Determination of causes of adult deaths using minimally invasive tissue sampling in Gandaki province of Nepal: a multicenter hospital-based study

BACKGROUND

Minimally Invasive Tissue Sampling (MITS) has been successfully used to establish the cause of death in low- and middle-income countries, mostly in stillbirths and neonates. The objective of this study was to determine the causes of death among adults using MITS in the Gandaki province of Nepal and to find out the contribution of MITS to identify the causes of death.

METHODS

A multicentric hospital-based pilot study was conducted to enroll 100 cases of adult deaths. The specimens of cerebrospinal fluid, blood, brain, lungs, and liver tissue were collected utilizing MITS. These specimens underwent standard histopathological, serological, and microbiological analyses. The findings from MITS, and if available, clinical records and forensic autopsy findings were compiled and the cause of death panel identified the causes of death. The final cause of death allocated to each case was based on the WHO International Medical Certificate of Death.

RESULTS

Among a total of 100 cases enrolled during the study period, infectious cause attributed to the immediate cause of death in 77 (77%), cardiovascular in 10 (10%), neurological in 8 (8%), malignancy in two (2%), and gastrointestinal and hepatobiliary cause in one (1%) case. The mean age of the cases was 50.8 ± 15.9 years and 76 (76%) were males. MITS established the cause of death in the causal chain of events in 81(81%) cases and identified the cause of death significantly more with infectious than non-infectious causes (p < 0.001).

CONCLUSIONS

MITS was useful in establishing the cause of death in the majority of adult deaths and the most common cause was infectious disease. Our findings suggest that MITS can be a valuable and alternative tool for mortality surveillance in low-resource settings, where complete diagnostic autopsies are less accepted or less prioritized.

Assessment of Suspected COVID-19 Deaths in Nonhealthcare Settings in Côte d'Ivoire, March 11 to July 31, 2020

According to hospital records, 5 months after reporting its first case of COVID-19, Côte d'Ivoire reported only 102 deaths. We conducted a community mortality survey in the 13 districts where 95% of COVID-19 cases were reported to assess COVID-19 mortality in nonhealthcare settings. To identify suspected COVID-19 deaths in communities, we used data from social and administrative institutions, such as police and fire departments, funeral homes, and places of worship, whose functions include providing services related to deaths. Our survey identified 54 (17.6%) suspected COVID-19 deaths, which is more than half of the official reported number. Our study showed that in areas with low access to healthcare and poorly functioning death notification and registration systems, community-based data sources could be used to identify suspected COVID-19 deaths outside of the health sector. They can provide early warning data on events, such as an unusual number of community deaths or diseases.

Place of death in France: impact of the first wave (March-May 2020) of the Covid-19 epidemic

BACKGROUND

The Covid-19 epidemic entailed a major public health issue in France challenging the efficiency of the public health system. The distribution of deaths by place in France may have been affected by the epidemic and mitigation actions. This article presents mortality rate ratios by place of death in France during the first lockdown (17 March - 10 May, 2020) of the Covid-19 epidemic.

METHODS

We considered five places of death recorded in death certificates. Deaths in 2020 were compared to deaths from 2015 to 2019. We employed quasi-Poisson regressions in order to stablish mortality rate ratios (MRR) during the Covid-19 epidemic, for all-cause and non-Covid-19 deaths. Analysis was conducted in Metropolitan France, and for three groups of regions defined according to the intensity of the first COVID-19 epidemic wave.

RESULTS

A significant increase in all-cause and non-COVID-19 mortality at home was observed for all age groups. Also, an increase in mortality was observed in nursing homes, mostly due to Covid-19. Non-covid-19 mortality in public hospitals decreased significantly in all the country. These trends were mainly observed for cancers.

CONCLUSIONS

Overall mortality increased during the first wave of the Covid-19 epidemic. Most Covid-19 deaths took place in public hospitals and nursing homes at old ages. There was a displacement of non-Covid-19 mortality from public hospitals to home and nursing homes, particularly in the most highly exposed area. Among hypotheses to explain such a displacement, population avoidance of hospital care, or redeployment of hospital activity in this emergent context can be cited. Further analysis is needed to understand the reasons of the increase in non-Covid-19 mortality in nursing homes and at home.

Causes of perinatal mortality and associated maternal factors in a tertiary referral hospital of Gandaki province of Nepal: a cross-sectional study from a hospital-based surveillance

BACKGROUND

Perinatal and neonatal death rates have decreased recently but it still poses a major challenge to the health system of Nepal. The study was conducted to explore the pattern and causes of perinatal deaths.

METHODS

This was a descriptive cross-sectional study conducted from September 2020 to June 2021 using the data of perinatal mortality of three years from June 15, 2017, to June 14, 2020. The demographic parameters of the mother consisted of maternal age, place of residence, ethnicity, antenatal care, the number of antenatal visits, gravida, gestational weeks, and the mode of delivery. The causes of death were categorized into fetal and early neonatal deaths. Fetal deaths were further classified as macerated stillbirth and fresh stillbirth. The attribution of the causes of deaths to fetal/neonatal and maternal conditions was done as per the guidelines of the WHO application of ICD-10 to deaths during the perinatal period.

RESULTS

There were a total of 145 perinatal deaths from 144 mothers among which 92 (63.5%) were males. Ten mothers (6.9%) had not sought even single antenatal care, whereas 32 (22.9%) had visited for antenatal care one to three times. At least one cause of death was identified in 114 (78.6%) and remained unknown in 31(21.4%) cases. Among the 28 cases of macerated stillbirths, the cause of death was not identified in 14 (50%), whereas preterm labor was attributed to the cause of death in four (14.3%). In 53 of the fresh stillbirths, intrapartum hypoxia was identified as the cause of death in 20 (37.7%) cases, preterm labor in nine (17%), and was left unknown in 15 (28.3%) cases. Among the 64 early neonatal deaths, prematurity was attributed as the cause of death in 32 (50%) cases, birth asphyxia, and infections each in 11 (17.2%).

CONCLUSIONS

The perinatal mortality surveillance system identified the causes of death in most of the cases in our observation. Prematurity was identified as the commonest cause of early neonatal deaths and preterm labor was the commonest cause responsible for perinatal deaths overall. The perinatal deaths should be investigated to establish exact causes of deaths which can be useful to develop prevention strategies.

Estimating causes of death where there is no medical certification: evolution and state of the art of verbal autopsy

Over the past 70 years, significant advances have been made in determining the causes of death in populations not served by official medical certification of cause at the time of death using a technique known as Verbal Autopsy (VA). VA involves an interview of the family or caregivers of the deceased after a suitable bereavement interval about the circumstances, signs and symptoms of the deceased in the period leading to death. The VA interview data are then interpreted by physicians or, more recently, computer algorithms, to assign a probable cause of death. VA was originally developed and applied in field research settings. This paper traces the evolution of VA methods with special emphasis on the World Health Organization's (WHO)'s efforts to standardize VA instruments and methods for expanded use in routine health information and vital statistics systems in low- and middle-income countries (LMICs). These advances in VA methods are culminating this year with the release of the 2022 WHO Standard Verbal Autopsy (VA) Toolkit. This paper highlights the many contributions the late Professor Peter Byass made to the current VA standards and methods, most notably, the development of InterVA, the most commonly used automated computer algorithm for interpreting data collected in the WHO standard instruments, and the capacity building in low- and middle-income countries (LMICs) that he promoted. This paper also provides an overview of the methods used to improve the current WHO VA standards, a catalogue of the changes and improvements in the instruments, and a mapping of current applications of the WHO VA standard approach in LMICs. It also provides access to tools and guidance needed for VA implementation in Civil Registration and Vital Statistics Systems at scale.

An integrated approach to processing WHO-2016 verbal autopsy data: the InterVA-5 model

BACKGROUND

Verbal autopsy is an increasingly important methodology for assigning causes to otherwise uncertified deaths, which amount to around 50% of global mortality and cause much uncertainty for health planning. The World Health Organization sets international standards for the structure of verbal autopsy interviews and for cause categories that can reasonably be derived from verbal autopsy data. In addition, computer models are needed to efficiently process large quantities of verbal autopsy interviews to assign causes of death in a standardised manner. Here, we present the InterVA-5 model, developed to align with the WHO-2016 verbal autopsy standard. This is a harmonising model that can process input data from WHO-2016, as well as earlier WHO-2012 and Tariff-2 formats, to generate standardised cause-specific mortality profiles for diverse contexts. The software development involved building on the earlier InterVA-4 model, and the expanded knowledge base required for InterVA-5 was informed by analyses from a training dataset drawn from the Population Health Metrics Research Collaboration verbal autopsy reference dataset, as well as expert input.

RESULTS

The new model was evaluated against a test dataset of 6130 cases from the Population Health Metrics Research Collaboration and 4009 cases from the Afghanistan National Mortality Survey dataset. Both of these sources contained around three quarters of the input items from the WHO-2016, WHO-2012 and Tariff-2 formats. Cause-specific mortality fractions across all applicable WHO cause categories were compared between causes assigned in participating tertiary hospitals and InterVA-5 in the test dataset, with concordance correlation coefficients of 0.92 for children and 0.86 for adults. The InterVA-5 model's capacity to handle different input formats was evaluated in the Afghanistan dataset, with concordance correlation coefficients of 0.97 and 0.96 between the WHO-2016 and the WHO-2012 format for children and adults respectively, and 0.92 and 0.87 between the WHO-2016 and the Tariff-2 format respectively.

CONCLUSIONS

Despite the inherent difficulties of determining "truth" in assigning cause of death, these findings suggest that the InterVA-5 model performs well and succeeds in harmonising across a range of input formats. As more primary data collected under WHO-2016 become available, it is likely that InterVA-5 will undergo minor re-versioning in the light of practical experience. The model is an important resource for measuring and evaluating cause-specific mortality globally.

[Trend on mortalities in all-cause and chronic non-communicable diseases among the labor force population in China, 2007-2016]

Objective: To analyze the trends on mortalities of all-cause and deaths caused by chronic and non-communicable diseases (NCDs) among Chinese labor force population during 2007 to 2016. Methods: Data on cause-of-death that collected from the National Mortality Surveillance System was used to analyze the age and area-related specific crude mortality rates, age-standardized mortality rates and component ratios of NCDs, among the Chinese labor force population, during 2007 to 2016. Trend of crude mortality rates and mortality component ratios of the three major diseases (infectious diseases, maternal and infant diseases, nutritional deficiency diseases; NCDs; injuries) were analyzed. Age-standardized mortality of cancer, COPD, cardiovascular and cerebrovascular diseases were also analyzed by gender. Age-standardized mortality was calculated based on the Year 2010 Population Census of China. Joinpoint regression model was used to obtain annual percentage change and 95%CI was set for assessing the trend. Results: In 2016, the age-standardized all-cause mortality rate was 217.23 per 100 000 among the Chinese labor force population, but decreased by -2.8% (95%CI: -3.8%- -1.7%) annually from 2007 to 2016. The gap between different gender and regions gradually narrowed. The proportion of deaths caused by NCDs increased annually by 0.8% (95%CI: 0.7%-0.9%). The age-standardized mortality rate of NCDs appeared as 171.89/100 000, among the Chinese labor force population in 2016, showing a downward trend by -2.4% (95%CI:-3.3% - -1.4%). However, in females, there appeared the greatest decrease, with an average annual change of -3.3% (95%CI:-4.0% - -2.5%). Diseases as cancer, COPD, cardiovascular and cerebrovascular diseases all showed downward trends in the whole country, with an average range of -2.0% (95%CI: -2.6%--1.3%), -8.0% (95%CI: -8.9% - -7.1%), -1.5% (95%CI: -2.9% - -0.1%), -2.3% (95%CI: -2.8% - -1.8%) in a ten-year period, respectively. Conclusion: All-cause and age-standardized mortality rates caused by NCDs among Chinese labor force population were decreasing during 2007 to 2016. However, the constituent ratios appeared increasing, year by year. Close attention needs to be paid on NCDs which affecting the health of the labor force population in China.

Integrating community-based verbal autopsy into civil registration and vital statistics (CRVS): system-level considerations

Background: Reliable and representative cause of death (COD) statistics are essential to inform public health policy, respond to emerging health needs, and document progress towards Sustainable Development Goals. However, less than one-third of deaths worldwide are assigned a cause. Civil registration and vital statistics (CRVS) systems in low- and lower-middle-income countries are failing to provide timely, complete and accurate vital statistics, and it will still be some time before they can provide physician-certified COD for every death.

Proposals: Verbal autopsy (VA) is a method to ascertain the probable COD and, although imperfect, it is the best alternative in the absence of medical certification. There is extensive experience with VA in research settings but only a few examples of its use on a large scale. Data collection using electronic questionnaires on mobile devices and computer algorithms to analyse responses and estimate probable COD have increased the potential for VA to be routinely applied in CRVS systems. However, a number of CRVS and health system integration issues should be considered in planning, piloting and implementing a system-wide intervention such as VA. These include addressing the multiplicity of stakeholders and sub-systems involved, integration with existing CRVS work processes and information flows, linking VA results to civil registration records, information technology requirements and data quality assurance.

Conclusions: Integrating VA within CRVS systems is not simply a technical undertaking. It will have profound system-wide effects that should be carefully considered when planning for an effective implementation. This paper identifies and discusses the major system-level issues and emerging practices, provides a planning checklist of system-level considerations and proposes an overview for how VA can be integrated into routine CRVS systems.

Under-estimation of maternal and perinatal mortality revealed by an enhanced surveillance system: enumerating all births and deaths in Pakistan

Background

Reliable and timely data on maternal and neonatal mortality is required to implement health interventions, monitor progress, and evaluate health programs at national and sub-national levels. In most South Asian countries, including Pakistan, vital civil registration and health information systems are inadequate. The aim of this study is to determine accurate maternal and perinatal mortality through enhanced surveillance of births and deaths, compared with prior routinely collected data.

Methods

An enhanced surveillance system was established that measured maternal, perinatal and neonatal mortality rates through more complete enumeration of births and deaths in a rural district of Pakistan. Data were collected over a period of 1 year (2015/16) from augmentation of the existing health information system covering public healthcare facilities (n = 19), and the community through 273 existing Lady Health Workers; and with the addition of private healthcare facilities (n = 10), and 73 additional Community Health Workers to cover a total study population of 368,454 consisting of 51,690 eligible women aged 18 to 49 years with 7580 pregnancies and 7273 live births over 1 year. Maternal, neonatal, perinatal and stillbirth rates and ratios were calculated, with comparisons to routine reporting from the previous period (2014–15).

Results

Higher maternal mortality, perinatal mortality and neonatal mortality rates were observed through enhanced surveillance compared to mortality rates in the previous 1.5 years from the routine monitoring system from increased completeness and coverage. Maternal mortality was 247 compared to 180 per 100, 000 live births (p = 0.36), neonatal mortality 40 compared to 20 per 1, 000 live births (p < 0.001), and perinatal mortality 60 compared to 47 per 1000 live births (p < 0.001). All the mortality rates were higher than provincial and national estimates proffered by international agencies based on successive Pakistan Demographic and Health Surveys and projections.

Conclusion

Extension of coverage and improvement in completeness through reconciliation of data from health information systems is possible and required to obtain accurate maternal, perinatal and neonatal mortality for assessment of health service interventions at a local level.

A 3-year surveillance on causes of death or reasons for euthanasia of domesticated dogs in Taiwan

Over the last 2 decades, there has been growing interest in research on the mortality of domesticated pets. These studies relied on an effective data-collecting system. During 2012-2014, a real-time reporting system was designed for mortality data in owned dogs and cats. The present retrospective study aimed to report on the causes of death (CODs) or reasons for euthanasia (RFEs) in domesticated dogs in Taiwan, and to investigate CODs/RFEs segregated by demographic variables. Data from 2306 domesticated dogs were acquired during the 3-year period in the present study. The median age at death of the study population was 10.2 years (median interquartile range 7.0-14.0; range 0.0-25.0). Crossbred, female, and neutered dogs showed greater ages at death than other groups. The most common COD/RFE was neoplasia, followed by multiple organ involvement (MOI) and cardiovascular diseases. Segregated by cut-off ages, the most common COD/RFE was infection among dogs younger than 3 years or 1year, and neoplasia among dogs at or older than 3 years or 1year of age; the most common COD/RFE was neoplasia among dogs younger than median age, and MOI among dogs at or older than median age. Segregated by geographic variables, the ranking and frequency of CODs/RFEs displayed different patterns between the capital city/non-capital areas, and among areas stratified by human population densities. The study provides various insights into age at death and CODs/RFEs in owned-dog population in Taiwan, and provides new directions for future research.

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.

Medicolegal Death Scene Investigations After Natural Disaster- and Weather-Related Events: A Review of the Literature

BACKGROUND

The number of disaster-related deaths recorded by vital statistics departments often differs from that reported by other agencies, including the National Oceanic and Atmospheric Administration-National Weather Service storm database and the American Red Cross. The Centers for Disease Control and Prevention (CDC) has launched an effort to improve disaster-related death scene investigation reporting practices to make data more comparable across jurisdictions, improve accuracy of reporting disaster-related deaths, and enhance identification of risk and protective factors. We conducted a literature review to examine how death scene data are collected and how such data are used to determine disaster relatedness.

METHODS

Two analysts conducted a parallel search using Google and Google Scholar. We reviewed published peer-reviewed articles and unpublished documents including relevant forms, protocols, and worksheets from coroners, medical examiners, and death scene investigators.

RESULTS

We identified 177 documents: 32 published peer-reviewed articles and 145 other documents (grey literature). Published articles suggested no consistent approach for attributing deaths to a disaster. Researchers generally depended on death certificates to identify disaster-related deaths; several studies also drew on supplemental sources, including medical examiner, coroner, and active surveillance reports.

CONCLUSIONS

These results highlight the critical importance of consistent, accurate data collection during a death investigation. Review of the grey literature found variation in use of death scene data collection tools, indicating the potential for widespread inconsistency in data captured for routine reporting and public health surveillance. Findings from this review will be used to develop guidelines and tools for capturing disaster-related death investigation data.

[Capture-mark-recapture analysis on the under-registration rate of mortality surveillance program in Jinan]

Objective: To evaluate the under-registration rate related to mortality surveillance program in Jinan city, from 2013 to 2014, using the capture-mark-recapture method. Methods: Under the stratified cluster random sampling method, samples were stratified, according to urban and rural areas. Two districts and three counties were chosen, with three towns/streets in each county/district and eight villages/communities in each township/street, randomly selected. With the participation of departments as civil affairs, public security, maternal/child institutions and community committees as well as individuals as village doctors and community leaders, a list of deaths from January 1, 2013 to December 31, 2014 was collected and compared to the National Mortality Surveillance System on the rates related to under-registration. Results: A total of 2 903 records on deaths were collected from 2013 to 2014,while 3 113 deaths were reported in the surveillance system of the same period. 3 772 (95% CI:3 741-3 802) deaths were estimated by the capture-mark-recapture method. The two-year total under-registration rate was 17.46%. The under-registration rates in 2013 and 2014 appeared as 19.29% and 15.57% (χ(2)=8.92, P<0.01), respectively, with the rates in urban and rural areas as 20.91% and 11.93% (χ(2)=47.35, P<0.01). The rates on male and female were 17.87% and 16.98% (χ(2)=0.48, P>0.05). The rates of <5 years old group and ≥5 years old group were 21.57% and 17.45% (χ(2)=0.03, P>0.05) respectively. Conclusions: Under-registration in the mortality surveillance was noticed in Jinan. The capture-mark-recapture method seemed useful for evaluating the under-registration rate in the mortality surveillance program. It is suggested that the survey on under-registration rate should be carried out on the regular base. The under-registration rate seemed useful in adjusting the mortality rate.

A real-time reporting system of causes of death or reasons for euthanasia: A model for monitoring mortality in domesticated cats in Taiwan

A novel, real-time mortality recording system was designed to collect mortality data in companion animals from veterinary hospitals in Taiwan. This retrospective study aims to introduce the system, and to utilize the data collected for further investigation of the lifespan and mortality of the domesticated cat population stratified by demographic variables. Our data revealed that 1325 domesticated cats were acquired between 2012 and 2014. The median age of the study population was 8.0 years (IQR 3.0–13.0; range 0.0–22.7). Neutered and purebred cats lived longer. The most common causes of death were renal and urologic disorders, followed by neoplasia, infection, cardiovascular disorders, and trauma. Independent factors for common causes were surveyed. Advanced age and neutering was found to be associated with death due to renal and urologic disorders as well as with neoplasia. In contrast, younger age was found to be associated with death due to trauma and infection; being unneutered and living in the capital city were found to be associated with death due to trauma. Being male or purebred was found to be associated with death due to cardiovascular disorders.

"Whenever they cry, I cry with them": Reciprocal relationships and the role of ethics in a verbal autopsy study in Papua New Guinea

Verbal autopsy (VA) methods usually involve an interview with a recently bereaved individual to ascertain the most probable cause of death when a person dies outside of a hospital and/or did not receive a reliable death certificate. A number of concerns have arisen around the ethical and social implications of the use of these methods. In this paper we examine these concerns, looking specifically at the cultural factors surrounding death and mourning in Papua New Guinea, and the potential for VA interviews to cause emotional distress in both the bereaved respondent and the VA fieldworker. Thirty one semi-structured interviews with VA respondents, the VA team and community relations officers as well as observations in the field and team discussions were conducted between June 2013 and August 2014. While our findings reveal that VA participants were often moved to cry and feel sad, they also expressed a number of ways they benefited from the process, and indeed welcomed longer transactions with the VA interviewers. Significantly, this paper highlights the ways in which VA interviewers, who have hitherto been largely neglected in the literature, navigate transactions with the participants and make everyday decisions about their relationships with them in order to ensure that they and VA interviews are accepted by the community. The role of the VA fieldworker should be more carefully considered, as should the implications for training and institutional support that follow.

The utility of medico-legal databases for public health research: a systematic review of peer-reviewed publications using the National Coronial Information System

BACKGROUND

Medico-legal death investigations are a recognised data source for public health endeavours and its accessibility has increased following the development of electronic data systems. Despite time and cost savings, the strengths and limitations of this method and impact on research findings remain untested. This study examines this issue using the National Coronial Information System (NCIS).

METHODS

PubMed, ProQuest and Informit were searched to identify publications where the NCIS was used as a data source for research published during the period 2000-2014. A descriptive analysis was performed to describe the frequency and characteristics of the publications identified. A content analysis was performed to identify the nature and impact of strengths and limitations of the NCIS as reported by researchers.

RESULTS

Of the 106 publications included, 30 reported strengths and limitations, 37 reported limitations only, seven reported strengths only and 32 reported neither. The impact of the reported strengths of the NCIS was described in 14 publications, whilst 46 publications discussed the impacts of limitations. The NCIS was reported to be a reliable source of quality, detailed information with comprehensive coverage of deaths of interest, making it a powerful injury surveillance tool. Despite these strengths, researchers reported that open cases and missing information created the potential for selection and reporting biases and may preclude the identification and control of confounders.

CONCLUSIONS

To ensure research results are valid and inform health policy, it is essential to consider and seek to overcome the limitations of data sources that may have an impact on results.