted: 01/23/2016] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Verbal autopsy (VA), the process of interviewing a deceased's family or caregiver about signs and symptoms leading up to death, employs tools that ask a series of closed questions and can include an open narrative where respondents give an unprompted account of events preceding death. The extent to which an individual interviewer, who generally does not interpret the data, affects the quality of this data, and therefore the assigned cause of death, is poorly documented. We aimed to examine inter-interviewer reliability of open narrative and closed question data gathered during VA interviews. METHODS During the introduction of VA data collection, as part of a larger study in Mchinji district, Malawi, we conducted partner interviews whereby two interviewers independently recorded open narrative and closed questions during the same interview. Closed questions were collected using a smartphone application (mobile-InterVA) and open narratives using pen and paper. We used mixed methods of analysis to evaluate the differences between recorded responses to open narratives and closed questions, causes of death assigned, and additional information gathered by open narrative. RESULTS Eighteen partner interviews were conducted, with complete data for 11 pairs. Comparing closed questions between interviewers, the median number of differences was 1 (IQR: 0.5-3.5) of an average 65 answered; mean inter-interviewer concordance was 92% (IQR: 92-99%). Discrepancies in open narratives were summarized in five categories: demographics, history and care-seeking, diagnoses and symptoms, treatment and cultural. Most discrepancies were seen in the reporting of diagnoses and symptoms (e.g., malaria diagnosis); only one pair demonstrated no clear differences. The average number of clinical symptoms reported was 9 in open narratives and 20 in the closed questions. Open narratives contained additional information on health seeking and social issues surrounding deaths, which closed questions did not gather. CONCLUSIONS The information gleaned during open narratives was subject to inter-interviewer variability and contained a limited number of symptom indicators, suggesting that their use for assigning cause of death is questionable. However, they contained rich information on care-seeking, healthcare provision and social factors in the lead-up to death, which may be a valuable source of information for promoting accountable health services.
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Affiliation(s)
- C King
- Institute for Global Health, University College London, 3rd Floor, 30 Guilford Street, London, WC1N 1EH, UK.
| | - C Zamawe
- Parent and Child Health Initiative, Lilongwe, Malawi.
| | - M Banda
- MaiMwana Project, Mchinji, Malawi.
| | - N Bar-Zeev
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, College of Medicine, University of Malawi, Blantyre, Malawi.
- Institute of Infection & Global Health, University of Liverpool, Liverpool, UK.
| | - J Beard
- Institute for Global Health, University College London, 3rd Floor, 30 Guilford Street, London, WC1N 1EH, UK.
- London School of Hygiene and Tropical Medicine, London, UK.
| | - J Bird
- Department of Computer Science, City University London, London, UK.
| | - A Costello
- Institute for Global Health, University College London, 3rd Floor, 30 Guilford Street, London, WC1N 1EH, UK.
| | - P Kazembe
- MaiMwana Project, Mchinji, Malawi.
- Baylor College of Medicine Children's Foundation, Lilongwe, Malawi.
| | - D Osrin
- Institute for Global Health, University College London, 3rd Floor, 30 Guilford Street, London, WC1N 1EH, UK.
| | - E Fottrell
- Institute for Global Health, University College London, 3rd Floor, 30 Guilford Street, London, WC1N 1EH, UK.
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Verbal Autopsy: Evaluation of Methods to Certify Causes of Death in Uganda. PLoS One 2015; 10:e0128801. [PMID: 26086600 PMCID: PMC4472780 DOI: 10.1371/journal.pone.0128801] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2014] [Accepted: 04/30/2015] [Indexed: 11/19/2022] Open
Abstract
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.
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12
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Melaku YA, Sahle BW, Tesfay FH, Bezabih AM, Aregay A, Abera SF, Abreha L, Zello GA. Causes of death among adults in northern Ethiopia: evidence from verbal autopsy data in health and demographic surveillance system. PLoS One 2014; 9:e106781. [PMID: 25188025 PMCID: PMC4154754 DOI: 10.1371/journal.pone.0106781] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Accepted: 08/08/2014] [Indexed: 11/19/2022] Open
Abstract
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.
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Affiliation(s)
- Yohannes Adama Melaku
- Department of Public Health, College of Health Sciences, Mekelle University, Mekelle, Ethiopia
| | | | - Fisaha Haile Tesfay
- Department of Public Health, College of Health Sciences, Mekelle University, Mekelle, Ethiopia
| | | | - Alemseged Aregay
- Department of Public Health, College of Health Sciences, Mekelle University, Mekelle, Ethiopia
| | - Semaw Ferede Abera
- Department of Public Health, College of Health Sciences, Mekelle University, Mekelle, Ethiopia
| | - Loko Abreha
- School of Medicine, College of Health Sciences, Mekelle University, Mekelle, Ethiopia
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Aleksandrowicz L, Malhotra V, Dikshit R, Gupta PC, Kumar R, Sheth J, Rathi SK, Suraweera W, Miasnikof P, Jotkar R, Sinha D, Awasthi S, Bhatia P, Jha P. Performance criteria for verbal autopsy-based systems to estimate national causes of death: development and application to the Indian Million Death Study. BMC Med 2014; 12:21. [PMID: 24495287 PMCID: PMC3912490 DOI: 10.1186/1741-7015-12-21] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2013] [Accepted: 11/26/2013] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Verbal autopsy (VA) has been proposed to determine the cause of death (COD) distributions in settings where most deaths occur without medical attention or certification. We develop performance criteria for VA-based COD systems and apply these to the Registrar General of India's ongoing, nationally-representative Indian Million Death Study (MDS). METHODS Performance criteria include a low ill-defined proportion of deaths before old age; reproducibility, including consistency of COD distributions with independent resampling; differences in COD distribution of hospital, home, urban or rural deaths; age-, sex- and time-specific plausibility of specific diseases; stability and repeatability of dual physician coding; and the ability of the mortality classification system to capture a wide range of conditions. RESULTS The introduction of the MDS in India reduced the proportion of ill-defined deaths before age 70 years from 13% to 4%. The cause-specific mortality fractions (CSMFs) at ages 5 to 69 years for independently resampled deaths and the MDS were very similar across 19 disease categories. By contrast, CSMFs at these ages differed between hospital and home deaths and between urban and rural deaths. Thus, reliance mostly on urban or hospital data can distort national estimates of CODs. Age-, sex- and time-specific patterns for various diseases were plausible. Initial physician agreement on COD occurred about two-thirds of the time. The MDS COD classification system was able to capture more eligible records than alternative classification systems. By these metrics, the Indian MDS performs well for deaths prior to age 70 years. The key implication for low- and middle-income countries where medical certification of death remains uncommon is to implement COD surveys that randomly sample all deaths, use simple but high-quality field work with built-in resampling, and use electronic rather than paper systems to expedite field work and coding. CONCLUSIONS Simple criteria can evaluate the performance of VA-based COD systems. Despite the misclassification of VA, the MDS demonstrates that national surveys of CODs using VA are an order of magnitude better than the limited COD data previously available.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | - Prabhat Jha
- Centre for Global Heath Research, St, Michael's Hospital, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.
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Weldearegawi B, Ashebir Y, Gebeye E, Gebregziabiher T, Yohannes M, Mussa S, Berhe H, Abebe Z. Emerging chronic non-communicable diseases in rural communities of Northern Ethiopia: evidence using population-based verbal autopsy method in Kilite Awlaelo surveillance site. Health Policy Plan 2013; 28:891-8. [PMID: 23293101 DOI: 10.1093/heapol/czs135] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION In countries where most deaths are outside health institutions and medical certification of death is absent, verbal autopsy (VA) method is used to estimate population level causes of death. METHODS VA data were collected by trained lay interviewers for 409 deaths in the surveillance site. Two physicians independently assigned cause of death using the International Classification of Diseases manual. RESULTS In general, infectious and parasitic diseases accounted for 35.9% of death, external causes 15.9%, diseases of the circulatory system 13.4% and perinatal causes 12.5% of total deaths. Mortalities attributed to maternal causes and malnutrition were low, 0.2 and 1.5%, respectively. Causes of death varied by age category. About 22.1, 12.6 and 8.4% of all deaths of under 5-year-old children were due to bacterial sepsis of the newborn, acute lower respiratory infections such as neonatal pneumonia and prematurity including respiratory distress, respectively. For 5-15-year-old children, accidental drowning and submersion, accounting for 34.4% of all deaths in this age category, and accidental fall, accounting for 18.8%, were leading causes of death. Among 15-49-year-old adults, HIV/AIDS (16.3%) and tuberculosis (12.8%) were commonest causes of death, whereas tuberculosis and cerebrovascular diseases were major killers of those aged 50 years and above. CONCLUSION In the rural district, mortality due to chronic non-communicable diseases was very high. The observed magnitude of death from chronic non-communicable disease is unlikely to be unique to this district. Thus, formulation of chronic disease prevention and control strategies is recommended.
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Affiliation(s)
- Berhe Weldearegawi
- Department of Public Health, Mekelle University, P.O. Box 1871, Mekelle, Ethiopia.
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15
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Suraweera W, Morris SK, Kumar R, Warrell DA, Warrell MJ, Jha P. Deaths from symptomatically identifiable furious rabies in India: a nationally representative mortality survey. PLoS Negl Trop Dis 2012; 6:e1847. [PMID: 23056661 PMCID: PMC3464588 DOI: 10.1371/journal.pntd.0001847] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2012] [Accepted: 08/20/2012] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND It is estimated that India has more deaths from rabies than any other country. However, existing estimates are indirect and rely on non-representative studies. METHODS AND PRINCIPAL FINDINGS We examined rabies deaths in the ongoing Million Death Study (MDS), a representative survey of over 122,000 deaths in India that uses enhanced types of verbal autopsy. We estimated the age-specific mortality rates of symptomatically identifiable furious rabies and its geographic and demographic distributions. A total of 140 deaths in our sample were caused by rabies, suggesting that in 2005 there were 12,700 (99% CI 10,000 to 15,500) symptomatically identifiable furious rabies deaths in India. Most rabies deaths were in males (62%), in rural areas (91%), and in children below the age of 15 years (50%). The overall rabies mortality rate was 1.1 deaths per 100,000 population (99%CI 0.9 to 1.4). One third of the national rabies deaths were found in Uttar Pradesh (4,300) and nearly three quarters (8,900) were in 7 central and south-eastern states: Chhattisgarh, Uttar Pradesh, Odisha, Andhra Pradesh, Bihar, Assam, and Madhya Pradesh. CONCLUSIONS AND SIGNIFICANCE Rabies remains an avoidable cause of death in India. As verbal autopsy is not likely to identify atypical or paralytic forms of rabies, our figure of 12,700 deaths due to classic and clinically identifiable furious rabies underestimates the total number of deaths due to this virus. The concentrated geographic distribution of rabies in India suggests that a significant reduction in the number of deaths or potentially even elimination of rabies deaths is possible.
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Affiliation(s)
- Wilson Suraweera
- Centre for Global Health Research (CGHR), Li
Ka Shing Knowledge Institute, St. Michael's Hospital and Dalla Lana School
of Public Health, University of Toronto, Toronto, Canada
| | - Shaun K. Morris
- Centre for Global Health Research (CGHR), Li
Ka Shing Knowledge Institute, St. Michael's Hospital and Dalla Lana School
of Public Health, University of Toronto, Toronto, Canada
- Division of Infectious Diseases, Hospital for
Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Rajesh Kumar
- School of Public Health, Post Graduate
Institute of Medical Research and Education, Chandigarh, India
| | - David A. Warrell
- Nuffield Department of Clinical Medicine,
University of Oxford, Oxford, United Kingdom
| | - Mary J. Warrell
- Oxford Vaccine Group, Centre for Clinical
Vaccinology & Tropical Medicine, University of Oxford, Churchill Hospital,
Oxford, United Kingdom
| | - Prabhat Jha
- Centre for Global Health Research (CGHR), Li
Ka Shing Knowledge Institute, St. Michael's Hospital and Dalla Lana School
of Public Health, University of Toronto, Toronto, Canada
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Morris SK, Awasthi S, Khera A, Bassani DG, Kang G, Parashar UD, Kumar R, Shet A, Glass RI, Jha P. Rotavirus mortality in India: estimates based on a nationally representative survey of diarrhoeal deaths. Bull World Health Organ 2012; 90:720-7. [PMID: 23109739 DOI: 10.2471/blt.12.101873] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2012] [Revised: 04/04/2012] [Accepted: 04/10/2012] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To estimate the number of rotavirus-associated deaths among Indian children younger than five years. METHODS We surveyed more than 23 000 child deaths from a nationally representative survey of 1.1 million Indian households during 2001-2003. Diarrhoeal deaths were characterized by region, age and sex and were combined with the proportion of deaths attributable to rotavirus, as determined by hospital microbiologic data collected by the Indian Rotavirus Strain Surveillance Network from December 2005 to November 2007. Rotavirus vaccine efficacy data from clinical trials in developing countries were used to estimate the number of deaths preventable by a national vaccination programme. Data were analysed using Stata SE version 10. FINDINGS Rotavirus caused an estimated 113 000 deaths (99% confidence interval, CI: 86 000-155 000); 50% (54 700) and 75% (85 400) occurred before one and two years of age, respectively. One child in 242 died from rotavirus infection before five years of age. Rotavirus-associated mortality rates overall, among girls and among boys were 4.14 (99% CI: 3.14-5.68), 4.89 (99% CI: 3.75-6.79) and 3.45 (99% CI: 2.58-4.66) deaths per 1000 live births, respectively. Rates were highest in Bihar, Uttar Pradesh and Madhya Pradesh, which together accounted for > 50% of deaths (64 400) nationally. Rotavirus vaccine could prevent 41 000-48 000 deaths among children aged 3-59 months. CONCLUSION The burden of rotavirus-associated mortality is high among Indian children, highlighting the potential benefits of rotavirus vaccination.
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Affiliation(s)
- Shaun K Morris
- Division of Infectious Diseases, Hospital for Sick Children, University of Toronto, 555 University Ave, Toronto, ON M5G1X8, Canada
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Montgomery AL, Morris SK, Bassani DG, Kumar R, Jotkar R, Jha P. Factors associated with physician agreement and coding choices of cause of death using verbal autopsies for 1130 maternal deaths in India. PLoS One 2012; 7:e33075. [PMID: 22470436 PMCID: PMC3314652 DOI: 10.1371/journal.pone.0033075] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2011] [Accepted: 02/09/2012] [Indexed: 12/16/2022] Open
Abstract
Background The Indian Sample Registration System (SRS) with verbal autopsy methods provides estimations of cause specific mortality for maternal deaths, where the majority of deaths occur at home, unregistered. We aim to examine factors that influence physician agreement and coding choices in assigning causes of death from verbal autopsies. Methodology/Principal Findings Among adult deaths identified in the SRS, pregnancy-related deaths recorded in 2001–2003 were assigned ICD-10 codes by two independent physicians. Inter-rater reliability was estimated using Landis Koch Kappa classification – poor to fair agreement; >– moderate agreement; >– substantial agreement; >– high agreement. We identified factors associated with physician agreement using multivariate logistic regression. A central consensus panel reviewed cases for errors and reclassified as needed based on 2011 ICD-10 coding guidelines. Of 1130 pregnancy-related deaths, 1040 were assigned ICD-10 codes by two physicians. We found substantial agreement regardless of the woman's residence, whether the death was registered, religion, respondent's or deceased's education, age, hospital admission or gestational age. Physician agreement was not influenced by the above variables, with the exception of greater agreement in cases where the respondent did not live with the deceased, or early gestational age at the time of death. A central consensus panel reviewed all cases and recoded 10% of cases due to insufficient use of information in the verbal autopsy by the coding physicians and rationale for this reclassification are discussed. Conclusion In the absence of complete vital registration and universal healthcare services, physician coded verbal autopsies continues to be heavily relied upon to ascertain pregnancy-related death. From this study, two independent physicians had good inter-rater reliability for assigning pregnancy-related causes of death in a nationally-represented sample, and physician coding does not appear to be heavily influenced by case characteristics or demographics.
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Affiliation(s)
- Ann L. Montgomery
- Centre for Global Health Research, Li Ka Shing Knowledge Institute, St. Michael Hospital, Toronto, Ontario, Canada
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
- * E-mail:
| | - Shaun K. Morris
- Centre for Global Health Research, Li Ka Shing Knowledge Institute, St. Michael Hospital, Toronto, Ontario, Canada
- Division of Infectious Diseases, Hospital for Sick Children, Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Diego G. Bassani
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Rajesh Kumar
- School of Public Health, Post Graduate Institute of Medical Education, Chandigarh, India
| | - Raju Jotkar
- Centre for Global Health Research, Li Ka Shing Knowledge Institute, St. Michael Hospital, Toronto, Ontario, Canada
| | - Prabhat Jha
- Centre for Global Health Research, Li Ka Shing Knowledge Institute, St. Michael Hospital, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
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Hsiao M, Morris SK, Bassani DG, Montgomery AL, Thakur JS, Jha P. Factors associated with physician agreement on verbal autopsy of over 11,500 injury deaths in India. PLoS One 2012; 7:e30336. [PMID: 22272338 PMCID: PMC3260270 DOI: 10.1371/journal.pone.0030336] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2011] [Accepted: 12/14/2011] [Indexed: 11/29/2022] Open
Abstract
Introduction Worldwide, injuries account for 9.8% of all deaths. The majority of these deaths occur in low- and middle-income countries where vital registration systems are often inadequate. Verbal autopsy (VA) is a tool used to ascertain cause of death in such settings. Validation studies for VA using hospital diagnosed causes of death as comparisons have shown that injury deaths can be reliably diagnosed by VA. However, no study has assessed the factors that may affect physicians' abilities to code specific causes of injury death using VA. Method/Principal Findings This study used data from over 11 500 verbal autopsies of injury deaths from the Million Death Study (MDS) in which 6.3 million people in India were monitored from 2001–2003 for vital events. Deaths that occurred in the MDS were coded by two independent physicians. This study focused on whether physician agreement on the classification of injury deaths was affected by characteristics of the deceased and respondent. Agreement was analyzed using three primary methods: 1) kappa statistic; 2) sensitivity and specificity analysis using the final VA diagnosed category of injury death as gold standard; and 3) multivariate logistic regression using a conceptual hierarchical model. The overall agreement for all injury deaths was 77.9% with a kappa of 0.74 (99% CI 0.74–0.75). Deaths in the injury categories of “transport”, “falls”, “drowning” and “other unintentional injury” occurring outside the home were associated with greater physician agreement than those occurring at home. In contrast, self-inflicted injury deaths that occurred outside the home were associated with lower physician agreement. Conclusions/Significance With few exceptions, most characteristics of the deceased and the respondent did not influence physician agreement on the classification of injury deaths. Physician training and continued adaptation of the VA tool should focus on the reasons these factors influenced physician agreement.
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Affiliation(s)
- Marvin Hsiao
- Centre for Global Health Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Canada.
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Mpimbaza A, Filler S, Katureebe A, Kinara SO, Nzabandora E, Quick L, Ratcliffe A, Wabwire-Mangen F, Chandramohan D, Staedke SG. Validity of verbal autopsy procedures for determining malaria deaths in different epidemiological settings in Uganda. PLoS One 2011; 6:e26892. [PMID: 22046397 PMCID: PMC3203164 DOI: 10.1371/journal.pone.0026892] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2011] [Accepted: 10/05/2011] [Indexed: 10/26/2022] Open
Abstract
BACKGROUND Verbal autopsy (VA) procedures can be used to estimate cause of death in settings with inadequate vital registries. However, the sensitivity of VA for determining malaria-specific mortality may be low, and may vary with transmission intensity. We assessed the diagnostic accuracy of VA procedures as compared to hospital medical records for determining cause of death in children under five in three different malaria transmission settings in Uganda, including Tororo (high), Kampala (medium), and Kisoro (low). METHODS AND FINDINGS Caretakers of children who died in participating hospitals were interviewed using a standardized World Health Organization questionnaire. Medical records from the child's hospitalization were also reviewed. Causes of death based on the VA questionnaires and the medical records were assigned independently by physician reviewers and then compared. A total of 719 cases were included in the final analysis, 67 in Tororo, 600 in Kampala, and 52 in Kisoro. Malaria was classified as the underlying or contributory cause of death by review of medical records in 33 deaths in Tororo, 60 in Kampala, and 0 in Kisoro. The sensitivity of VA procedures for determining malaria deaths in Tororo was 61% (95% CI 44-78%) and 50% in Kampala (95% CI 37-63%). Specificity for determining malaria deaths in Tororo and Kampala was high (>88%), but positive predictive value varied widely, from 83% in Tororo to 34% in Kampala (difference 49%, 95% CI 31-67, p<0.001). The difference between the cause-specific mortality fraction for malaria as determined by VA procedures and medical records was -11% in Tororo, +5% in Kampala, and +14% in Kisoro. CONCLUSIONS Our results suggest that these VA methods have an acceptable level of diagnostic accuracy for determining malaria deaths at the population level in high and medium transmission areas, but not in low transmission areas.
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Affiliation(s)
- Arthur Mpimbaza
- Uganda Malaria Surveillance Project Kampala, Kampala, Uganda.
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Byass P, Kahn K, Fottrell E, Mee P, Collinson MA, Tollman SM. Using verbal autopsy to track epidemic dynamics: the case of HIV-related mortality in South Africa. Popul Health Metr 2011; 9:46. [PMID: 21819601 PMCID: PMC3160939 DOI: 10.1186/1478-7954-9-46] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2011] [Accepted: 08/05/2011] [Indexed: 11/15/2022] Open
Abstract
Background Verbal autopsy (VA) has often been used for point estimates of cause-specific mortality, but seldom to characterize long-term changes in epidemic patterns. Monitoring emerging causes of death involves practitioners' developing perceptions of diseases and demands consistent methods and practices. Here we retrospectively analyze HIV-related mortality in South Africa, using physician and modeled interpretation. Methods Between 1992 and 2005, 94% of 6,153 deaths which occurred in the Agincourt subdistrict had VAs completed, and coded by two physicians and the InterVA model. The physician causes of death were consolidated into a single consensus underlying cause per case, with an additional physician arbitrating where different diagnoses persisted. HIV-related mortality rates and proportions of deaths coded as HIV-related by individual physicians, physician consensus, and the InterVA model were compared over time. Results Approximately 20% of deaths were HIV-related, ranging from early low levels to tenfold-higher later population rates (2.5 per 1,000 person-years). Rates were higher among children under 5 years and adults 20 to 64 years. Adult mortality shifted to older ages as the epidemic progressed, with a noticeable number of HIV-related deaths in the over-65 year age group latterly. Early InterVA results suggested slightly higher initial HIV-related mortality than physician consensus found. Overall, physician consensus and InterVA results characterized the epidemic very similarly. Individual physicians showed marked interobserver variation, with consensus findings generally reflecting slightly lower proportions of HIV-related deaths. Aggregated findings for first versus second physician did not differ appreciably. Conclusions VA effectively detected a very significant epidemic of HIV-related mortality. Using either physicians or InterVA gave closely comparable findings regarding the epidemic. The consistency between two physician coders per case (from a pool of 14) suggests that double coding may be unnecessary, although the consensus rate of HIV-related mortality was approximately 8% lower than by individual physicians. Consistency within and between individual physicians, individual perceptions of epidemic dynamics, and the inherent consistency of models are important considerations here. The ability of the InterVA model to track a more than tenfold increase in HIV-related mortality over time suggests that finely tuned "local" versions of models for VA interpretation are not necessary.
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Affiliation(s)
- Peter Byass
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
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Mwanyangala MA, Urassa HM, Rutashobya JC, Mahutanga CC, Lutambi AM, Maliti DV, Masanja HM, Abdulla SK, Lema RN. Verbal autopsy completion rate and factors associated with undetermined cause of death in a rural resource-poor setting of Tanzania. Popul Health Metr 2011; 9:41. [PMID: 21819584 PMCID: PMC3160934 DOI: 10.1186/1478-7954-9-41] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2011] [Accepted: 08/05/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Verbal autopsy (VA) is a widely used tool to assign probable cause of death in areas with inadequate vital registration systems. Its uses in priority setting and health planning are well documented in sub-Saharan Africa (SSA) and Asia. However, there is a lack of data related to VA processing and completion rates in assigning causes of death in a community. There is also a lack of data on factors associated with undetermined causes of death documented in SSA. There is a need for such information for understanding the gaps in VA processing and better estimating disease burden. OBJECTIVE The study's intent was to determine the completion rate of VA and factors associated with assigning undetermined causes of death in rural Tanzania. METHODS A database of deaths reported from the Ifakara Health and Demographic Surveillance System from 2002 to 2007 was used. Completion rates were determined at the following stages of processing: 1) death identified; 2) VA interviews conducted; 3) VA forms submitted to physicians; 4) coding and assigning of cause of death. Logistic regression was used to determine factors associated with deaths coded as "undetermined." RESULTS The completion rate of VA after identification of death and the VA interview ranged from 83% in 2002 and 89% in 2007. Ninety-four percent of deaths submitted to physicians were assigned a specific cause, with 31% of the causes coded as undetermined. Neonates and child deaths that occurred outside health facilities were associated with a high rate of undetermined classification (33%, odds ratio [OR] = 1.33, 95% confidence interval [CI] (1.05, 1.67), p = 0.016). Respondents reporting high education levels were less likely to be associated with deaths that were classified as undetermined (24%, OR = 0.76, 95% CI (0.60, -0.96), p = 0.023). Being a child of the deceased compared to a partner (husband or wife) was more likely to be associated with undetermined cause of death classification (OR = 1.35, 95% CI (1.04, 1.75), p = 0.023). CONCLUSION Every year, there is a high completion rate of VA in the initial stages of processing; however, a number of VAs are lost during the processing. Most of the losses occur at the final step, physicians' determination of cause of death. The type of respondent and place of death had a significant effect on final determination of the plausible cause of death. The finding provides some insight into the factors affecting full coverage of verbal autopsy diagnosis and the limitations of causes of death based on VA in SSA. Although physician review is the most commonly used method in ascertaining probable cause of death, we suggest further work needs to be done to address the challenges faced by physicians in interpreting VA forms. There is need for an alternative to or improvement of the methods of physician review.
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Affiliation(s)
- Mathew A Mwanyangala
- Ifakara Health Institute, Off passage, P,o,Box 53, Off Mlabani, Ifakara, Kilombero, Morogoro, Tanzania.
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Lozano R, Lopez AD, Atkinson C, Naghavi M, Flaxman AD, Murray CJ. Performance of physician-certified verbal autopsies: multisite validation study using clinical diagnostic gold standards. Popul Health Metr 2011; 9:32. [PMID: 21816104 PMCID: PMC3160925 DOI: 10.1186/1478-7954-9-32] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2011] [Accepted: 08/04/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Physician review of a verbal autopsy (VA) and completion of a death certificate remains the most widely used approach for VA analysis. This study provides new evidence about the performance of physician-certified verbal autopsy (PCVA) using defined clinical diagnostic criteria as a gold standard for a multisite sample of 12,542 VAs. The study was also designed to analyze issues related to PCVA, such as the impact of a second physician reader on the cause of death assigned, the variation in performance with and without household recall of health care experience (HCE), and the importance of local information for physicians reading VAs. METHODS The certification was performed by 24 physicians. The assignment of VA was random and blinded. Each VA was certified by one physician. Half of the VAs were reviewed by a different physician with household recall of health care experience included. The completed death certificate was processed for automated ICD-10 coding of the underlying cause of death. PCVA was compared to gold standard cause of death assignment based on strictly defined clinical diagnostic criteria that are part of the Population Health Metrics Research Consortium (PHMRC) gold standard verbal autopsy study. RESULTS For individual cause assignment, the overall chance-corrected concordance for PCVA against the gold standard cause of death is less than 50%, with substantial variability by cause and physician. Physicians assign the correct cause around 30% of the time without HCE, and addition of HCE improves performance in adults to 45% and slightly higher in children to 48%. Physicians estimate cause-specific mortality fractions (CSMFs) with considerable error for adults, children, and neonates. Only for neonates for a cause list of six causes with HCE is accuracy above 0.7. In all three age groups, CSMF accuracy improves when household recall of health care experience is available. CONCLUSIONS Results show that physician coding for cause of death assignment may not be as robust as previously thought. The time and cost required to initially collect the verbal autopsies must be considered in addition to the analysis, as well as the impact of diverting physicians from servicing immediate health needs in a population to review VAs. All of these considerations highlight the importance and urgency of developing better methods to more reliably analyze past and future verbal autopsies to obtain the highest quality mortality data from populations without reliable death certification.
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Affiliation(s)
- Rafael Lozano
- Institute for Health Metrics and Evaluation, University of Washington, 2301 Fifth Ave, Suite 600, Seattle, WA 98121, USA.
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Morris SK, Bassani DG, Awasthi S, Kumar R, Shet A, Suraweera W, Jha P. Diarrhea, pneumonia, and infectious disease mortality in children aged 5 to 14 years in India. PLoS One 2011; 6:e20119. [PMID: 21629660 PMCID: PMC3101242 DOI: 10.1371/journal.pone.0020119] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2011] [Accepted: 04/15/2011] [Indexed: 11/18/2022] Open
Abstract
Background Little is known about the causes of death in children in India after age five years. The objective of this study is to provide the first ever direct national and sub-national estimates of infectious disease mortality in Indian children aged 5 to 14 years. Methods A verbal autopsy based assessment of 3 855 deaths is children aged 5 to 14 years from a nationally representative survey of deaths occurring in 2001–03 in 1·1 million homes in India. Results Infectious diseases accounted for 58% of all deaths among children aged 5 to 14 years. About 18% of deaths were due to diarrheal diseases, 10% due to pneumonia, 8% due to central nervous system infections, 4% due to measles, and 12% due to other infectious diseases. Nationally, in 2005 about 59 000 and 34 000 children aged 5 to 14 years died from diarrheal diseases and pneumonia, corresponding to mortality of 24·1 and 13·9 per 100 000 respectively. Mortality was nearly 50% higher in girls than in boys for both diarrheal diseases and pneumonia. Conclusions Approximately 60% of all deaths in this age group are due to infectious diseases and nearly half of these deaths are due to diarrheal diseases and pneumonia. Mortality in this age group from infectious diseases, and diarrhea in particular, is much higher than previously estimated.
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Affiliation(s)
- Shaun K Morris
- Centre for Global Health Research, Li Ka Shing Knowledge Institute, St Michael's Hospital, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.
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Bassani DG, Kumar R, Awasthi S, Morris SK, Paul VK, Shet A, Ram U, Gaffey MF, Black RE, Jha P. Causes of neonatal and child mortality in India: a nationally representative mortality survey. Lancet 2010; 376:1853-60. [PMID: 21075444 PMCID: PMC3042727 DOI: 10.1016/s0140-6736(10)61461-4] [Citation(s) in RCA: 300] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND More than 2·3 million children died in India in 2005; however, the major causes of death have not been measured in the country. We investigated the causes of neonatal and child mortality in India and their differences by sex and region. METHODS The Registrar General of India surveyed all deaths occurring in 2001-03 in 1·1 million nationally representative homes. Field staff interviewed household members and completed standard questions about events that preceded the death. Two of 130 physicians then independently assigned a cause to each death. Cause-specific mortality rates for 2005 were calculated nationally and for the six regions by combining the recorded proportions for each cause in the neonatal deaths and deaths at ages 1-59 months in the study with population and death totals from the United Nations. FINDINGS There were 10,892 deaths in neonates and 12,260 in children aged 1-59 months in the study. When these details were projected nationally, three causes accounted for 78% (0·79 million of 1·01 million) of all neonatal deaths: prematurity and low birthweight (0·33 million, 99% CI 0·31 million to 0·35 million), neonatal infections (0·27 million, 0·25 million to 0·29 million), and birth asphyxia and birth trauma (0·19 million, 0·18 million to 0·21 million). Two causes accounted for 50% (0·67 million of 1·34 million) of all deaths at 1-59 months: pneumonia (0·37 million, 0·35 million to 0·39 million) and diarrhoeal diseases (0·30 million, 0·28 million to 0·32 million). In children aged 1-59 months, girls in central India had a five-times higher mortality rate (per 1000 livebirths) from pneumonia (20·9, 19·4-22·6) than did boys in south India (4·1, 3·0-5·6) and four-times higher mortality rate from diarrhoeal disease (17·7, 16·2-19·3) than did boys in west India (4·1, 3·0-5·5). INTERPRETATION Five avoidable causes accounted for nearly 1·5 million child deaths in India in 2005, with substantial differences between regions and sexes. Expanded neonatal and intrapartum care, case management of diarrhoea and pneumonia, and addition of new vaccines to immunisation programmes could substantially reduce child deaths in India. FUNDING US National Institutes of Health, International Development Research Centre, Canadian Institutes of Health Research, Li Ka Shing Knowledge Institute, and US Fund for UNICEF.
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