Adapting the 2022 WHO verbal autopsy tool for use in Lagos State, Nigeria: insights from the LVASA-SRS project

BackgroundGlobally, clinical certification of the cause of neonatal death is not commonly available in developing countries. Under such circumstances it is imperative to use available WHO verbal autopsy tool to ascertain causes of death for strategic health planning in countries where resources are limited and the burden of neonatal death is high. The study explores the diagnostic accuracy of WHO revised verbal autopsy tool for ascertaining the causes of neonatal deaths against reference standard diagnosis obtained from standardized clinical and supportive hospital data.MethodsAll neonatal deaths were recruited between August 2006 –February 2008 from two tertiary teaching hospitals in Province Sindh, Pakistan. The reference standard cause of death was established by two senior pediatricians within 2 days of occurrence of death using the International Cause of Death coding system. For verbal autopsy, trained female community health worker interviewed mother or care taker of the deceased within 2–6 weeks of death using a modified WHO verbal autopsy tool. Cause of death was assigned by 2 trained pediatricians. The performance was assessed in terms of sensitivity and specificity.ResultsOut of 626 neonatal deaths, cause-specific mortality fractions for neonatal deaths were almost similar in both verbal autopsy and reference standard diagnosis. Sensitivity of verbal autopsy was more than 93 % for diagnosing prematurity and 83.5 % for birth asphyxia. However the verbal autopsy didn’t have acceptable accuracy for diagnosing the congenital malformation 57 %. The specificity for all five major causes of neonatal deaths was greater than 90 %.ConclusionThe WHO revised verbal autopsy tool had reasonable validity in determining causes of neonatal deaths. The tool can be used in resource limited community-based settings where neonatal mortality rate is high and death certificates from hospitals are not available.

Background: Verbal Autopsy/Social Autopsy (VASA) tools should be based on a well-holistic conceptual framework, allowing them to record and organize a wide range of determinants and contributors of child mortality in developing countries. This paper aims to review how successfully VASA studies have been able to record and organize biological and social determinants of child mortality, in pursuit of World Health Organization’s (WHO) guidelines for verbal autopsy (VA) and Kalter’s recommendations for social autopsy (SA).
 Methodology: A systematic search of literature from January 1995 to January 2018 was conducted on primary studies which attempted VA and SA on deceased cases of under-5 child mortalities using VA and SA questionnaires. A thorough search revealed 16 directly relevant papers.
 Results: Sixteen relevant studies from 14 countries revealed the two most common conceptual frameworks which were utilized for VASA studies. VA component of three studies followed W.H.O.’s guidelines, while the SA component of the other three studies followed Kalter’s recommendations. The most robust VA tools identified were INDEPTH Network VA tool, INCLEN VA tool, and WHO VA tool; while CHERG SA tool and BASICS SA tool were found as the most robust SA tools.
 Conclusion: Due to the fact that only separate recommendations for VA, and conceptual frameworks for SA exists and no evidence on integrated conceptual framework exists, we suggest that there is a great need for developing a conceptual framework, based on which an integrated VASA tool can be developed and utilized in VASA based child mortality investigations in developing countries.

To present the validation of a verbal autopsy (VA) tool using inpatient deaths in order to ultimately assess the burden of adult pre-hospital trauma mortality in Lilongwe, Malawi. A WHO VA tool was administered at the Kamuzu Central Hospital (KCH) morgue in Lilongwe to family members of inpatient deceased. Two physicians assigned cause of death as 'trauma' or 'non-trauma' as well as a standard VA cause of death based on the VA tool. These assignments were compared to the 'gold standard' of physician review of hospital records using a kappa statistic. The VA method had near-perfect agreement with the hospital record in determining 'trauma' vs. 'non-trauma'. There was moderate agreement when comparing types of death, for example cardiovascular vs. infectious disease, and limited agreement when comparing specific causes of death. This VA tool can accurately ascertain trauma-related mortality with almost perfect agreement. The next step is to assess pre-hospital trauma mortality burden using the VA tool to determine whether hospital records underestimate the burden of trauma in the community.

BackgroundSickle cell disease (SCD) is common in many parts of sub-Saharan Africa (SSA), where it is associated with high early mortality. In the absence of newborn screening, most deaths among children with SCD go unrecognized and unrecorded. As a result, SCD does not receive the attention it deserves as a leading cause of death among children in SSA. In the current study, we explored the potential utility of verbal autopsy (VA) as a tool for attributing underlying cause of death (COD) in children to SCD.MethodsWe used the 2007 WHO Sample Vital Registration with Verbal Autopsy (SAVVY) VA tool to determine COD among child residents of the Kilifi Health and Demographic Surveillance System (KHDSS), Kenya, who died between January 2008 and April 2011. VAs were coded both by physician review (physician coded verbal autopsy, PCVA) using COD categories based on the WHO International Classification of Diseases 10th Edition (ICD-10) and by using the InterVA-4 probabilistic model after extracting data according to the 2012 WHO VA standard. Both of these methods were validated against one of two gold standards: hospital ICD-10 physician-assigned COD for children who died in Kilifi District Hospital (KDH) and, where available, laboratory confirmed SCD status for those who died in the community.ResultsOverall, 6% and 5% of deaths were attributed to SCD on the basis of PCVA and the InterVA-4 model, respectively. Of the total deaths, 22% occurred in hospital, where the agreement coefficient (AC1) for SCD between PCVA and hospital physician diagnosis was 95.5%, and agreement between InterVA-4 and hospital physician diagnosis was 96.9%. Confirmatory laboratory evidence of SCD status was available for 15% of deaths, in which the AC1 against PCVA was 87.5%.ConclusionsOther recent studies and provisional data from this study, outlining the importance of SCD as a cause of death in children in many parts of the developing world, contributed to the inclusion of specific SCD questions in the 2012 version of the WHO VA instruments, and a specific code for SCD has now been included in the WHO and InterVA-4 COD listings. With these modifications, VA may provide a useful approach to quantifying the contribution of SCD to childhood mortality in rural African communities. Further studies will be needed to evaluate the generalizability of our findings beyond our local context.

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.

Cause-of-death (CoD) information is crucial for health policy formulation, planning, and program implementation. Verbal Autopsy (VA) is an approach employed for the collection and analysis of CoD estimates at the population level where medical certification of cause of death is low and, secondly, for integrating it with the existing public health system by utilizing the grassroots level workforce. The study aims to understand the field perspectives on implementing the 2022 WHO VA instrument in rural India through the existing public health system. This article is derived from a qualitative arm of study that was conducted in one of the blocks of Kanpur district, Uttar Pradesh. Frontline health workers (FHWs), as well as Medical Officers (MOs) serving in the Community Health Centre (CHC) area, were selected as study participants. A 5-day training and orientation workshop was conducted to train the FHWs to conduct computer-assisted personal interview VA using the 2022 WHO VA instrument. MOs have been trained to assign the CoD via Physician-Certified VA (PCVA). In-depth interviews (IDIs) were conducted with FHWs involved in conducting VA and physicians involved in conducting PCVA within the field practice area. A total of 13 IDIs were conducted, consisting of 10 FHWs and 3 MOs, within the selected CHC area of Ghatampur. Based on the responses received, five major themes were identified. Although VA is being used to collect CoD information from the community in India through a Sample Registration Survey (SRS), the key findings suggest that this activity could be scaled up by utilizing the existing public health system. However, additional manpower may be required for constant monitoring and evaluation of the program. Incentivization of FHWs would aid in the timely completion of VAs and coordination with local and higher health authorities. The perception of healthcare workers about the feasibility and acceptability of VA in this study highlighted some of the challenges and possible solutions that could aid in developing a comprehensive model to improve CoD information at the population level through the existing public health system.

Background: During the surge of COVID-19 pandemic, the mechanism of reporting and documentation of deaths was inadequate. It is crucial to establish the mechanism for measuring the actual events of COVID-19 and associated mortalities as well during this pandemic situation. This is the first instance of application of different rapid methods for death estimation during the pandemic situation. If found to be valid, these methods may be useful for other countries with limited resources and less developed death registration system. Objective: To find out the feasibility, acceptability of different rapid method for estimating the cause of deaths among the general population & healthcare workers and also to estimate the number of deaths among allopathic doctors. Methodology: The study was conducted from September 2022 to October 2023. Target population being adult deceased person between 1st April 2020 to 30th November 2022 among general population, health care worker and allopathic doctor. For the general population, the study was conducted in one urban municipal area and two sub-centres of Habra Block I under North 24 Parganas district with WHO Verbal Autopsy (VA) tool for adult. Complete enumeration with snowballing, compartmental and capture-recapture method was adopted for general population, health care worker and allopathic doctor respectively. Results: Overall, 300 VA could be performed (121 urban & 179 rural) among general population. There were challenges related to both feasibility & acceptability in terms of data access, permission and cooperation. Research team employed a combination of persistence, local collaboration, and strategic decision-making to successfully collect data. Acceptability was more in rural area. Total number of deceased doctors was estimated to be 246 from two different lists. Conclusion: Rapid methods may be employed as a part of response systems during pandemic or any future disasters if adequate governmental support and assistance is obtained along with aid from the local people.

In resource-limited countries with weak healthcare systems, women of reproductive age are particularly vulnerable during times of conflict. In Tigray, Ethiopia, where a war broke out on 04 November 2020, there is a lack of information on causes of death (CoD) among women of reproductive age. This study aims to determine the underlying CoD among women of reproductive age during the armed conflict in Tigray. This community-based survey was carried out in six Tigray zones, excluding the western zone for security reasons. We used a multistage stratified cluster sampling method to select the smallest administrative unit known as Tabiya. Data were collected using a standardized 2022 WHO Verbal Autopsy (VA) tool. The collected data were analyzed using the InterVA model using R analytic software. The study reported both group-based and cause-specific mortality fractions. A total of 189,087 households were screened and 832 deaths were identified among women of reproductive age. The Global Burden of Disease classification showed that infectious and maternal disorders were the leading CoD, accounting for 42.9% of all deaths. External causes contributed to 26.4% of fatalities, where assault accounted for 13.2% of the deaths. Maternal deaths made up 30.0% of the overall mortality rate. HIV/AIDS was the primary CoD, responsible for 13.2% of all deaths and 54.0% of infectious causes. Other significant causes included obstetric hemorrhage (11.7%) and other and unspecified cardiac disease (6.6%). The high proportion of infectious diseases related CoD, including HIV/AIDS, as well as the occurrence of uncommon external CoD among women, such as assault, and a high proportion of maternal deaths are likely the result of the impact of war in the region. This highlights the urgent need for targeted interventions to address these issues and prioritize sexual and reproductive health as well as maternal health in Tigray.

Verbal autopsy-assigned causes of death among adults being investigated for TB in South Africa

Verbal autopsy (VA) is the systematic and retrospective inquiry (from relatives) about the symptoms of an illness prior to death. In tribal India, 67-75 per cent of deaths occur at home with an unknown cause of death (CoD). Hence, the aim of this study was to determine the CoD in the 16-60 yr age group utilizing VA. A prospective, community based longitudinal study was conducted in 32 tribal villages in the Melghat region of Maharashtra, between 2004 and 2020. Number of deaths and VAs in 16-60 yr age group were collected by village health workers (VHWs) and supervisors, verified by five different persons (internal-external) and cross-checked by three VA interpretation trained physicians. A modified version of WHO VA was used. Cause-specific mortality fractions were calculated. Of the 1011 deaths recorded, mortality in males was significantly higher than females (P<0.001). A total of 763 VAs were conducted which revealed that tuberculosis was the leading CoD, followed by jaundice, heart diseases, diarrhoea, central nervous system infections and suicide. Suicides were significantly more common among males than in females (P=0.046). Significantly, more deaths occurred during the monsoon (P=0.002), especially diarrhoeal deaths (P=0.024). The findings of this study suggest that, in Indian tribal areas, infectious diseases are the leading causes of morbidity and one of the major causes of deaths in economically productive age group. Intensified VHW-mediated interventions are required to reduce the premature deaths.

Why are people dying due to tuberculosis? A study from Alappuzha District, Kerala, India

Background: Infant deaths from Bhavnagar rural areas were studied by using a verbal autopsy tool.Methods: Community visit based retrospective study of Bhavnagar rural by WHO verbal autopsy questionnaire.Results: Of the 92 deaths analyzed, 59 % (early), 12% (late), and 29% were during the post neonatal period. Male deaths were 55 (60%). The most common immediate causes were infection (39%), birth asphyxia (23%), and hyaline membrane disease (15%). Underlying causes were: maternal illness with feeding problem (45%), prematurity (26%), meconium aspiration syndrome (9%), and congenital/genetic anomalies (10%). Infant and neonatal deaths were seen more with illiteracy of mother, age of mother (25-29 years), third parity, anemia, and vaginal discharge; and non-breastfed, low birth weight and preterm. Birth asphyxia and hyaline membrane disease were during early, and meningitis and pneumonia were after the neonatal period. Verbal autopsy was accurate in 18/23 (78%) of the facility-based deaths where the cause of death was available. Ethics approval was obtained.Conclusions: Reproductive health education to adolescent girls and mothers, regarding the treatment of fever, vaginal discharge; and breastfeeding counselling with vitamin B12 should be used as more infant deaths are associated with anemia of mother. Health workers should be skilled in neonatal resuscitation, prematurity management, and referral, after stabilization, identification of congenital anomaly, antenatal screening by USG, and neonatal metabolic screen. Recent 2018 data obtained from Bhavnagar District Health Authority shows that over a period of eight years, institutional deliveries have increased and home deliveries, early neonatal deaths, HMD, and septicemia have decreased. Perinatal care should be check-list based, monitored, and mentored.

Background: Neonatal death is defined as no. of deaths during the first 28 completed days of life per 1000 live births in a given year or period. Around 2.6 million deaths or roughly 46% of all under five deaths had occurred during this period in 2016 which means that 7000 newborn deaths occur each day. Most of the neonatal deaths occur on the first day and week accounting to about 1 million dying on the 1st day. Objective of this study was to ascertain various causes of neonatal mortality using verbal autopsy in Etawah district.Methods: The present study was a retrospective cross-sectional study carried out for a period of 1 year (July 17 to June 2018) using WHO verbal autopsy questionnaire by finding out the study subjects from medical information system of UPUMS, Saifai and district hospital, Etawah. A total of 89 neonatal deaths were found out of which 87 were interviewed by going to their residences to get the relevant information regarding the causes of deaths.Results: Most common cause of neonatal mortality came out to be low birth weight with prematurity 44 of 87 (50.6%), followed by birth asphyxia 23 of 87 (26.4%) and sepsis 8 of 87 (9.2%).Conclusions: Effective interventions should be incorporated into policy decisions to reduce neonatal mortality due to these causes.

BackgroundDengue epidemic in Lahore (2011) resulted in hundreds of deaths and affected thousands. As most of the studies were focused on its diagnosis and treatment, scanty data is available on associated diseases/co-morbidities in these patients that could have contributed to a higher mortality. There were no local guidelines available on recording, reporting and management of these co-morbidities. The objective of this study was to analyze the initial presentations of dengue cases and to estimate the frequency of co-morbidities in dengue patients.MethodsData of 556 dengue cases was retrieved from 2 major public sector tertiary-care hospitals for patients who were admitted during 2011 epidemic and a case record analysis was done. Data was retrieved from patient’s information reports which included demography, signs and symptoms and the laboratory investigations. In addition verbal autopsy of deceased cases was also done from their relatives using standardized WHO verbal autopsy form after making modifications as per needed.ResultsOf 556 cases studied, 390 (70%) were males. The mean age was 36 years and 30% of the cases were between 20-29 years. Average duration of the hospital stay was 6 days. Out of the total, 435 (78%) were dengue fever (DF) cases followed by dengue hemorrhagic fever (DHF) in 95 (17%) and dengue shock syndrome (DSS) in 26 (4%) cases. A total of 40 cases died and among them 17 were diagnosed with DSS, 13 DF and 10 DHF. Further the verbal autopsy from relatives of deceased cases showed 29 (60%) deceased had co-morbid diseases which included hypertension, diabetes etc. DSS was common in patients who had hypertension (27) either alone or associated with other illnesses.ConclusionsCo-morbidities with dengue infection were seen in 60% deceased cases indicating the reasons for high dengue related complications and death.

BackgroundLow- and middle-income countries are often described as being at intermediate stages of epidemiological transition, but there is little population-based data with reliable cause of death assignment to examine the situation in more detail. Non-communicable diseases are widely seen as a coming threat to population health, alongside receding burdens of infection. The INDEPTH Network has collected empirical population data in a number of health and demographic surveillance sites in low- and middle-income countries which permit more detailed examination of mortality trends over time.ObjectiveTo examine cause-specific mortality trends across all ages at INDEPTH Network sites in Africa and Asia during the period 1992–2012. Emphasis is given to the 15–64 year age group, which is the main focus of concern around the impact of the HIV pandemic and emerging non-communicable disease threats.MethodsINDEPTH Network public domain data from 12 sites that each reported at least five years of cause-specific mortality data were used. Causes of death were attributed using standardised WHO verbal autopsy methods, and mortality rates were standardised for comparison using the INDEPTH standard population. Annual changes in mortality rates were calculated for each site.ResultsA total of 96,255 deaths were observed during 9,487,418 person years at the 12 sites. Verbal autopsies were completed for 86,039 deaths (89.4%). There were substantial variations in mortality rates between sites and over time. HIV-related mortality played a major part at sites in eastern and southern Africa. Deaths in the age group 15–64 years accounted for 43% of overall mortality. Trends in mortality were generally downwards, in some cases quite rapidly so. The Bangladeshi sites reflected populations at later stages of transition than in Africa, and were largely free of the effects of HIV/AIDS.ConclusionsTo some extent the patterns of epidemiological transition observed followed theoretical expectations, despite the impact of the HIV pandemic having a major effect in some locations. Trends towards lower overall mortality, driven by decreasing infections, were the general pattern. Low- and middle-income country populations appear to be in an era of rapid transition.