Civil Registration System Research Articles

DOP21 Disease activity patterns of paediatric Inflammatory Bowel Disease – A Danish nationwide cohort study 1996-2018

Abstract Background Inflammatory bowel diseases (IBD) are heterogenous diseases in terms of their clinical presentation including frequency and severity of flares. We aimed to describe disease activity (DA) patterns in a Danish nationwide cohort including all IBD patients diagnosed < 18 years of age between 1996 and 2018. Methods Paediatric patients diagnosed with Crohn’s disease (pCD) or ulcerative colitis (pUC) were identified from national registers (Danish Civil Registration System, National Patient Registry, Danish National Prescription Registry and Danish Pathology Data Bank). DA was assessed in both incident and prevalent pIBD patients and categorised as mild-moderate in case of a course of topical corticosteroids, oral budesonide, or topical 5-ASA. Episodes were categorised as severe if they involved hospitalization, surgery, oral corticosteroids or biological therapy. DA patterns in incident patients were assessed for 5- and 10-year periods from diagnosis as follows: The 5-year DA pattern: A) No years with DA. B) 1 or 2 years with at least one episode of DA in each year. C) 3 or 4 years with at least one episode of DA in each year. D) All 5 years with at least one yearly episode of DA. The 10-year DA pattern: A) Decreasing: First 5 years with 2 or more years with DA; following 5 years with 2 years or less with DA. B) Increasing: First 5 years with less than 2 years with DA; following 5 years with 2 or more years with DA. C) Chronic continuous: First 10 years with at least 8 years with DA. D) Quiescent: First 10 years with one year or less with DA. E) Chronic intermittent: DA pattern that does not meet the criteria above. Results 1,965 pCD and 1,838 pUC incident patients were included. At diagnosis severe DA was found in 87% in pCD and 80% in pUC, in addition to 6.1% of pUC patients who had a colectomy the first year. After 5 years of disease the annual proportion of pCD and pUC with no DA 70% and 61%. This remained constant after 10 years (pCD:72% and pUC: 64%). In pUC, 12% and 16% required colectomy 5 and 10 years after diagnosis. In prevalent pCD (N=2,515) and pUC (N=2,428) the proportion with no DA each calendar year was stable (pCD: 59%-73% and pUC: 50%-60%, prior to 2010). The majority of both pCD and pUC patients experienced one or two years with at least one episode of DA within the first five years (pCD: 51%, pUC: 53%). During the first 10 years from diagnosis, the decreasing DA pattern was the most common in both pCD and pUC (43% and 47%, respectively) (Figure). Conclusion DA patterns in pIBD are characterised by a high proportion of severe activity initially with a decreasing pattern after 5 and 10 years follow-up. No change in the proportion of patients with no DA was seen despite the introduction of biologic therapy in the period.

Birth registration in Nepal: An assessment of progress based on two national surveys.

Birth registration, an essential component of the civil registration system, is expected to be complete and universal. This study assesses the progress made in recent years and identifies gaps in birth registration in Nepal. Data from the Multiple Indicator Cluster Surveys undertaken in 2014 and 2019 are used for the analysis. The two surveys included a total of 12,007 children under five years of age living with their mothers at the time of the surveys. The survey respondents were 11,821 mothers and 186 caretakers (in the case of those without mothers) of the children. The variations in the proportion of births registered among various subgroups of the children are assessed by performing bivariate analysis and binary logistic regression. Birth registration increased considerably, from 58% (95% CI: 57-59%) in 2014 to 77% (95% CI: 76-78%) in 2019. Several of the disparities between and among the various population subgroups that were evident in the 2014 survey had been considerably reduced or eliminated by 2019. The disparities in registration between boys and girls attenuated over time. Although birth registration increased for all children (ages 0-59 months old), infants still had comparatively lower levels of registration. The relatively disadvantaged provinces showed significant progress between the two survey periods. Considerable and significant progress has been made in birth registration in recent years. However, achieving universal and complete birth registration would require sustaining recent achievements and applying proven strategic interventions to ensure the inclusion of the unregistered births.

Reference Values for Daily Physical Activity Measured with Accelerometers in a Danish Background Population between 18 and 80 Years of Age

Physical activity provides essential information to assess general health and evaluate the outcome of interventions. However, evaluation of physical activity necessitates reference values for comparison. The current study aimed to present reference values for accelerometer-based data on physical activity in a background population. We conducted a population-based cross-sectional study using accelerometer-based data on physical activity and self-reported data on demographics and health from a cohort of randomly selected individuals of 18–80 years of age registered in the Danish Civil Registration System (CRS) (n = 242). Participants took an average of 6095 daily steps, had an average cadence of 98.5, spent 3.7 h standing, 1.4 h walking, 3.8 min cycling, 7.0 h in sedentary activities, and had 43 sit to stand transfers. The results varied when examining sex and individual age groups. Our findings are important to clinical practice and research, as they provide sex- and age-specific reference values to enable comparison of daily physical activity levels.

Maternal Mortality in a Rural District of Pakistan and Contributing Factors.

Pakistan is among the ten countries that account for 60% of global maternal mortality. Lack of accurate data on maternal mortality and a complex interrelation of access and quality of healthcare services, healthcare delivery system, and socio-economic and demographic factors contribute significantly to inadequate progress in reducing maternal mortality. A population-based prospective cohort study was conducted in a rural district of Pakistan using data obtained from an enhanced surveillance system. A total of 7572 pregnancies and their outcomes were recorded by 273 Lady Health Workers and 73 Community Health Workers over 2016-2017. Logistic regression was used to calculate the unadjusted and adjusted odds ratios (OR) for maternal mortality for each risk factor. Population Attributable Fraction (PAF) was derived from the ORs and risk factor prevalence. The study recorded 18 maternal deaths. The maternal mortality rate was estimated at 238/100,000 pregnancies (95% CI 141-376), and the maternal mortality ratio was 247/100,000 live births (95% CI 147-391). Half of the maternal deaths (9) were from obstetric hemorrhage, and 28% (5) from puerperal sepsis. Postpartum hemorrhage was associated with a 17-fold higher risk of maternal mortality (PAF = 40%) and puerperal sepsis with a 12-fold higher mortality risk (PAF = 29%) compared to women without these conditions. Women delivered by unskilled birth attendants had a three-fold (PAF = 21%), and women having prolonged labour had a fourfold risk of maternal mortality compared to those with these conditions. Women with leg swelling (47%) and pre-eclampsia (26%) are at seven times the risk of maternal mortality compared to those without these conditions. Mortality in women delivered by unskilled birth attendants was three times higher than with skilled attendants. The study, among a few large-scale prospective cohort studies conducted at the community level in a rural district of Pakistan, provides a better understanding of the risk factors determining maternal mortality in Pakistan. Poverty emerged as a significant risk factor for maternal mortality in the study area and contributes to the underutilization of health facilities and skilled birth attendants. Incorporating poverty reduction strategies across all sectors, including health, is urgently required to address higher maternal mortality in Pakistan. A paradigm shift is required in Maternal and Child health related programs and interventions to include poverty estimation and measuring mortality through linking mortality surveillance with the Civil Registration and Vital Statistics system. Accelerated efforts to expand the coverage and completeness of mortality data with risk factors to address inequalities in access and utilization of health services.

Heavy prenatal alcohol exposure and overall morbidities: a Danish nationwide cohort study from 1996 to 2018

Heavy prenatal alcohol exposure is harmful and can lead to fetal alcohol spectrum disorders. A systematic review and meta-analysis identified 428 comorbidities in individuals with fetal alcohol spectrum disorders, and reported pooled prevalence estimates. We aimed to investigate overall risk of morbidities in heavy prenatal alcohol-exposed children by estimating risk of the identified comorbidities, and previously unidentified diseases and health-related problems. Our Danish nationwide register-based cohort study included all singleton births. Individuals were followed up to age 18 years, between 1996 and 2018. Stillbirths and children of immigrants were not included in the study, and births of women who migrated within 1 year before or during pregnancy were also excluded due to loss to follow-up. Data on health and education were extracted from the Danish Medical Birth Register, the Danish National Patient Registry, the Danish National Prescription Registry, the Danish Civil Registration System, and the Population Education Register. We estimated crude and standardised risk differences of hospital diagnoses. Heavy prenatal alcohol exposure was defined by hospital contacts with alcohol-attributable diagnoses given to the mother or her child, or by maternal redeemed prescriptions for drugs to treat alcohol dependence 1 year before or during pregnancy. Of 1 407 689 identified singleton births, 219 186 were excluded for reasons including they were born to immigrants, lost to follow-up, or were stillbirths. Of the remaining 1 188 503 children, 4799 (0·4%) had heavy prenatal alcohol exposure and 1 183 704 (99·6%) were classified as non-alcohol-exposed births. 578 179 (48·6%) babies were female and 610 324 (51·4%) were male. We found 234 of 428 previously identified comorbidities in individuals with fetal alcohol spectrum disorder, of which 29 conditions had a standardised risk difference of at least 0·5%, predominantly related to brain function, behavioural disorders, infections, and neonatal conditions. The four highest standardised risk differences were found for low birthweight (4·70% [95% CI 3·70-5·71]), small for gestational age (4·63% [3·72-5·55]), delayed milestone (3·81% [2·99-4·64]), and other preterm infants (2·69% [1·71-3·68]). Of previously unidentified diseases and health-related problems, 32 of 719 had a standardised risk difference of at least 1·0%, mainly related to brain function, some injuries, substance-related conditions, and childhood adversities. Heavy prenatal alcohol exposure is associated with an overall increased risk of child morbidities and previously unrecognised alcohol-related health problems. Prenatal alcohol exposure is a key public health issue with a potential negative impact on child and adolescent health. This study urges for renewed efforts and substantiates the profound degree to which pre-conceptional care is mandatory. The Obel Family Foundation, The Health Foundation, TrygFonden, Aase and Ejnar Danielsens Foundation, The North Denmark Region Health Science and Research Foundation, Holms Memorial Foundation, Dagmar Marshalls Foundation, the A.P. Møller Foundation, King Christian X Foundation, Torben and Alice Frimodts Foundation, the Axel and Eva Kastrup-Nielsens Foundation, and the A.V. Lykfeldts Foundation.

Heavy prenatal alcohol exposure and obstetric and birth outcomes: a Danish nationwide cohort study from 1996 to 2018

Heavy alcohol use during pregnancy can harm the fetus, but the relation to most obstetric outcomes remains unclear. We therefore aimed to describe maternal characteristics and estimate the association between heavy prenatal alcohol exposure and 22 adverse obstetric and birth outcomes. We carried out a Danish nationwide register-based historical cohort study, including all singleton births from Jan 1, 1996, to Dec 31, 2018. Births of women who had emigrated to Denmark were excluded from the study due to missing data and women who migrated within 1 year before or during pregnancy were also excluded due to loss to follow-up. Data were extracted from the Danish Medical Birth Register, the Danish National Patient Registry, the Danish National Prescription Registry, the Danish Civil Registration System, and the Population Education Register. Logistic regression models were used to estimate crude and adjusted odds ratios (ORs) of obstetric and birth outcomes. Heavy alcohol use was defined by hospital contacts for alcohol-attributable diagnoses given to the mother, her infant, or both, or maternal redeemed prescriptions for drugs to treat alcohol dependence within 1 year before or during pregnancy. Of 1 191 295 included births, 4823 (0·40%) were defined as heavily alcohol-exposed and 1 186 472 were categorised as a reference group with no identified heavy prenatal alcohol exposure. Heavy-alcohol-exposed births more often had mothers with psychiatric diagnoses (49·8% vs 9·6%), substance use (22·0% vs 0·4%), tobacco use (64·3% vs 15·8%), and low educational level (64·1% vs 17·6%) than did the reference group. For heavy-alcohol-exposed births, significantly increased adjusted ORs were found for small for gestational age (OR 2·20 [95% CI 1·97-2·45]), preterm birth (OR 1·32 [1·19-1·46]), haemorrhage in late pregnancy (OR 1·25 [1·05-1·49]), and preterm prelabour rupture of membranes (OR 1·18 [1·00-1·39]). Decreased adjusted ORs were found for postpartum haemorrhage (500-999 mL; OR 0·80 [95% CI 0·69-0·93]), gestational diabetes (OR 0·81 [0·67-0·99]), planned caesarean section (OR 0·82 [0·72-0·94]), pre-eclampsia and eclampsia (OR 0·83 [0·71-0·96]), and abnormalities of forces of labour (OR 0·92 [0·86-0·99]). Heavy prenatal alcohol exposure is associated with adverse obstetric and birth outcomes and high proportions of maternal low educational level, psychiatric disease, and lifestyle risk behaviours. These findings highlight a need for holistic public health programmes and policy attention on improving pre-conceptional care and antenatal care. The Obel Family Foundation, The Health Foundation, TrygFonden, Aase and Ejnar Danielsens Foundation, The North Denmark Region Health Science and Research Foundation, Holms Memorial Foundation, Dagmar Marshalls Foundation, the A.P. Møller Foundation, King Christian X Foundation, Torben and Alice Frimodts Foundation, the Axel and Eva Kastrup-Nielsens Foundation, the A.V. Lykfeldts Foundation.

Bidirectional 5-year risks of diabetic retinopathy, glaucoma and/or ocular hypertension: Results from a national screening programme.

We aimed to investigate if diabetic retinopathy (DR), glaucoma and/or ocular hypertension (OHT) are prospectively linked, as previous studies have proposed cross-sectional associations, but longitudinal data from larger cohorts are lacking. We performed a bidirectional 5 years prospective, registry-based cohort study. We extracted data from national registers, including the Danish Registry of Diabetic Retinopathy, the Danish Civil Registration System, the Danish National Patient Register and the Danish National Prescription Registry. DR level was defined by the highest level of the two eyes. Glaucoma and/or OHT was defined by diagnostic codes (H40*) or at least three redeemed prescriptions of glaucoma medication (S01E*) within 1 year. We included 205 970 persons with diabetes and 1 003 170 age- and gender-matched non-diabetes controls. Exposures were level-specific DR (i) and glaucoma and/or OHT (ii), and outcomes were hazard ratios (HRs) for 5 years incident glaucoma and/or OHT (i) and DR (ii). Persons with diabetes were more likely to develop glaucoma and/or OHT (multivariable adjusted HR 1.11, 95% CI 1.06-1.15), but this did not depend on the level of DR. In persons with diabetes, those with glaucoma and/or OHT were more likely to develop DR (multivariable adjusted HR 1.12, 95% CI 1.03-1.23) within 5 years. In a national cohort, diabetes associated with a little higher risk of upcoming glaucoma and/or OHT, and, inversely, the presence of the latter predicted a higher risk of incident DR. Nevertheless, our data do not seem to justify including glaucoma evaluation in the national Danish DR-screening programme.

The association between mental disorders and subsequent years of working life: a Danish population-based cohort study

Mental disorders can affect workforce participation via a range of mechanisms. In this study, we aimed to estimate the association between different types of mental disorders and working years lost, defined as the number of years not actively working or enrolled in an educational programme. In this population-based cohort study, we included all people aged 18-65 years (mean 38·0 [SD 13·9]) in the Danish Civil Registration System from Jan 1, 1995 to Dec 31, 2016. Information on mental disorders was obtained from the Danish Psychiatric Central Research Register and information on labour market characteristics was obtained from administrative registers. Follow-up started at age 18 years, immigration to Denmark, or on Jan 1, 1995, whichever came later; and it ended at age 65 years, death, emigration from Denmark, disability pension, voluntary early retirement, or Dec 31, 2016 (whichever came earlier). As the main outcome, we estimated working years lost for those diagnosed with any mental disorder and 24 types of mental disorders, as well as for the general population of same age and sex. We decomposed total working years lost into periods of unemployment or sick leave, disability pension, voluntary early retirement, or death. Data on ethnicity were not available through administrative registers. A total of 5 163 321 individuals, 2 642 383 men and 2 520 938 women, were followed up for 65·4 million person-years. Overall, 488 775 (9·47%) individuals were diagnosed with a mental disorder. On average, individuals with mental disorders lost an additional 10·52 (95% CI 10·48-10·57) years of working life compared with the general Danish population. Receiving a disability pension (7·54 [7·49-7·59] years) and longer periods of unemployment (2·24 [2·21-2·27] years) accounted for most of this difference. Our findings foreground the substantial impact of mental disorders on workforce participation. There is a need to invest in programmes that reduce the burden of working years lost and assist people with mental disorders in returning to the workforce. Lundbeck Foundation and Danish National Research Foundation.

Estimation of national and subnational all-cause mortality indicators in Nepal, 2017

BackgroundDespite the civil registration and vital statistics (CRVS) system in Nepal operating for several decades, it has not been used to produce routine mortality statistics. Instead, mortality statistics rely on irregular surveys and censuses that primarily focus on child mortality. To fill this knowledge gap, this study estimates levels and subnational differentials in mortality across all ages in Nepal, primarily using CRVS data adjusted for incompleteness.MethodsWe analyzed death registration data (offline or paper-based) and CRVS survey reported death data, estimating the true crude death rate (CDR) and number of deaths by sex and year for each province and ecological belt. The estimated true number of deaths for 2017 was used with an extension of the empirical completeness method to estimate the adult mortality (45q15) and life expectancy at birth by sex and subnational level. Plausibility of subnational mortality estimates was assessed against poverty head count rates.ResultsAdult mortality in Nepal for 2017 is estimated to be 159 per 1000 for males and 116 for females, while life expectancy was estimated as 69.7 years for males and 73.9 years for females. Subnationally, male adult mortality ranges from 129 per 1000 in Madhesh to 224 in Karnali and female adult mortality from 89 per 1000 in Province 1 to 159 in Sudurpashchim. Similarly, male life expectancy is between 64.9 years in Karnali and 71.8 years in Madhesh and female male life expectancy between 69.6 years in Sudurpashchim and 77.0 years in Province 1. Mountain ecological belt and Sudurpashchim and Karnali provinces have high mortality and high poverty levels, whereas Terai and Hill ecological belts and Province 1, Madhesh, and Bagmati and Gandaki provinces have low mortality and poverty levels.ConclusionsThis is the first use of CRVS system data in Nepal to estimate national and subnational mortality levels and differentials. The national results are plausible when compared with Global Burden of Disease and United Nations World Population Prospects estimates. Understanding of the reasons for inequalities in mortality in Nepal should focus on improving cause of death data and further strengthening CRVS data.

Registry-based cohort study of alpha-1 antitrypsin deficiency prevalence, incidence and mortality in Denmark 2000–2018

ObjectiveTo estimate the prevalence of diagnosed alpha-1 antitrypsin deficiency (dAATD) in Denmark as of 31 December 2018, and dAATD incidence and mortality from 1 January 2000 to 31 December 2018.Study...

Acquired Loss of a Sex Chromosome Is a Positive Prognostic Factor for Patients with Multiple Myeloma Undergoing ASCT

Introduction: In patients with multiple myeloma (MM), small somatic genetic lesions in non-malignant blood cells, i.e. clonal hematopoiesis, has been found to be associated with inferior survival and other adverse outcomes (Mouheddine T.H. et al. - Nature Comm. 2020). However, large-scale alterations on a chromosomal level are also acquired in ageing blood cells and may impact patient outcomes. Methods: Using a novel bioinformatic approach, we performed a genome-wide analyses of chromosomal aberrations in 998 patients with multiple myeloma before undergoing autologous stem cell transplant (ASCT) in a national population-based cohort. Post-induction harvest samples were analyzed with a custom Illumina deCODE Genetics SNP array and further processed using MoChA bioinformatic pipeline (Loh P., Genovese G. et al. - Nature 2020) to identify acquired mosaic chromosomal alterations (mCAs). Comprehensive clinical data was collected from nationwide registries with long-term follow-up (the Danish Multiple Myeloma Registry and the Danish Civil Registration System). Data included information on diagnostic criteria, peripheral blood counts, M protein, β-2 microglobulin, albumin, genetic myeloma aberrations by FISH, treatment, response to ASCT, progression, and death. Results: We identified 178 patients (17.8%) with acquired chromosomal alterations before undergoing ASCT. Autosomal mCAs were identified in 77 patients (7.7%), while 109 patients (10.9%) had loss of sex chromosomes (X or Y). Alterations were found on all chromosomes. Median cell fraction of autosomal mCA clones was 6.6% (IQR 2.7-20.4) in the analyzed harvest samples. Loss of sex chromosome was strongly associated with higher age (Wilcoxon P < 0.0001), while the age association was less robust for autosomal mCAs (Wilcoxon P = 0.094). There was no impact of type of induction regimen on frequency of mCAs. Full clinical annotation was available for 799 patients. Median follow-up was 6.4 years. Interestingly, at MM diagnosis, bone marrow plasma cell infiltration was significantly lower in patients with loss of chromosome X or Y (β coefficient -9.1%, P = 0.003). In accordance, hemoglobin level at diagnosis was also significantly higher in patients with sex chromosome loss (P = 0.027), despite these patients being older. In addition, the response to ASCT was superior in patients with loss of a sex chromosome. In patients that obtained at least a very good partial response after ASCT, 12.9% had sex chromosome loss, while only 4.7% of patients with poorer responses had sex chromosome loss (chi-square test P = 0.0017). In relation to these findings, overall survival was found to be superior in patients with loss of chromosome X, also when adjusted for age and sex (adj.P = 0.02). This survival difference was however only observed for long-term survivors (after more than four years of follow-up), indicating a possible interaction with later treatments. On the contrary, detection of multiple autosomal mCAs (n=14 patients) was associated with early age-independent inferior survival (adj.P = 0.005). A single autosomal mCA did not affect overall survival. To identify possible infiltration of malignant cells in the stem cell harvest, in a subset of patients (n=360) we were able to cross-check mCAs with FISH data on chromosomal variants identified in CD138+ sorted myeloma cells. We found no overlap between common myeloma chromosomal aberrations by FISH and identified mCAs. This indicates that the identified mCAs are from cells of the non-malignant hematopoietic system and not from myeloma plasma cells. Conclusion: In a longitudinal nationwide cohort of MM patients we examined the impact of acquired hematopoietic chromosomal alterations. Somatic mCAs or loss of sex chromosome was detected in stem cell harvest material in almost one fifth of patients undergoing ASCT. Sex chromosome loss was significantly associated with higher age, but surprisingly, it was also significantly associated with better response to ASCT and longer overall survival. The underlying biological causes of these findings remain to be elucidated. With regards to clonal origins, we did not identify any chromosomal variants to be present in both the myeloma clone (by diagnostic CD138+ FISH) and in the harvest product (by mCA analysis) in the same patient.

Improving Estimates of Injury Burden in Nepal: A Qualitative Study.

Routinely collected injury data can help to identify populations at risk of injury, circumstances surrounding those injuries, and can be used to developtargeted interventions. However, routinely collected injury data in Nepal are at risk of being incomplete or poorly coded and are underutilised. Therefore, this study aimed to explore the strengths, and opportunities for improvement, of systems that routinely measure injury incidence in Nepal. This study employed a qualitative design where data were collected through interviews with personnel working in four routine data systems; the Health Management Information System, the Road Accident Reporting System, the Daily Incident Reporting System, and the Civil Registration System. Interviews were conducted with front-line data collectors as well as strategic decision makers working in these data systems. Interviews were audio-recorded, transcribed, translated into English and analysed using framework analysis. A total of 32 interviews were completed, 19 interviews with front-line data collectors and 13 interviews with strategic decision makers. The data recording and reporting process of the four systems were identified and described. The analysis of data yielded 11 themes that described the strengths and limitations of the data collected through the four systems, challenges for effective data systems, and user recommendations for system improvement. This study identified the strengths, limitations, system challenges, and opportunities to improve data quality of each of the four routine data collection systems. These findings may be useful in engaging stakeholders in strengthening existing routine injury data collection systems or implementing alternative systems.

Registration and medical certification of deaths in the Indian States: a comparative analysis of data of CRS and MCCD reports (2010–2019)

The medical certification of cause of death under Civil Registration System has been implemented in the States/UTs to provide data on cause of death but use of this data is compromised due to incomplete coverage and inadequate quality. The completeness of registration of death (CoRD) and completeness of medically certified deaths (CoMeRD) were assessed to understand the trend over time and also to identify gaps in data to improve data quality. CoRD and CoMeRD for each year for each state was calculated from the CRS reports and MCCD reports, respectively, for the period 2010–2019. Data were analyzed nationally as per geographical region and individual state. The CoRD in India have increased in the CRS from 66.9% in 2010 to 92% in 2019, a significant increase of 37.7% over 9 years (P < 0.001), whereas India has not witnessed a substantial increase in the CoMeRD in MCCD which has increased from 17.1% in 2010 to only 20.6% in 2019. Among the 29 States, 18 (62%) had CoRD > 95% in 2019, with 15 states recording 100% of CoRD however just 3 states (10.3%) have CoMeRD more than 50%. Despite the significant progress made in CoRD, importance of medical certification cannot be undermined; critical differences between the States within the CRS and MCCD remain a cause of concern. Concentrated efforts to assess the strengths and weaknesses at the State level of the MCCD and CRS processes, quality of data, and plausibility of information generated are needed.

Incidence in atrial fibrillation in Denmark in relation to country of origin: a nationwide register-based study

Abstract Background Immigrants' healthcare needs can be a considerable challenge, as their risk profile can differ from the native population, and they may experience barriers to accessing health services in recipient countries. Immigration is projected to increase further due to conflicts and climate changes, and awareness on immigrants' health status is therefore warranted. Atrial fibrillation (AF) is the most common sustained arrhythmia with an estimated prevalence of approximately 2%. However, there is a paucity of data on AF epidemiology among immigrants. Purpose The aim of this study is to examine incidence of AF hospital diagnoses according to country of origin and to study if there is a difference in risk between immigrants and Danish born individuals. Methods The study period included 1st of January 1998 to 31st of December 2017 and the population consisted of all Danish citizens aged 45 or older. We included individuals as they turned 45 during the study period. Individuals who had been diagnosed with AF were excluded. Data was obtained from the Danish National Patient Registry and the Civil Registration System. Country of origin was based on the ten most represented counties in the population. Immigrants were defined as people born outside Denmark with none of the parents being both Danish citizens and born in Denmark. AF was defined as a hospital diagnosis according to international Classification of Diseases (ICD) version 8 and 10. Poisson regression were used to compute relative risk (RR) and associated 95% confidence intervals (CI). RRs were adjusted for sex, age, socioeconomic status, visits to general practitioner and comorbidity. Results The study population consist of 3,596,234 Danish-Born and 215,401 immigrants. A total of 334,636 had an incident AF diagnosis during the study period. Compared to Danish-born individuals, migrants from the Nordic countries had a higher adjusted RR of being diagnosed with AF: Norway 1.21 [95% CI: 1.05; 1.40], Sweden 1.16 [95% CI: 0.99; 1.35] and Germany 1.17 [95% CI: 1.06; 1.28]. In contrast, lower adjusted RRs were observed for individuals from Poland (0.82 [95% CI: 0.67; 1.01]), UK (0.89 [95% CI: 0.73; 1.08]), and the US (0.95 [95% CI: 0.72; 1.25]), respectively, and in particular for individuals from the non-Western countries: Turkey (0.49 [95% CI: 0.40; 0.59], Iran (0.48 [95% CI: 0.36; 0.65]), Iraq (0.32 [95% CI: 0.22; 0.45] and Bosnia-Herzegovina (0.63 [95% CI: 0.49; 0.79]). Conclusion Substantial variation in the incidence rate of incident AF hospital diagnoses according to country of origin. Further studies are warranted in order to clarify to what extent these differences reflets true differences in AF incidence or ethnic inequalities in the detection of AF in the health care system. Funding Acknowledgement Type of funding sources: Foundation. Main funding source(s): Karen Elise Jensen Foundation

Mortality Statistics in India: Current Status and Future Prospects.

When plague epidemics swept India in the second half of the 19th century, there was an epidemiological need for mortality statistics; as a result, vital event registration systems were established. However, despite the existence of multiple sources of mortality statistics in many ministries/departments of the government, neither the number of deaths nor the causes of deaths reported annually are complete yet. Multilateral international organisations have supported modelling for the generation of mortality statistics in developing countries rather than supporting and funding the development of real-time mortality data. With specific initiatives for decentralising the registration process to primary health centres and sub-health centres, the civil registration system despite its flaws, can be improved for gathering accurate data on mortality, including the causes of deaths.

The impact of civil registration-based demographic heterogeneity on community thefts

Because of China's unique civil registration system (Hukou), using the proportion of floating population or domestic migrants as an index of racial/ethnic heterogeneity is a common practice to apply social disorganization theory to explain crime in Chinese cities. However, this method does not fully reflect the substantive connotation of racial/ethnic heterogeneity in Chinese cities. In this study, we add the heterogeneity of civil registration, i.e. Hukou, in addition to the proportion of floating population when studying crime in a big Chinese city. Following social disorganization theory, we use negative binomial regression models with theft data in 2017, the Sixth National Population Census data, and Point of interests (POI) to delineate effects of the heterogeneity of civil registration and proportion of floating population on thefts. We have four major findings: 1) the Hukou-based ethnic heterogeneity index can better illustrate the ethnic heterogeneity in the Chinese context and have a significant impact on thefts; 2) communities with more rental housing units tend to experience more thefts; 3) there are more thefts in communities that are under the jurisdiction of neighborhood committee; and 4) the agglomeration of Internet cafes, banks, supermarkets, and restaurants tend to exacerbate the thefts in communities. This study subdivides the community residents' civil registration categories to delineate racial/ethnic heterogeneity, explores its impact on community thefts, and constructs a more optimized indicator that better suits communities in China. This is a meaningful supplement to crime theory and existing methods in non-western societies.

Performance evaluation of machine learning and Computer Coded Verbal Autopsy (CCVA) algorithms for cause of death determination: A comparative analysis of data from rural South Africa.

Computer Coded Verbal Autopsy (CCVA) algorithms are commonly used to determine the cause of death (CoD) from questionnaire responses extracted from verbal autopsies (VAs). However, they can only operate on structured data and cannot effectively harness information from unstructured VA narratives. Machine Learning (ML) algorithms have also been applied successfully in determining the CoD from VA narratives, allowing the use of auxiliary information that CCVA algorithms cannot directly utilize. However, most ML-based studies only use responses from the structured questionnaire, and the results lack generalisability and comparability across studies. We present a comparative performance evaluation of ML methods and CCVA algorithms on South African VA narratives data, using data from Agincourt Health and Demographic Surveillance Site (HDSS) with physicians' classifications as the gold standard. The data were collected from 1993 to 2015 and have 16,338 cases. The random forest and extreme gradient boosting classifiers outperformed the other classifiers on the combined dataset, attaining accuracy of 96% respectively, with significant statistical differences in algorithmic performance (p < 0.0001). All our models attained Area Under Receiver Operating Characteristics (AUROC) of greater than 0.884. The InterVA CCVA attained 83% Cause Specific Mortality Fraction accuracy and an Overall Chance-Corrected Concordance of 0.36. We demonstrate that ML models could accurately determine the cause of death from VA narratives. Additionally, through mortality trends and pattern analysis, we discovered that in the first decade of the civil registration system in South Africa, the average life expectancy was approximately 50 years. However, in the second decade, life expectancy significantly dropped, and the population was dying at a much younger average age of 40 years, mostly from the leading HIV related causes. Interestingly, in the third decade, we see a gradual improvement in life expectancy, possibly attributed to effective health intervention programmes. Through a structure and semantic analysis of narratives where experts disagree, we also demonstrate the most frequent terms of traditional healer consultations and visits. The comparative approach also makes this study a baseline that can be used for future research enforcing generalization and comparability. Future study will entail exploring deep learning models for CoD classification.

Improving Birth Registration Using the Health System: A Case Study from Somali Region of Ethiopia

Birth registration is the process by which the event and characteristics of a child’s birth are recorded in a country’s civil registry. Ethiopia has one of the lowest levels of civil registration in general globally, and of birth registration in particular with only 3 per cent of children under the age 5 registered with civil authorities. In Somali Region of Ethiopia, only 1% of children under 5 have their births registered. A major gap identified in the civil registration system in Ethiopia is the linkage between the health and the civil registration sectors with most children delivered at the health facilities or in the communities not appropriately registered. This case study used qualitative and quantitative methods to describe the process and outcome of a pilot project on improving birth registration using the health system (health facilities and the community health structures) in 2 project woredas (districts) in Somali region of Ethiopia where no birth had been registered more than five years prior the pilot.&#x0D; Within the one-year study period, all 577 births assisted by health extension workers were provided with birth notification slips and 795 (98%) newborns have their birth registered and received birth certificates out of 809 total births reported in the project sites. The study demonstrated the effectiveness of health workers and community structure (mentor mothers) through their community sensitization and mobilization and active reporting process in facilitating registration of births in the civil registration system.

Adverse childhood experiences among children of parents who are refugees affected by trauma in Denmark: a register-based cohort study

Children in families who are refugees might experience more adversities than their peers. Adverse childhood experiences (ACEs) are well known risk factors for poorer adulthood health and adjustment. The risk of ACEs for children with a parent who is a refugee affected by trauma is unknown. We aimed to estimate the hazard of individual and cumulative ACEs using a unique sample of children with parents who are refugees affected by and seeking treatment for trauma and population level data. This was a register-based cohort study carried out in Denmark. All children aged 0-15 years, residing in Denmark between Jan 1, 1990, and Dec 31, 2016, were followed up from birth or migration into the country to their 15th birthday. We linked data from the Danish Civil Registration System, the Danish National Patient Register, the Danish Psychiatric Central Research Register, the Employment Classification Module, the Register of Causes of Death, and the Income Statistics Register to investigate ten ACE categories (parental: natural and unnatural death, serious mental illness, substance use disorder, somatic illness, and disability; child: residential instability, family disruption, poverty, and stressors) and the cumulative number of ACE categories for children with a parent from a refugee-sending country and children with a parent who is a refugee in treatment for trauma. The main outcome was the hazard ratio (HR) of the individual and cumulative ACEs among children with a parent from a refugee-sending country and children with a parent who is a refugee affected by trauma, compared with the general population of children in Denmark, both adjusted and unadjusted for parental country of origin. 2 688 794 children were included in the study, 252 310 of whom had parents from refugee-sending countries. 11 603 children had parents affected by trauma and seeking treatment, of whom 1163 (10%) migrated to Denmark before their second birthday and 10 440 (90%) were born in Denmark. Compared with the general population of children in Denmark, the hazard for most ACEs was significantly higher for both children with parents from a refugee-sending country and children with parents who are refugees affected by trauma. For children with a parent from a refugee-sending country, the highest HR was related to the child living in relative poverty for 3 years (3·62 [95% CI 3·52-3·73]). After adjusting for parental country of origin, the hazards for five ACEs were significantly greater for children of parents who are refugees affected by trauma compared with the remaining children of parents from the same countries. The highest HR for this child group was for parental serious mental illness (1·98 [1·85-2·12]). The hazard for experiencing multiple ACEs was significantly higher for both child groups compared with the general population. Our findings suggest that children with parents from refugee-sending countries have a higher rate of several ACEs compared with the general population. Furthermore, having a parent who is a refugee affected by trauma and seeking treatment seems to be an independent risk factor for poorer health and adjustment in adulthood. This study informs decision makers and caregivers that there might be much added value in addressing needs within the whole family, as opposed to only attending to the parent who is seeking treatment. The Lundbeck Foundation.

Colorectal cancer and occupational exposure to solar ultraviolet B radiation in Denmark

ObjectivesSolar ultraviolet B radiation (UV) may reduce the risk of cancer, including colorectal cancer (CRC), although the evidence is inconclusive. To contribute with evidence, the present largescale register-based nested case-control study aimed to investigate the association between occupational UV exposure and CRC in Denmark. MethodsThe Danish Cancer Registry was used to identify a total of 12,268 men and women diagnosed with primary CRC before age 70. Five controls matched on year of birth and sex, alive and free of CRC at the time of diagnosis of the index case were randomly selected from The Danish Civil Registration System. Occupational UV exposure was assessed by obtainment of full employment history from the Danish Supplementary Pension Fund Register, which was linked to a job exposure matrix. Conditional logistic regression was used to estimate odds ratios (ORs) with corresponding 95% confidence intervals. ResultsWe observed an inverse association between longer duration of UV exposure and CRC in women (≥20 years: OR = 0.84, 95% CI: 0.69–1.03), while no noteworthy associations were observed in men. When focusing on colon cancer only, longer duration of UV exposure (>20 years: OR = 0.92, 95% CI: 0.83–1.01) and higher cumulative UV exposure (highest exposure category: OR = 0.90, 95% CI: 0.83–0.99) were indicated to lower the risk in the study population including both men and women, although the risk reduction appeared to be more evident for women. No consistent risk patterns were observed for rectal cancer. ConclusionsThe present study suggests a modest protective effect from long-term occupational UV exposure on the risk of colon cancer. The effect may be greater in women and these findings need further attention in future large-scale studies.