Verbal Autopsy Research Articles

A Retrospective Analysis of Lessons Learned and Perspectives on Expansion of Verbal Autopsy Implementation in Zambia, 2023.

Accurate cause-of-death statistics are vital for public health policy, but less than one-third of deaths globally are assigned a cause. Verbal autopsy (VA) methods are crucial in low- and middle-income countries lacking complete civil registration and vital statistics (CRVS) systems. We explored VA implementation in Zambia by using a previously developed framework. The National Mortality Surveillance Subcommittee under the Monitoring and Evaluation Technical Working Group within the Ministry of Health coordinates mortality surveillance activities in Zambia. To date, passive, non-population-representative VA data collection mechanisms have been used, leading to underrepresentation of some communities. In spite of the use of electronic data collection tools, VA systems have not been electronically linked to public health surveillance or CRVS systems. Funding for VA has largely been donor driven. Increasing government funding may ensure sustainability, while the adoption of sample-based platforms while linking VA information technology systems may make VA data more useful, timely, and accessible.

Childhood dead-before-arrival, our experience at a tertiary hospital in Southern Nigeria: a clarion call to stakeholders in the health sector

Dead-Before-Arrival (DBA) is a term used to describe patients who have no sign of life at the time of presentation to the hospital. There is a dearth of information about this cohort of children at most healthcare service delivery points. In fact, these children are also never captured in most of our national and local healthcare data. This research is aimed at sharing our experience on DBA at the Children’s Emergency Room of a tertiary hospital in the South-South geopolitical region of Nigeria, by determining the prevalence, probable disease cause, and pattern of DBA among children presenting at our facility. This is a cross-sectional study that used a standardized verbal autopsy instrument to ascertain the details of all the children aged 1 month to 17 years who were cases of DBA at the Children’s Emergency Room of the University of Benin Teaching Hospital, Benin City, Edo State, Nigeria, over 24 months (January 2018 to December 2019). Socio-demographic characteristics, symptoms before demise, treatment received, and suspected cause(s) of death were documented. The prevalence of DBA was compared to the in-hospital mortality during the period. A total of 96 (3.2%) compared to 144 (4.9%) in-hospital of the 2,914 emergency admissions were cases of DBA, with a 2:1 male-to-female ratio. The age group of 1-6 months had the highest proportion (41.7%). Children under two were 62.5% and 81.3% were under-fives. Infections such as diarrhea, bronchopneumonia, and sepsis were the most common suspected causes of death, followed by non-infectious causes such as perinatal asphyxia, Chronic Kidney Disease (CKD), cyanotic congenital heart disease, drowning, and electrocution. Cases of DBA were significantly lower than in-hospital mortality (144 cases) during the study period (3.2% vs 4.9%) The DBA prevalence as recorded in this hospital-based study may be the tip of the iceberg compared to what happens in the community. Making our primary and secondary health care services more accessible, affordable, and optimally functional may help reduce the burden of DBA.

Unveiling challenges of maternal health in India’s tribal mothers: Insights from a case series of maternal deaths

ABSTRACT Maternal mortality remains a significant public health concern globally, with disparities often evident among marginalized populations, including tribal communities. This case series delves into the complexities surrounding maternal mortality among tribal populations in India, shedding light on the multifaceted factors contributing to this persistent public health issue. Through verbal autopsy and retrospective review of medical records, a series of maternal deaths among tribal mothers were examined. Maternal deaths have been broadly divided into two categories Bottlenecks in quality antenatal services and missed opportunities.

Effect of a participatory whole-systems approach on mortality in children younger than 5 years in Jigawa state, Nigeria (INSPIRING trial): a community-based, parallel-arm, pragmatic, cluster randomised controlled trial and concurrent mixed-methods process evaluation

In 2019, Nigeria reported the highest mortality rate in children younger than 5 years globally. We aimed to assess a whole-systems approach to improving child mortality in northern Nigeria. We conducted a community-based, parallel-arm, pragmatic, cluster randomised controlled trial in Kiyawa local government area, Jigawa state, Nigeria, and a concurrent mixed-methods process evaluation using ethnography and quantitative implementation monitoring. Trial clusters were population catchment areas of 32 government primary health-care facilities. Compounds were randomly sampled, proportional to cluster size, and all women aged 16-49 years and children younger than 5 years who were permanent residents were eligible for inclusion and recruited as the evaluation population. Children younger than 7 days were recruited but excluded from analysis. Evaluation clusters were allocated to intervention or control via simple randomisation with a 1:1 ratio. Cluster names were written on paper, folded, and placed in a container by community representatives. Different community representatives took out names one by one, with the first half assigned to receive the intervention. The intervention consisted of three components: participatory learning and action (PLA) groups for men and women (including compound heads [ie, the member of the compound that residents deemed most senior]), partnership defined quality scorecard (PDQS), and health-care worker capacity building; it was delivered from March 1, 2021, to Dec 31, 2022. We could not mask participants, field staff, or intervention-delivery staff to cluster allocation but baseline, endline, and follow-up data excluded information on cluster allocation. PLA groups involved separate groups of up to 25 men or women from all villages in the intervention clusters. The primary outcome was all-cause mortality in children aged 7 days to 59 months between Oct 1, 2021, and Sept 20, 2022, referred to as the evaluation period. The trial was prospectively registered (ISRCTN 39213655) and the protocol has been published. We recruited 3800 compounds at baseline, with 12 893 children contributing to analysis of the primary outcome (7316 [56·8%] of 12 893 in the intervention group and 5577 [43·3%] in the control group). 6617 (51·3%) of 12 893 children were male, 6275 (48·7%) were female, and one (<0·1%) child had missing sex data. Sampled compounds randomly came from 388 (91·3%) of 425 villages in the 32 clusters. We conducted verbal autopsies for 1182 deaths, of which 369 (31·2%) were children aged 7 days to 59 months during the evaluation period. Of these 369, 91 (24·7%) were classified as pneumonia deaths. Children contributed a median 361 days (IQR 236-365) to the analysis, with 369 (2·9%) of 12 893 children censored on their date of death, 1545 (12·0%) on their 5th birthday, and 3392 (26·3%) on the date of the most recent follow-up in which their residence or survival status was known. We found no significant decrease in all-cause mortality (hazard ratio 0·95, 95% CI 0·68-1·33; p=0·79) or suspected pneumonia mortality (0·79, 0·43-1·46; p=0·46) in the intervention group. The process evaluation showed low coverage and issues in reach of the intervention, but qualitative data highlighted mechanisms for positive effects on health and relationships. Our intervention did not affect mortality. However, due to the high child mortality in this region, further efforts should be made to adapt our participatory whole-systems approach to use communities of action within compounds. GSK and Save the Children UK. For the Hausa translation of the abstract see Supplementary Materials section.

Mortality in type 1 diabetes mellitus: A single centre experience from the ICMR – Youth onset diabetes registry in India

IntroductionThe prevalence of youth onset diabetes is rising globally along with a greater burden of complications and mortality in them. The current study was undertaken to examine the mortality and causes of death in patients with youth onset diabetesregistered in a tertiary care hospital in North India. MethodsWe analyzed mortality and causes of death in 1088 patients with youth onset diabetes registered from 2006 to 2019 at University College of Medical Sciences, Delhi. Information of death was obtained telephonically or by home visit or from hospital records wherever available. Verbal autopsy according to ICMR questionnaire was performed and cause of death determined as per WHO ICD-10/11. ResultsAmong 898 youth onset type 1 diabetes mellitus (T1D) patients who had a mean follow up of 6.4 years, 105 deaths (11.6 %) occurred. Forty three percent of deaths had diabetes onset at 15 years or below, and 75.6 % had HbA1C > 10 %. Deaths occurred in 24.2 % within 2 years and in 53.6 % within 3 years of diagnosis. Chronic Kidney disease, infections and ketoacidosis were the commonest causes. ConclusionWe found poor glycaemic control and high mortality in people with youth onset T1D being treated at a tertiary care hospital in north India.

Text mining of verbal autopsy narratives to extract mortality causes and most prevalent diseases using natural language processing

Verbal autopsy (VA) narratives play a crucial role in understanding and documenting the causes of mortality, especially in regions lacking robust medical infrastructure. In this study, we propose a comprehensive approach to extract mortality causes and identify prevalent diseases from VA narratives utilizing advanced text mining techniques, so as to better understand the underlying health issues leading to mortality. Our methodology integrates n-gram-based language processing, Latent Dirichlet Allocation (LDA), and BERTopic, offering a multi-faceted analysis to enhance the accuracy and depth of information extraction. This is a retrospective study that uses secondary data analysis. We used data from the Agincourt Health and Demographic Surveillance Site (HDSS), which had 16338 observations collected between 1993 and 2015. Our text mining steps entailed data acquisition, pre-processing, feature extraction, topic segmentation, and discovered knowledge. The results suggest that the HDSS population may have died from mortality causes such as vomiting, chest/stomach pain, fever, coughing, loss of weight, low energy, headache. Additionally, we discovered that the most prevalent diseases entailed human immunodeficiency virus (HIV), tuberculosis (TB), diarrhoea, cancer, neurological disorders, malaria, diabetes, high blood pressure, chronic ailments (kidney, heart, lung, liver), maternal and accident related deaths. This study is relevant in that it avails valuable insights regarding mortality causes and most prevalent diseases using novel text mining approaches. These results can be integrated in the diagnosis pipeline for ease of human annotation and interpretation. As such, this will help with effective informed intervention programmes that can improve primary health care systems and chronic based delivery, thus increasing life expectancy.

Laying the foundations for high-quality mortality surveillance in Sierra Leone: Early learnings from the Child Health and Mortality Prevention Surveillance (CHAMPS) Network

Background More than four million child deaths occur annually; most are neither adequately documented nor investigated. The Child Health and Mortality Prevention Surveillance (CHAMPS) program was launched in Sierra Leone (SL) to generate high-quality data to determine definitive causes of stillbirths and under-five mortality (U5M) to inform decision-makers. Despite the multiple challenges of a greenfield research site, we highlight the experience of setting up a high-quality mortality surveillance (MS) system, including the viability of Minimal Invasive Tissue Sampling (MITS). Methods To establish the MS program, we implemented qualitative research and community entry, a sensitive system for timely identification and notification of deaths and followed CHAMPS standard operating procedures for investigating deaths and assigning accurate and definitive causes of death. CHAMPS in SL was implemented in four phases during 2017-2019 by a consortium. Enrolled stillbirths and U5M underwent verbal autopsy, clinical-data-abstractions, MITS, microbiology, molecular and histopathological diagnoses, and Determination of Cause of Death (DeCoDe). Results CHAMPS achieved a 93% consent rate, capitalizing on existing Ministry of Health infrastructure, community involvement, and local ownership. As of December 2022, 3,433 deaths were registered, with 1,056 (31%) eligible for enrolment. Of 439 cases DeCoDed, 402 (92%) of case-families had received feedback on the cause of death. Using findings and recommendations from the DeCoDe experts, CHAMPS is implementing interventions to reduce stillbirths and U5M at CHAMPS SL, including clinical review meetings, provision of emergency drugs and routine child death audits. Conclusion Implementing innovative MS in a challenging context, such as SL, is possible. Building on local knowledge and infrastructure has enabled the CHAMPS project to achieve remarkably high consent rates, given the cultural, religious and sensitivity challenges surrounding seeking consent for MITS from caregivers who have just lost a child. The programme has invested significantly in upscaling local technical capacity for surveillance and laboratory diagnostics.

Causes of Pediatric Deaths in Lusaka, Zambia: A Quantitative Geographic Information Systems Approach.

While childhood mortality has been declining in Zambia, it remains high at 58 per 1000 live births. Importantly, many leading causes of mortality in Zambia are preventable. This study was conducted to identify clusters of childhood mortality, causes of death of recently deceased children, barriers to care, and risk factors for mortality in Lusaka, Zambia. This study was conducted as a prospective cohort study. Family members or lawfully authorized representatives (LARs) were interviewed when they came to pick up death certificates for recently deceased children from Lusaka Children's Hospital. Each interview included a verbal autopsy, determination of the child's location of residence, and collection of demographic information. Demographic data was also collected from a healthy control group. Quantitative Geographic Information Systems was used to visualize mortality and evaluate for clustering. Leading primary causes of death included malnutrition (21%), complications of chronic illnesses (16%), and central nervous system infections (13%), while the leading barriers to care were cost (58%) and difficulties with travel (53%). Compared to controls, recently deceased children came from families with significantly lower incomes (1905 Kwacha vs. 2412 Kwacha, p = 0.03) and were significantly more likely to have a history of malnutrition (16.7% vs. 1.4%, p = 0.005). Mortality was clustered in two high-population density, low-income neighborhoods in Lusaka. Systems to reduce financial barriers to care and improve access to transportation could reduce childhood mortality in Lusaka. The aforementioned neighborhoods are ideal locations for public health interventions or improved healthcare services.

Child Health and Mortality Prevention Surveillance (CHAMPS): Manhiça site description, Mozambique

The Manhiça Health Research Centre (Manhiça HDSS) was established in 1996 in Manhiça, a rural district at Maputo Province in the southern part of Mozambique with approximately 49,000 inhabited households, a total population of 209.000 individuals, and an annual estimated birth cohort of about 5000 babies. Since 2016, Manhiça HDSS is implementing the Child Health and Mortality Prevention Surveillance (CHAMPS) program aiming to investigate causes of death (CoD) in stillbirths and children under the age of 5 years using an innovative post-mortem technique known as Minimally Invasive Tissue sampling (MITS), comprehensive pathogen screening using molecular methods, clinical record abstraction and verbal autopsy. Both in-hospital and community pediatric deaths are investigated using MITS. For this, community-wide socio-demographic approaches (notification of community deaths by key informants, formative research involving several segments of the community, availability of free phone lines for notification of medical emergencies and deaths, etc.) are conducted alongside to foster community awareness, involvement and adherence as well as to compute mortality estimates and collect relevant information of health and mortality determinants. The main objective of this paper is to describe the Manhiça Health and Demographic Surveillance System (HDSS) site and the CHAMPS research environment in place including the local capacities among its reference hospital, laboratories, data center and other relevant areas involved in this ambitious surveillance and research project, whose ultimate aim is to improve child survival through public health actions derived from credible estimates and understanding of the major causes of childhood mortality in Mozambique.

High SARS-CoV-2 seroincidence but low excess COVID mortality in Sierra Leone in 2020-2022.

While SARS-CoV-2 infection appears to have spread widely throughout Africa, documentation of associated mortality is limited. We implemented a representative serosurvey in one city of Sierra Leone in Western Africa, paired with nationally representative mortality and selected death registration data. Cumulative seroincidence using high quality SARS-CoV-2 serological assays was 69% by July 2021, rising to 84% by April 2022, mostly preceding SARS-CoV-2 vaccination. About half of infections showed evidence of neutralizing antibodies. However, excess death rates were low, and were concentrated at older ages. During the peak weeks of viral activity, excess mortality rates were 22% for individuals aged 30-69 years and 70% for those over 70. Based on electronic verbal autopsy with dual independent physician assignment of causes, excess deaths during viral peaks from respiratory infections were notable. Excess deaths differed little across specific causes that, a priori, are associated with COVID, and the pattern was consistent among adults with or without chronic disease risk factors. The overall 6% excess of deaths at ages ≥30 from 2020-2022 in Sierra Leone is markedly lower than reported from South Africa, India, and Latin America. Thus, while SARS-CoV-2 infection was widespread, our study highlights as yet unidentified mechanisms of heterogeneity in susceptibility to severe disease in parts of Africa.

Neurological Symptoms and Cause of Death Among Young Children in Low- and Middle-Income Countries

The emergence of acute neurological symptoms in children necessitates immediate intervention. Although low- and middle-income countries (LMICs) bear the highest burden of neurological diseases, there is a scarcity of diagnostic and therapeutic resources. Therefore, current understanding of the etiology of neurological emergencies in LMICs relies mainly on clinical diagnoses and verbal autopsies. To characterize the association of premortem neurological symptoms and their management with postmortem-confirmed cause of death among children aged younger than 5 years in LMICs and to identify current gaps and improve strategies to enhance child survival. This cross-sectional study was conducted between December 3, 2016, and July 22, 2022, at the 7 participating sites in the Child Health and Mortality Prevention Surveillance (CHAMPS) network (Bangladesh, Ethiopia, Kenya, Mali, Mozambique, Sierra Leone, and South Africa). Minimally invasive tissue sampling was performed at the CHAMPS sites with specimens from deceased children aged younger than 5 years. This study included deceased children who underwent a premortem neurological evaluation and had a postmortem-confirmed cause of death. Data analysis was performed between July 22, 2022, and January 15, 2023. Descriptive analysis was performed using neurological evaluations from premortem clinical records and from postmortem determination of cause of death (based on histopathology, microbiological testing, clinical records, and verbal autopsies). Of the 2127 deaths of children codified during the study period, 1330 (62.5%) had neurological evaluations recorded and were included in this analysis. The 1330 children had a median age of 11 (IQR, 2-324) days; 745 (56.0%) were male and 727 (54.7%) presented with neurological symptoms during illness before death. The most common postmortem-confirmed neurological diagnoses related to death were hypoxic events (308 [23.2%]), meningoencephalitis (135 [10.2%]), and cerebral malaria (68 [5.1%]). There were 12 neonates with overlapping hypoxic events and meningoencephalitis, but there were no patients with overlapping meningoencephalitis and cerebral malaria. Neurological symptoms were similar among diagnoses, and no combination of symptoms was accurate in differentiating them without complementary tools. However, only 25 children (18.5%) with meningitis had a lumbar puncture performed before death. Nearly 90% of deaths (442 of 511 [86.5%]) with neurological diagnoses in the chain of events leading to death were considered preventable. In this cross-sectional study of children aged younger than 5 years, neurological symptoms were frequent before death. However, clinical phenotypes were insufficient to differentiate the most common underlying neurological diagnoses. The low rate of lumbar punctures performed was especially worrying, suggesting a challenge in quality of care of children presenting with neurological symptoms. Improved diagnostic management of neurological emergencies is necessary to ultimately reduce mortality in this vulnerable population.

Mechanisms and causes of death after abdominal surgery in low-income and middle-income countries: a secondary analysis of the FALCON trial

Death after surgery is devasting for patients, families, and communities, but remains common in low-income and middle-income countries (LMICs). We aimed to use high-quality data from an existing global randomised trial to describe the causes and mechanisms of postoperative mortality in LMICs. To do so, we developed a novel framework, learning from both existing classification systems and emerging insights during data analysis. This study was a preplanned secondary analysis of the FALCON trial in 54 hospitals across seven LMICs (Benin, Ghana, India, Mexico, Nigeria, Rwanda, and South Africa). FALCON was a pragmatic, 2 × 2 factorial, randomised controlled trial that compared the effectiveness of two types of interventions for skin preparation (10% aqueous povidone-iodine vs 2% alcoholic chlorhexidine) and sutures (triclosan-coated vs uncoated). Patients who did not have surgery or were lost to follow-up were excluded (n=231). The primary outcomes of the present analysis were the mechanism and cause of death within 30-days of surgery, determined using a modified verbal autopsy strategy from serious adverse event reports. Factors associated with mortality were explored in a mixed-effects Cox proportional hazards model. The FALCON trial is registered with ClinicalTrials.gov, NCT03700749. This preplanned secondary analysis of the FALCON trial included 5558 patients who underwent abdominal surgery, of whom 4248 (76·4%) patients underwent surgery in tertiary, referral centres and 1310 (23·6%) underwent surgery in primary referral (ie, district or rural) hospitals. 3704 (66·7%) of 5558 surgeries were emergent. 306 (5·5%) of 5558 patients died within 30 days of surgery. 226 (74%) of 306 deaths were due to circulatory system failure, which included 173 (57%) deaths from sepsis and 29 (9%) deaths from hypovolaemic shock including bleeding. 47 (15%) deaths were due to respiratory failure. 60 (20%) of 306 patients died without a clear cause of death: 45 (15%) patients died with sepsis of unknown origin and 15 (5%) patients died of an unknown cause. 46 (15%) of 306 patients died within 24 h, 111 (36%) between 24 h and 72 h, 57 (19%) between >72 h and 168 h, and 92 (30%) more than 1 week after surgery. 248 (81%) of 306 patients died in hospital and 58 (19%) patients died out of hospital. The adjusted Cox regression model identified age (hazard ratio 1·01, 95% CI 1·01-1·02; p<0·0001), ASA grade III-V (4·93, 3·45-7·03; p<0·0001), presence of diabetes (1·47, 1·04-2·41; p=0·033), being an ex-smoker (1·59, 1·10-2·30; p=0·013), emergency surgery (2·08, 1·45-2·98; p<0·0001), cancer (1·98, 1·42-2·76; p<0·0001), and major surgery (3·94, 2·30-6·75; p<0·0001) as risk factors for postoperative mortality INTERPRETATION: Circulatory failure leads to most deaths after abdominal surgery, with sepsis accounting for almost two-thirds. Variability in timing of death highlights opportunities to intervene throughout the perioperative pathway, including after hospital discharge. A high proportion of patients without a clear cause of death reflects the need to improve capacity to rescue and cure by strengthening perioperative systems. National Institute for Health and Care Research Global Health Research Unit.

Under-five mortality during the war in Tigray: A community-based study

BackgroundChild mortality is one of the key indicators of the Sustainable development goals. The Ethiopian healthcare system in general and Tigray’s healthcare system in particular has shown a remarkable progress in terms of reducing maternal, neonatal, and under-five mortality in the last couple of decades. However, the war erupted in November 2020 caused the healthcare system to collapse and little is known about the status of child mortality in Tigray. Thus, this study aimed to examine the magnitude and causes of under-five child mortality in the embattled Tigray region was conducted from October 2020 – May 2022.MethodsA cross-sectional community-based survey was employed. The study included all zones except the western zone and some areas of eastern and north western Tigray bordering Eritrea. These areas were skipped for security reasons. Based on multistage cluster sampling, 121 tabiyas in districts were selected. Census was conducted to survey 189,087 households in the 121 Tabiyas. A locally developed household screening tool and the latest world health organization verbal autopsy instrument were used. The Verbal Autopsy data was processed using the Inter-VA–5.1 (probabilistic modeling) to assign the cause of death. Under-five mortality rate (U5MR) was calculated per 1000 live births with a 95% confidence interval (CI).ResultsIn the present study, out of 29,761 live births, 1761 under-five children died giving an under-five mortality rate of 59(95% CI, 57–62) per 1000 live births. Deaths in the neonatal period and post-neonatal period accounted for 60% and 19.9% of the deaths respectively. Overall, the top 3 causes of under-five child mortality in the present study were: Perinatal asphyxia (n = 277,18%,) prematurity (n = 235,16%) and diarrheal diseases (n = 162, 12.5%). In those who died after first month of life, diarrheal diseases, lower respiratory tract infection, sever acute malnutrition and HIV were the main causes of death. Concerning the place of death, 61.6% of the children died at home.ConclusionThe present study revealed the doubling of under-five mortality in Tigray from where the figure stood in the pre-war period. The leading causes of death in under-five mortality are potentially preventable in situation where the healthcare system is functioning. Restoring the healthcare system and its apparatus, improving access to skilled institutional delivery, smooth perinatal transition, improving nutrition status of children, access to full course of vaccines could ameliorate the staggering under-five mortality rate in the war in Tigray.

Comparison of causes of stillbirth and child deaths as determined by verbal autopsy and minimally invasive tissue sampling.

In resource-limited settings where vital registration and medical death certificates are unavailable or incomplete, verbal autopsy (VA) is often used to attribute causes of death (CoD) and prioritize resource allocation and interventions. We aimed to determine the CoD concordance between InterVA and CHAMPS's method. The causes of death (CoDs) of children <5 were determined by two methods using data from seven low- and middle-income countries (LMICs) enrolled in the Child Health and Mortality Prevention Surveillance (CHAMPS) network. The first CoD method was from the DeCoDe panel using data from Minimally Invasive Tissue Sampling (MITS), whereas the second method used Verbal Autopsy (VA), which utilizes the InterVA software. This analysis evaluated the agreement between the two using Lin's concordance correlation coefficient. The overall concordance of InterVA4 and DeCoDe in assigning causes of death across surveillance sites, age groups, and causes of death was poor (0.75 with 95% CI: 0.73-0.76) and lacked precision. We found substantial differences in agreement by surveillance site, with Mali showing the lowest and Mozambique and Ethiopia the highest concordance. The InterVA4 assigned CoD agrees poorly in assigning causes of death for U5s and stillbirths. Because VA methods are relatively easy to implement, such systems could be more useful if algorithms were improved to more accurately reflect causes of death, for example, by calibrating algorithms to information from programs that used detailed diagnostic testing to improve the accuracy of COD determination.

Temporal changes in cause of death among adolescents and adults in six countries in eastern and southern Africa in 1995–2019: a multi-country surveillance study of verbal autopsy data

The absence of high-quality comprehensive civil registration and vital statistics systems across many settings in Africa has led to little empirical data on causes of death in the region. We aimed to use verbal autopsy data to provide comparative, population-based estimates of cause-specific mortality among adolescents and adults in eastern and southern Africa. In this surveillance study, we harmonised verbal autopsy and residency data from nine health and demographic surveillance system (HDSS) sites in Kenya, Malawi, Tanzania, South Africa, Uganda, and Zimbabwe, each with variable coverage from Jan 1, 1995, to Dec 31, 2019. We included all deaths to adolescents and adults aged 12 or over that were residents of the study sites and had a verbal autopsy conducted. InSilicoVA, a probabilistic model, was used to assign cause of death on the basis of the signs and symptoms reported in the verbal autopsy. Levels and trends in all-cause and cause-specific mortality rates and cause-specific mortality fractions were calculated, stratified by HDSS site, sex, age, and calendar periods. 52 484 deaths and 5 157 802 person-years were reported among 1 071 913 individuals across the nine sites during the study period. 47 961 (91·4%) deaths had a verbal autopsy, of which 46 570 (97·1%) were assigned a cause of death. All-cause mortality generally decreased across the HDSS sites during this period, particularly for adults aged 20-59 years. In many of the HDSS sites, these decreases were driven by reductions in HIV and tuberculosis-related deaths. In 2010-14, the top causes of death were: road traffic accidents, HIV or tuberculosis, and meningitis or sepsis in adolescents (12-19 years); HIV or tuberculosis in adults aged 20-59 years; and neoplasms and cardiovascular disease in adults aged 60 years and older. There was greater between-HDSS and between-sex variation in causes of death for adolescents compared with adults. This study shows progress in reducing mortality across eastern and southern Africa but also highlights age, sex, within-HDSS, and between-HDSS differences in causes of adolescent and adult deaths. These findings highlight the importance of detailed local data to inform health needs to ensure continued improvements in survival. National Institute of Child Health and Human Development of the US National Institutes of Health.

Trends and levels of the global, regional, and national burden of appendicitis between 1990 and 2021: findings from the Global Burden of Disease Study 2021

Appendicitis is a common surgical emergency that poses a large clinical and economic burden. Understanding the global burden of appendicitis is crucial for evaluating unmet needs and implementing and scaling up intervention services to reduce adverse health outcomes. This study aims to provide a comprehensive assessment of the global, regional, and national burden of appendicitis, by age and sex, from 1990 to 2021. Vital registration and verbal autopsy data, the Cause of Death Ensemble model (CODEm), and demographic estimates from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) were used to estimate cause-specific mortality rates (CSMRs) for appendicitis. Incidence data were extracted from insurance claims and inpatient discharge sources and analysed with disease modelling meta-regression, version 2.1 (DisMod-MR 2.1). Years of life lost (YLLs) were estimated by combining death counts with standard life expectancy at the age of death. Years lived with disability (YLDs) were estimated by multiplying incidence estimates by an average disease duration of 2 weeks and a disability weight for abdominal pain. YLLs and YLDs were summed to estimate disability-adjusted life-years (DALYs). In 2021, the global age-standardised mortality rate of appendicitis was 0·358 (95% uncertainty interval [UI] 0·311-0·414) per 100 000. Mortality rates ranged from 1·01 (0·895-1·13) per 100 000 in central Latin America to 0·054 (0·0464-0·0617) per 100 000 in high-income Asia Pacific. The global age-standardised incidence rate of appendicitis in 2021 was 214 (174-274) per 100 000, corresponding to 17 million (13·8-21·6) new cases. The incidence rate was the highest in high-income Asia Pacific, at 364 (286-475) per 100 000 and the lowest in western sub-Saharan Africa, at 81·4 (63·9-109) per 100 000. The global age-standardised rates of mortality, incidence, YLLs, YLDs, and DALYs due to appendicitis decreased steadily between 1990 and 2021, with the largest reduction in mortality and YLL rates. The global annualised rate of decline in the DALY rate was greatest in children younger than the age of 10 years. Although mortality rates due to appendicitis decreased in all regions, there were large regional variations in the temporal trend in incidence. Although the global age-standardised incidence rate of appendicitis has steadily decreased between 1990 and 2021, almost half of GBD regions saw an increase of greater than 10% in their age-standardised incidence rates. Slow but promising progress has been observed in reducing the overall burden of appendicitis in all regions. However, there are important geographical variations in appendicitis incidence and mortality, and the relationship between these measures suggests that many people still do not have access to quality health care. As the incidence of appendicitis is rising in many parts of the world, countries should prepare their health-care infrastructure for timely, high-quality diagnosis and treatment. Given the risk that improved diagnosis may counterintuitively drive apparent rising trends in incidence, these efforts should be coupled with improved data collection, which will also be crucial for understanding trends and developing targeted interventions. Bill and Melinda Gates Foundation.

Understanding the outcome and management of children aged 2–59 months with chest indrawing pneumonia: a study protocol for an observational study in Ethiopia, India, Nigeria, Pakistan, Uganda and Zambia

IntroductionChildhood pneumonia is a leading cause of morbidity and mortality among children aged 2–59 months, particularly in low-income and middle-income countries (LMICs), where healthcare providers face significant challenges in diagnosing...

BAYESIAN NESTED LATENT CLASS MODELS FOR CAUSE-OF-DEATH ASSIGNMENT USING VERBAL AUTOPSIES ACROSS MULTIPLE DOMAINS.

Understanding cause-specific mortality rates is crucial for monitoring population health and designing public health interventions. Worldwide, two-thirds of deaths do not have a cause assigned. Verbal autopsy (VA) is a well-established tool to collect information describing deaths outside of hospitals by conducting surveys to caregivers of a deceased person. It is routinely implemented in many low- and middle-income countries. Statistical algorithms to assign cause of death using VAs are typically vulnerable to the distribution shift between the data used to train the model and the target population. This presents a major challenge for analyzing VAs, as labeled data are usually unavailable in the target population. This article proposes a latent class model framework for VA data (LCVA) that jointly models VAs collected over multiple heterogeneous domains, assigns causes of death for out-of-domain observations and estimates cause-specific mortality fractions for a new domain. We introduce a parsimonious representation of the joint distribution of the collected symptoms using nested latent class models and develop a computationally efficient algorithm for posterior inference. We demonstrate that LCVA outperforms existing methods in predictive performance and scalability. Supplementary Material and reproducible analysis codes are available online. The R package LCVA implementing the method is available on GitHub (https://github.com/richardli/LCVA).

Distribution of COVID-19 related deaths in municipalities from Sonora, Mexico, 2020

Introduction: The COVID-19 pandemic has challenged societies, not only because of its magnitude and impact, but also because it has deepened health inequalities and inequities. Socially disadvantaged groups show a higher frequency of adverse health events due to COVID-19, particularly in Latin America. With that in mind, we describe the distribution of deaths in COVID-19 patients stratified by sociodemographic characteristics and medical comorbidities, and explore perceptions related to disease-care, in selected rural and urban localities from Sonora, Mexico. Methods: We conducted a cross-sectional study on 160 deaths attributed to COVID-19, from the period April 1st and July 31st 2020, using death certificates as a data source. Furthermore, to explore the variables of interest, a verbal autopsy was applied to a relative caregiver for the patient’s health. Data collected was analyzed by descriptive statistics and qualitative technique. Results: We did not find significant differences in sociodemographic conditions among the COVID-19 deaths. Interestingly, 85.6% of the deceased had a chronic medical condition and 74.4% of all deaths took place in an urban locality. Caregivers frequently consigned deficiencies from medical services over the disease-care process of COVID-19 deaths.

Climate change: A pointer to increased small-scale fisher drowning deaths.

Drowning is an overlooked public health concern and drowning risk is dependent on environmental risk factors. The preponderance of drowning deaths occurs in low- and middle-income countries. Small-scale fishers face high occupational risk of drowning. Climate change increases the frequency and intensity of storms, thereby exacerbating fishers' risks and creating a need to examine the contribution of storms to fisher drowning deaths for the development of mitigation strategies. We examined this relationship between weather and fisher drowning deaths in Lake Victoria, which is Africa's largest lake, a site of high fishing pressure, and where climate change is predicted to increase thunderstorms. We conducted a verbal autopsy with people knowledgeable about recent fatal fisher drowning incidents to collect information about the deceased fishers and circumstances surrounding the incidents across 43 landing sites in the Kenyan shore of Lake Victoria. Semi-structured interviews with stakeholders also elucidated community perspectives on drowning risks. Fatal drownings were often attributed to bad weather (41.8%). Other risk factors, such as non-use of life jacket and navigation equipment, co-occurred with bad weather at high rates (69.5% and 67.8%, respectively) to jointly contribute to fatal drowning incidents. Such co-occurrence of risk factors indicates that actions across multiple risk factors can help mitigate the issue. Stakeholder analysis revealed a range of opportunities for improved communication of risks and action to mitigate risks across boat operators and manufacturers, as well as multiple levels of management. Across global small-scale fisheries, limited use of safety equipment and intensive fishing pressure may coincide with increases in extreme weather events, necessitating action to address current and mitigate future drowning risks to small-scale fishers.