Verbal Autopsy Methods Research Articles

Causes of Mortality for Indonesian Hajj Pilgrims: Comparison between Routine Death Certificate and Verbal Autopsy Findings

BackgroundIndonesia provides the largest single source of pilgrims for the Hajj (10%). In the last two decades, mortality rates for Indonesian pilgrims ranged between 200–380 deaths per 100,000 pilgrims over the 10-week Hajj period. Reasons for high mortality are not well understood. In 2008, verbal autopsy was introduced to complement routine death certificates to explore cause of death diagnoses. This study presents the patterns and causes of death for Indonesian pilgrims, and compares routine death certificates to verbal autopsy findings.MethodsPublic health surveillance was conducted by Indonesian public health authorities accompanying pilgrims to Saudi Arabia, with daily reporting of hospitalizations and deaths. Surveillance data from 2008 were analyzed for timing, geographic location and site of death. Percentages for each cause of death category from death certificates were compared to that from verbal autopsy.ResultsIn 2008, 206,831 Indonesian undertook the Hajj. There were 446 deaths, equivalent to 1,968 deaths per 100,000 pilgrim years. Most pilgrims died in Mecca (68%) and Medinah (24%). There was no statistically discernible difference in the total mortality risk for the two pilgrimage routes (Mecca or Medinah first), but the number of deaths peaked earlier for those traveling to Mecca first (p=0.002). Most deaths were due to cardiovascular (66%) and respiratory (28%) diseases. A greater proportion of deaths were attributed to cardiovascular disease by death certificate compared to the verbal autopsy method (p<0.001). Significantly more deaths had ill-defined cause based on verbal autopsy method (p<0.001).ConclusionsDespite pre-departure health screening and other medical services, Indonesian pilgrim mortality rates were very high. Correct classification of cause of death is critical for the development of risk mitigation strategies. Since verbal autopsy classified causes of death differently to death certificates, further studies are needed to assess the method’s utility in this setting.

Can computers measure the chronic disease burden using survey questionnaires? The Symptomatic Diagnosis Study

BackgroundMeasuring the burden of chronic conditions in the developing world is a critical global health challenge. Scarce resources and the lack of biometry tests for chronic conditions such as depression and arthritis limit current measurement. Computer-based diagnosis based on self-reported signs and symptoms (symptomatic diagnosis) is a promising method for more accurately measuring the chronic disease burden. MethodsAs part of the Population Health Metrics Research Consortium (PHMRC) study, we collected 1379 questionnaires in Mexico from individuals who had a chronic condition that had been diagnosed with gold-standard diagnostic criteria or individuals who did not have any of the ten target conditions. Our primary analytical goal was to develop an algorithm to accurately diagnose chronic conditions. To this end, we tested methods previously developed for verbal autopsy. We analysed the performance of each method and compared performance to existing epidemiological measurement techniques. FindingsThe top-performing method is capable of achieving 68% concordance with gold-standard diagnosis. Concordance ranged from approximately 90% for depression, angina pectoris, and cirrhosis, to 40% for osteoarthritis and vision loss. The prevalence fraction of each condition could be measured with less than 3% absolute error. These findings roughly parallel validated verbal autopsy methods at an expectedly higher performance level. InterpretationSymptomatic diagnosis outperforms current techniques and is a viable method for measuring the burden of chronic diseases in areas with low health information infrastructure. It is a critical global health challenge to better characterise the epidemiology of chronic conditions in these areas, and is a powerful, unique solution capable of collecting an array of prevalence data in a single survey. This technology can provide myriad benefits to the field of epidemiology, including higher-resolution prevalence data, flexible data collection with rapid interpretability, and individual diagnosis for certain conditions. FundingThe Population Health Metrics Research Consortium funded the data collection as part of a Gates Grand Challenges in Global Health initiative (GC-13).

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

In countries where most deaths are outside health institutions and medical certification of death is absent, verbal autopsy (VA) method is used to estimate population level causes of death. VA data were collected by trained lay interviewers for 409 deaths in the surveillance site. Two physicians independently assigned cause of death using the International Classification of Diseases manual. In general, infectious and parasitic diseases accounted for 35.9% of death, external causes 15.9%, diseases of the circulatory system 13.4% and perinatal causes 12.5% of total deaths. Mortalities attributed to maternal causes and malnutrition were low, 0.2 and 1.5%, respectively. Causes of death varied by age category. About 22.1, 12.6 and 8.4% of all deaths of under 5-year-old children were due to bacterial sepsis of the newborn, acute lower respiratory infections such as neonatal pneumonia and prematurity including respiratory distress, respectively. For 5-15-year-old children, accidental drowning and submersion, accounting for 34.4% of all deaths in this age category, and accidental fall, accounting for 18.8%, were leading causes of death. Among 15-49-year-old adults, HIV/AIDS (16.3%) and tuberculosis (12.8%) were commonest causes of death, whereas tuberculosis and cerebrovascular diseases were major killers of those aged 50 years and above. In the rural district, mortality due to chronic non-communicable diseases was very high. The observed magnitude of death from chronic non-communicable disease is unlikely to be unique to this district. Thus, formulation of chronic disease prevention and control strategies is recommended.

Assessing the quality of evidence for verbal autopsy diagnosis of stroke in Vietnam

Background:Information on the leading causes of mortality will continue to rely on verbal autopsy (VA) in developing countries. The accuracy of VA methods in correctly ascertaining the cause for each individual death is crucial in order to have confidence in the data collected through the procedure. Accuracy of the VA procedure is generally established by carrying out validation studies involving a comparison of the underlying cause of death derived from the VA with a reference underlying cause from medical records. Such validation is only possible in cases for which clinical records are available, and this is clearly not the case for most deaths in developing countries. We attempt to verify the accuracy of VA evidence by reviewing the responses to specific symptom questions and other information recorded in verbal autopsy questionnaires that were assigned cerebrovascular conditions (stroke) as causes of death upon physician review in Vietnam.Materials and Methods:A national sample mortality surveillance activity identified deaths and causes of death that had occurred during 2008 in selected communes in 16 provinces distributed across Vietnam. All cases from the northern provinces of Hanoi, Hai Duong, Quang Ninh and Thanh Hoa with ICD codes pertaining to cerebrovascular diseases were identified. A total of 326 VA questionnaires for deaths from cerebrovascular diseases were reviewed and analysed in detail for the presence of symptoms pertaining to stroke. The respondents’ narration of the chronological disease history and the hospital diagnosis was also examined with an aim to explore supporting signs for diagnosis and to verify the quality of VA interview. Differences between responses among cases with and without hospital admission were examined using Chi-squared test of statistical significance.Results:Ninty percent of the cases diagnosed as stroke were found to have positive response to the key symptoms; viz., paralysis (in structured question or free text) and history of stroke. For the remaining 10% of cases, stroke was assigned as a cause-of-death based on other suggestive cardiac signs and symptoms such as hypertension, unconsciousness, or headache, etc. Community had different perspectives of “paralysis” and “stroke” which might have affected the diagnosis of stroke in some aspects. Respondents of cases with hospital admission or visit were found to have a better recall of disease symptoms than those without hospital admission.Conclusion:The results of this study suggest the possible utility of VA content analysis method to back up the low coverage of conventional validation studies in developing countries owing to nonavailability of medical records. The understanding of the VA content would also form the basis for improvement in the quality of interviews and collection of data to achieve better quality information in future.

Road traffic related mortality in Vietnam: Evidence for policy from a national sample mortality surveillance system

BackgroundRoad traffic injuries (RTIs) are among the leading causes of mortality in Vietnam. However, mortality data collection systems in Vietnam in general and for RTIs in particular, remain inconsistent and incomplete. Underlying distributions of external causes and body injuries are not available from routine data collection systems or from studies till date. This paper presents characteristics, user type pattern, seasonal distribution, and causes of 1,061 deaths attributable to road crashes ascertained from a national sample mortality surveillance system in Vietnam over a two-year period (2008 and 2009).MethodsA sample mortality surveillance system was designed for Vietnam, comprising 192 communes in 16 provinces, accounting for approximately 3% of the Vietnamese population. Deaths were identified from commune level data sources, and followed up by verbal autopsy (VA) based ascertainment of cause of death. Age-standardised mortality rates from RTIs were computed. VA questionnaires were analysed in depth to derive descriptive characteristics of RTI deaths in the sample.ResultsThe age-standardized mortality rates from RTIs were 33.5 and 8.5 per 100,000 for males and females respectively. Majority of deaths were males (79%). Seventy three percent of all deaths were aged from 15 to 49 years and 58% were motorcycle users. As high as 80% of deaths occurred on the day of injury, 42% occurred prior to arrival at hospital, and a further 29% occurred on-site. Direct causes of death were identified for 446 deaths (42%) with head injuries being the most common cause attributable to road traffic injuries overall (79%) and to motorcycle crashes in particular (78%).ConclusionThe VA method can provide a useful data source to analyse RTI mortality. The observed considerable mortality from head injuries among motorcycle users highlights the need to evaluate current practice and effectiveness of motorcycle helmet use in Vietnam. The high number of deaths occurring on-site or prior to hospital admission indicates a need for effective pre-hospital first aid services and timely access to emergency facilities. In the absence of standardised death certification, sustained efforts are needed to strengthen mortality surveillance sites supplemented by VA to support evidence based monitoring and control of RTI mortality.

Factors Associated with Physician Agreement and Coding Choices of Cause of Death Using Verbal Autopsies for 1130 Maternal Deaths in India

BackgroundThe Indian Sample Registration System (SRS) with verbal autopsy methods provides estimations of cause specific mortality for maternal deaths, where the majority of deaths occur at home, unregistered. We aim to examine factors that influence physician agreement and coding choices in assigning causes of death from verbal autopsies.Methodology/Principal FindingsAmong adult deaths identified in the SRS, pregnancy-related deaths recorded in 2001–2003 were assigned ICD-10 codes by two independent physicians. Inter-rater reliability was estimated using Landis Koch Kappa classification – poor to fair agreement; > – moderate agreement; > – substantial agreement; >– high agreement. We identified factors associated with physician agreement using multivariate logistic regression. A central consensus panel reviewed cases for errors and reclassified as needed based on 2011 ICD-10 coding guidelines. Of 1130 pregnancy-related deaths, 1040 were assigned ICD-10 codes by two physicians. We found substantial agreement regardless of the woman's residence, whether the death was registered, religion, respondent's or deceased's education, age, hospital admission or gestational age. Physician agreement was not influenced by the above variables, with the exception of greater agreement in cases where the respondent did not live with the deceased, or early gestational age at the time of death. A central consensus panel reviewed all cases and recoded 10% of cases due to insufficient use of information in the verbal autopsy by the coding physicians and rationale for this reclassification are discussed.ConclusionIn the absence of complete vital registration and universal healthcare services, physician coded verbal autopsies continues to be heavily relied upon to ascertain pregnancy-related death. From this study, two independent physicians had good inter-rater reliability for assigning pregnancy-related causes of death in a nationally-represented sample, and physician coding does not appear to be heavily influenced by case characteristics or demographics.

Identifying and verifying causes of death in Turkey: National verbal autopsy survey

The aim of this study was to identify the national, rural, and urban mortality rates, and to define the medical causes of death for the 0-28 days and 29 days-5 years age groups, as well as adult mortality in Turkey. A cross-sectional survey, which identified the causes of death using the verbal autopsy(VA) method, and a methodological study, which determined the validity of the verbal autopsy method was used in conjunction with each other. The verbal autopsy method, based on a representative sampling according to age and gender in Turkey, was used. A methodological study was additionally used, which determined the validity of the VA method. The crude death rate calculated from the VA survey was 0.51% with rates of 0.60% in males, 0.42% in females, 0.48% in urban areas, and 0.56% in rural areas. Life expectancy at birth was 72.6 years for males and 77.2 years for females. The mean life expectancy at birth for both sexes together was 74.8 years. The VA form has a high degree of validity although no study or form can take the place of a records-based surveillance system with accurate information; the VA form is a useful tool for collecting data during certain periods or specific areas. However, healthcare providers must work towards establishing a well-designed, routine surveillance system in the long term. The mortality rates and life expectancies were consistent with other similar studies in the country and the Turkish VA method may be safely used to determine causes of death in countries with inadequate record and registry systems.

Classifying perinatal mortality using verbal autopsy: is there a role for nonphysicians?

BackgroundBecause of a physician shortage in many low-income countries, the use of nonphysicians to classify perinatal mortality (stillbirth and early neonatal death) using verbal autopsy could be useful.ObjectiveTo determine the extent to which underlying perinatal causes of deaths assigned by nonphysicians in Guatemala, Pakistan, Zambia, and the Democratic Republic of the Congo using a verbal autopsy method are concordant with underlying perinatal cause of death assigned by physician panels.MethodsUsing a train-the-trainer model, 13 physicians and 40 nonphysicians were trained to determine cause of death using a standardized verbal autopsy training program. Subsequently, panels of two physicians and individual nonphysicians from this trained cohort independently reviewed verbal autopsy data from a sample of 118 early neonatal deaths and 134 stillbirths. With the cause of death assigned by the physician panel as the reference standard, sensitivity, specificity, positive and negative predictive values, and cause-specific mortality fractions were calculated to assess nonphysicians' coding responses. Robustness criteria to assess how well nonphysicians performed were used.ResultsCauses of early neonatal death and stillbirth assigned by nonphysicians were concordant with physician-assigned causes 47% and 57% of the time, respectively. Tetanus filled robustness criteria for early neonatal death, and cord prolapse filled robustness criteria for stillbirth.ConclusionsThere are significant differences in underlying cause of death as determined by physicians and nonphysicians even when they receive similar training in cause of death determination. Currently, it does not appear that nonphysicians can be used reliably to assign underlying cause of perinatal death using verbal autopsy.

Feasibility of using a World Health Organization-standard methodology for Sample Vital Registration with Verbal Autopsy (SAVVY) to report leading causes of death in Zambia: results of a pilot in four provinces, 2010.

BackgroundVerbal autopsy (VA) can be used to describe leading causes of death in countries like Zambia where vital events registration does not produce usable data. The objectives of this study were to assess the feasibility of using verbal autopsy to determine age-, sex-, and cause-specific mortality in a community-based setting in Zambia and to estimate overall age-, sex-, and cause-specific mortality in the four provinces sampled.MethodsA dedicated census was conducted in regions of four provinces chosen by cluster-sampling methods in January 2010. Deaths in the 12-month period prior to the census were identified during the census. Subsequently, trained field staff conducted verbal autopsy interviews with caregivers or close relatives of the deceased using structured and unstructured questionnaires. Additional deaths were identified and respondents were interviewed during 12 months of fieldwork. After the interviews, two physicians independently reviewed each VA questionnaire to determine a probable cause of death.ResultsAmong the four provinces (1,056 total deaths) assessed, all-cause mortality rate was 17.2 per 1,000 person-years (95% confidence interval [CI]: 12.4, 22). The seven leading causes of death were HIV/AIDS (287, 27%), malaria (111, 10%), injuries and accidents (81, 8%), diseases of the circulatory system (75, 7%), malnutrition (58, 6%), pneumonia (56, 5%), and tuberculosis (50, 5%). Those who died were more likely to be male, have less than or equal to a primary education, and be unmarried, widowed, or divorced compared to the baseline population. Nearly half (49%) of all reported deaths occurred at home.ConclusionsThe 17.2 per 1,000 all-cause mortality rate is somewhat similar to modeled country estimates. The leading causes of death -- HIV/AIDS, malaria, injuries, circulatory diseases, and malnutrition -- reflected causes similar to those reported for the African region and by other countries in the region. Results can enable the targeting of interventions by region, disease, and population to reduce preventable death. Collecting vital statistics using standardized Sample Vital Registration with Verbal Autopsy (SAVVY) methods appears feasible in Zambia. If conducted regularly, these data can be used to evaluate trends in estimated causes of death over time.

Use of verbal autopsy in a national health information system: Effects of the investigation of ill-defined causes of death on proportional mortality due to injury in small municipalities in Brazil

BackgroundThe Mortality Information System (MIS) in Brazil records mortality data in hospitals and civil registries with the responsibility of compiling underlying cause of death. Despite continuous improvements in the MIS, some areas still maintain a high proportion of deaths assigned to ill-defined causes. Deaths coded to this category have most likely been considered as miscoded deaths from communicable and noncommunicable diseases. However, some local studies have provided evidence of underreporting of injury in Brazil. The aim of this study was to investigate ill-defined causes of death using the verbal autopsy (VA) method to estimate injury-specific mortality fraction in small municipalities in northeastern Minas Gerais, Brazil.MethodsA sample size of reported death certificates with ill-defined conditions in a random sample of 10 municipalities was obtained, and then trained interviewers questioned family members using a standardized VA questionnaire to elicit information on symptoms experienced by the deceased before death. All attempts were made to collect existing information about the disease or death using health facilities records. Probable causes of death were assigned by a physician after review of the completed questionnaires following rules of the 10th revision of the International Classification of Diseases (ICD-10).ResultsOf 202 eligible ill-defined deaths, 151 were investigated using the VA methodology, and 12.6% had injury as the underlying cause of death. The proportional mortality fraction from injury among all causes of death increases from 4.4% to 8.2% after investigation. Different specific injury category causes were observed between recorded injury causes and those detected by VA. Drowning was the top specific injury cause detected after investigation.ConclusionsThis study provides evidence that the use of VA in the investigation of registered ill-defined conditions in an existing MIS can furnish information on the relevance of injury as a priority health problem in small municipalities of Minas Gerais. Local research with VA should be brought to the attention of regional health policymakers to improve the quality of data for their planning.

An improved method for physician-certified verbal autopsy reduces the rate of discrepancy: experiences in the Nouna Health and Demographic Surveillance Site (NHDSS), Burkina Faso

BackgroundThrough application of the verbal autopsy (VA) approach, trained fieldworkers collect information about the probable cause of death (COD) by using a standardized questionnaire to interview family members who were present at the time of death. The physician-certified VA (PCVA), an independent review of this questionnaire data by up to three physicians trained in VA coding, is currently recommended by the World Health Organization (WHO) and is widely used in the INDEPTH Network. Even given its appropriateness in these contexts, a large percentage of causes of death assigned by VAs remains undetermined. As physicians often do not agree upon a final COD classification, there remains substantial room to improve the standard VA method, potentially leading to a reduction in physician discordance in COD coding.MethodsWe present an extension of the current method of PCVA and compare it to the standard WHO-recommended procedure. We used VA data collected in the Nouna Health and Demographic Surveillance Site (NHDSS) between 2009 and 2010 using a locally-adapted version of an INDEPTH standard verbal autopsy questionnaire. Until 2009, physicians in the NHDSS followed the WHO method (Method 1). As an extension of Method 1, starting in 2010, the use of a panel of physicians was added to the coding process in the case where a third physician's final conclusions resulted in an undetermined COD (Method 2). Two independent samples of VA questionnaires were compared for the year 2009 (using Method 1) and the year 2010 (using Method 2).ResultsThe WHO-recommended method used for 2009 yielded a high level of undetermined CODs, where the final coding was "undetermined" in 50.8% of all questionnaires due to disagreement among participating physicians (Method 1). By introducing a panel of physicians in 2010 for cases where the principal physicians disagreed on the cause of death, the revised method significantly reduced the proportion of undetermined CODs to 1.5% (Method 2).ConclusionsAs the extended method of PCVA significantly improved the accuracy of the VA procedure, we suggest the adoption of this method for those countries where alternatives like computer-based VA coding are not available. Based on the results of our study, further research should be pursued.

Advances in verbal autopsy: pragmatic optimism or optimistic theory?

Commentary In recent decades, verbal autopsy (VA) methods have been increasingly used to identify likely causes of death in settings where the majority of deaths occur without medical attention or certification as to cause [1]. Developments in the 1980s and 1990s advanced the conceptual and methodological aspects of the science considerably but fell short of providing a clear message about best practices for those who rely on VA data [2-10]. There has been a hiatus of methodological development since then, due in part to persistent, narrow assumptions as to the desire and need for cause of death data and unrealistic evaluation standards. This has not limited the application of VA methods in the world’s poorest settings, but it has almost certainly limited the usefulness and comparability of the data. There remains scarce evidence on which to base choice of methods at the various stages of the VA data process. However, the first ever Global Congress on Verbal Autopsy, held in Bali, Indonesia in February 2011, represents a resurgence of methodological and conceptual developments VA is arguably one of the most important fields in global health today. Methodological development in recent years, particularly in relation to probabilistic interpretation of VA data, has brought VA into an exciting era that is creating new opportunities for reliable, timely, and useful cause-specific mortality measurement. A shift away from limited individual-level and clinical paradigms towards population-based epidemiological thinking and public health utility has been characterized by a flurry of new methodological thinking and innovations from relatively small groups of researchers. Among these like-minded researchers, however, there is risk of a divide between pragmatic optimists and optimistic theorists. The pragmatic optimists are driven by the realities, perils, and pitfalls of real-life health measurement in low-income settings and strive to enhance health knowledge with methods that are good enough to fill data gaps reliably and efficiently. The optimistic theorists, whose methodological developments are often theoretically superior, are often far from offering practical solutions to those on the ground who need to know the major burdens of cause-specific mortality in their populations simply, quickly, and cheaply in the absence of pre-existing data and where “true validity” is difficult to establish. Such dichotomization is perhaps somewhat artificial, but there is a real risk that unrealistic standards and expectations in method development and evaluation will become the enemy of good enough methods that are able to provide essential data to those who need it. The Global Congress on VA was attended by over 100 delegates representing numerous agencies and academic institutions from around the globe. This level of participation illustrates not only the persistent desire to know who died from what in the world’s poorest settings, but also a desire for clear leadership on what the best methods are and how to use them. Whilst methodological favoritism, ideology, and competition can be a threat to an objective answer to this question, such factors are, in reality, likely to be minor and secondary to the more fundamental difficulty of recognizing the range of users who need cause of death data and what data they need. Differing cause of death data needs have been well described previously and the nonexistence of a one-sizefits-all solution to all needs is likely to persist [11]. This statement is grounded in recognition of the realities of health metrics in the world’s poorest populations and the imperfect world of lay-reported signs and symptoms, dubious record keeping, and biases in remembering, reporting, and recording certain events. It is in recognition of these realities that the gap between the pragmatic optimists and the optimistic theorists may grow: the first believing that method development cannot necessarily rely on pre-existing data and should be evaluated in terms of comparability to reference (but not Correspondence: Edward.Fottrell@epiph.umu.se Umea Centre for Global Health Research, Department of Public Health and Clinical Medicine, Umea University, Sweden Full list of author information is available at the end of the article Fottrell Population Health Metrics 2011, 9:24 http://www.pophealthmetrics.com/content/9/1/24

Verbal autopsy: who needs it?

Commentary Verbal autopsy has long been used to generate mortality data, often with the needs of specific programs, such as child and maternal mortality, in mind [1,2]. This led to a proliferation of instruments and the resulting data were rarely comparable across research sites or over time [3]. Demands for standardization led to the 2007 publication of the World Health Organization (WHO) verbal autopsy standards, which many researchers have adopted [4,5]. Increased convergence around standards has stimulated interest in using verbal autopsy outside research settings on a routine basis. Decision-makers, program managers, donors, and development partners have identified the need for simple data collection instruments, implemented using mobile phones or other hand-held devices and linked to the provision of care [6]. These potential users of verbal autopsy methods have different perspectives from researchers, tending to prioritize instrument simplicity, feasibility, and program relevance above technical performance. Verbal autopsy offers a solution to the challenge of generating cause of death information in settings where deaths occur outside the health care system. The “gold standard” is medical certification of cause according to the International Classification of Diseases (ICD) [7]. The WHO verbal autopsy tools are designed to generate causes of death that are “ICD compatible.” WHO recommends that mortality data derived from verbal autopsy be tabulated separately from data derived using medical certification and ICD coding [7]. While verbal autopsy may not be as reliable as hospital-based certification for identifying causes of death, it is able to produce information not available from a medical certificate. Alongside questions about signs and symptoms in the deceased person, verbal autopsy can ask about risk factors and health care seeking prior to death, elucidating social, economic, behavioral, and health system issues that may have contributed to death. This contextual knowledge is invaluable to health care managers and planners. Potential users of data generated through verbal autopsy include communities, health care planners and managers, researchers, global decision-makers, and donors [8]. While there is a degree of overlap, these users have different perspectives on the uses of mortality data. These in turn have an impact on the desirable characteristics of data collection instruments. Researchers, epidemiologists, and global-level decision-makers want mortality data to inform burden of disease estimation and program evaluation. Cause of death estimates must be scientifically validated, meet high standards of accuracy, and be comparable over time and across countries. Uncertainty in cause-specific mortality fractions can be managed. National/subnational decision-makers and health system managers want cause of death data for planning, budgeting, and resource allocation and for monitoring and reporting to donors. The ability to track trends over time is more important than cross-country comparability. Uncertainty is problematic, especially when data are needed to inform allocation of resources. Data need to be actionable and program relevant, implying an interest in information on socio-economic determinants of mortality [9]. Data collection instruments should be feasible and cost-effective to implement and adaptable to local circumstances and conditions. Disease-specific programs want data that highlight specific areas of interest and data collection instruments that are feasible, appropriate, and program relevant. They often have a particular interest in data on socioeconomic and health system factors associated with avoidable mortality. Beyond the health sector, civil registrars-general and national statistics offices want mortality information generated through verbal autopsy to complement data from routine administrative sources. Data collection instruments should be endorsed by technical partners such as WHO and should be simple and straightforward for implementation in routine registration encounters.

The epidemiology of ‘bewitchment’ as a lay-reported cause of death in rural South Africa

BackgroundCases of premature death in Africa may be attributed to witchcraft. In such settings, medical registration of causes of death is rare. To fill this gap, verbal autopsy (VA) methods...

Use of Verbal Autopsy as a Proxy to Determine the Possible Cause of Neonatal Deaths

Introduction: Information on causes of death is extremely important for policy making, planning, monitoring, field research, future management statergies and epidemic awareness. The best method of finding the cause of death is by post mortem examination but since this is difficult, post death analysis by verbal autopsy is a good method to determine the same. Objective: To asses the role of verbal autopsy method in the investigation of neonatal death and to determine the probable, causes of neonatal death. Materials and Methods: A pre-tested questionnaire in Hindi was administered to 50 mothers and/or next of kin or other care givers of the deceased residing in villages around 200 Kms. of Bhopal and in urban slums of Municipal Corporation, Bhopal. Results: 84 % of the total death occurred with in seven days of birth, 88 % of death occurred in villages where health facilities were available. As per verbal autopsy 36 % and 20 % of the infants died because of Birth asphyxia and Respiratory Distress Syndrome respectively and further 2%, 4% and 6% because of neonatal tetanus, hypothermia and other causes respectively. Conclusion: Verbal autopsy could be one of the possible cost effective and a reliable tool for determining the causes of neonatal deaths at present. Key words: Verbal Autopsy; Neonatal death; Reliable respondents and category of villages. DOI: 10.3126/jnps.v31i1.2942J Nep Paedtr Soc 2010;31(1):44-48

An alternative strategy for perinatal verbal autopsy coding: single versus multiple coders

To determine the comparability between cause of death (COD) by a single physician coder and a two-physician panel, using verbal autopsy. The study was conducted between May 2007 and June 2008. Within a week of a perinatal death in 38 rural remote communities in Guatemala, the Democratic Republic of Congo, Zambia and Pakistan, VA questionnaires were completed. Two independent physicians, unaware of the others decisions, assigned an underlying COD, in accordance with the causes listed in the chapter headings of the International classification diseases and related health problems, 10th revision (ICD-10). Cohen's kappa statistic was used to assess level of agreement between physician coders. There were 9461 births during the study period; 252 deaths met study enrolment criteria and underwent verbal autopsy. Physicians assigned the same COD for 75% of stillbirths (SB) (K = 0.69; 95% confidence interval: 0.61-0.78) and 82% early neonatal deaths (END) (K = 0.75; 95% confidence interval: 0.65-0.84). The patterns and proportion of SBs and ENDs determined by the physician coders were very similar compared to causes individually assigned by each physician. Similarly, rank order of the top five causes of SB and END was identical for each physician. This study raises important questions about the utility of a system of multiple coders that is currently widely accepted and speculates that a single physician coder may be an effective and economical alternative to VA programmes that use traditional two-physician panels to assign COD.

Causes of Child Deaths in India, 1985–2008: A Systematic Review of Literature

To understand the causes of child deaths in order to implement appropriate child survival interventions in the country. We present a systematic review of studies reporting causes of child, infant, and neonatal deaths from India for 1985 to 2008. PubMed, EMBASE, Google Scholar, and WHO regional databases were searched along with a hand search and personal communication with researchers in child health to obtain studies and reports for the database. Study data was summarized and analyzed using appropriate statistical tools. We identified 28 published/unpublished studies and reports (6 multi-centric and 22 single sites). There was one nation wide study and rest were from 15 unique sites in 9 different states of India. There were differences in study design and cause of death assignment methods between the studies, which made comparisons and synthesis difficult. The median percentage of causes of deaths in neonatal period were sepsis/pneumonia: 24.9% (Q1: 19.6% and Q3: 33.4%); asphyxia: 18.5% (Q1: 14.2% and Q3: 21.9%); and pre-maturity/LBW: 16.8% (Q1: 12.5% and Q3: 26.5%). Amongst the infants, sepsis/pneumonia, asphyxia, and prematurity/low birth weight (LBW) remain substantial causes of deaths. The median proportional contribution of neonatal deaths to total infant deaths was 48.5% (Q1: 36.5-Q3: 57.5%). The proportion of deaths due to infectious diseases like diarrhoea, pneumonia, and measles seem to be greater in infancy, in comparison to that in neonatal period. There was no statistically significant difference in the proportional contribution of neonatal deaths to total deaths occurring during infancy (<1 year) between the two equal periods before and after 1996 (p = 0.141). There also was no difference in the proportional contribution by cause of death assignment method (Verbal autopsy vs. other methods; p = 0.715) or by study setting (urban vs. rural; p = 0.175). The median percentage of neonatal deaths by day 1 is 36.7% (Range: 20.0-58.0%). The median cumulative percentage of neonatal deaths by day 3 was 49.7% (Range 35.0-64.6%), and 70.9% (Range: 46.5-92.3%) by day 7. In addition, the timing of deaths during neonatal period seems to be static during the last 2 decades, with majority of deaths occurring during first week of life. This review demonstrates the need for more studies with consistent methodological rigor investigating the causes of child death in India. We conclude that the structure of neonatal causes of death in India may be different from the rest of the world and that interventions to reduce neonatal deaths in first week of life may rapidly improve child survival in the country.

Verbal autopsy methods questioned

Verbal autopsy methods questioned

Changement de protocole dans la méthode d’autopsie verbale et mesure de la mortalité palustre en milieu rural sénégalais

In rural Senegal, three populations have been followed up since several decades and the malaria mortality trend has been observed since the mid-1980s. However, limits are associated with the verbal autopsy method used to determine causes of death, especially deaths due to malaria. A change in protocol occurred in recent years in two of these three sites with the involvement of two physicians (instead of only one) in the diagnosis. The objective is here to measure its potential impact on diagnosis of malaria deaths. Five hundred and fifteen diagnoses reported on child deaths occurred from 2000 to 2005 have been analysed. We have identified, on the basis of a multinomial logistic regression model, factors affecting the determination of malaria deaths among the characteristics of the child, the death, the illness and its symptoms, and we also took into account method factors. Factors related to the method do not play on the malaria diagnosis. This result insures the continuity of the series on malaria mortality statistics since 2000 in the two sites despite changes in the method. However, the new protocol leads to vanish possibility of having deaths among ill-defined or unknown causes. In the African context of absence of health statistics, data obtained through the verbal autopsy method in demographic surveillance system can provide accurate information in the epidemiological field, even regarding malaria.

Unintentional injury mortality in India, 2005 – estimates from a nationally representative mortality survey of 1.1 million homes

BackgroundStudies have suggested considerable injury mortality in India, a large proportion of these is due to unintentional injuries. However no reliable data are available to provide national estimates for these...