Vital Registration Research Articles

Experiences of parents and caretakers going through the consent process to perform minimally invasive tissue sampling (MITS) on their deceased children in Quelimane, Mozambique: A qualitative study.

In Mozambique, the Countrywide Mortality Surveillance for Action (COMSA) Program implemented a child mortality surveillance to strengthen vital events registration (pregnancies, births, and deaths) and investigate causes of death using verbal autopsies. In Quelimane district, in addition to the abovementioned cause of death determination approaches, minimally invasive tissue sampling (MITS) was performed on deceased children <5years of age. This study focused on understanding deceased children parents' and caretakers' experiences of the consent process to perform MITS in order to contribute to the improvement of approaches to cause of death investigation and inform efforts to maximize acceptability of mortality surveillance activities. A qualitative study was conducted in six urban and semi-urban communities in Quelimane district. A total of 40 semi-structured interviews with family members of deceased children and 50 non-participant observations of the consent process were conducted to explore their experience with informed consent request to perform MITS on their child. Data analysis of the interviews and observations was thematic, being initially deductive (predetermined codes) followed by the generation of new codes according to the data (inductive).The Consolidated criteria for reporting qualitative research (COREQ) guidelines for reporting qualitative studies were performed. Although most participants consented to the performance of MITS on their deceased child, some stated they had not fully understood the MITS procedure despite the informed consent process due to unclear information and their state of mind after their loss. Consenting to MITS and doing so with family members disagreeing were also identified as stress-enhancing factors. Participants also described dissatisfaction of family members, resulting from the condition of the body delivered after tissue collection. In addition, the waiting time to receive the body and resulting delays for the funeral were considered additional factors that may increase stress and compromise the acceptability of MITS. Family experiences were influenced by operational and logistical issues linked to the procedure itself and by it being in tension with social and cultural issues, which caused stress and discontentment on parents and caretakers of deceased children. The main factors that contributed to the experience of going through the MITS process were the state of mind after the death, complex decision making processes within the family, washing of the body for purification after MITS and seepage, and limited understanding of consent for MITS. When requesting consent for MITS, emphasis should be placed on transmitting clear and understandable information about MITS procedures to participants.

Alternative epidemic indicators for COVID-19 in three settings with incomplete death registration systems.

Not all COVID-19 deaths are officially reported, and particularly in low-income and humanitarian settings, the magnitude of reporting gaps remains sparsely characterized. Alternative data sources, including burial site worker reports, satellite imagery of cemeteries, and social media-conducted surveys of infection may offer solutions. By merging these data with independently conducted, representative serological studies within a mathematical modeling framework, we aim to better understand the range of underreporting using examples from three major cities: Addis Ababa (Ethiopia), Aden (Yemen), and Khartoum (Sudan) during 2020. We estimate that 69 to 100%, 0.8 to 8.0%, and 3.0 to 6.0% of COVID-19 deaths were reported in each setting, respectively. In future epidemics, and in settings where vital registration systems are limited, using multiple alternative data sources could provide critically needed, improved estimates of epidemic impact. However, ultimately, these systems are needed to ensure that, in contrast to COVID-19, the impact of future pandemics or other drivers of mortality is reported and understood worldwide.

Pattern and trends of the total and age-specific fertility rates during 1990–2018 in Pakistan

BackgroundPakistan has an inadequate vital event registration system, leading to fewer than half of all births being registered, and this issue is further exacerbated by systematic recall errors and omission of births. This study aims to evaluate direct and indirect methods of fertility estimation to analyze the trends and patterns of fertility rates in Pakistan from 1990 to 2018.Design/methodology/approachIndirect methods are utilized in this study to evaluate the direction and extent of changes in total and age-specific fertility rates, and these findings are compared to direct estimates. The study draws data on livebirths from four waves of the Pakistan Demographic and Health Survey that took place between 1990 and 2018. To ensure the quality of data, graphical methods and Whipple and Myers indices are employed. Additionally, the Brass Relational Gompertz model was used to analyze the data.ResultsThe Relational Gompertz model revealed that total fertility rates (TFRs) were higher than direct estimates by 0.4 children and age-specific fertility rates (ASFR) were higher for all age groups except the oldest. The difference was more significant among younger women aged 15–24, and less so for age groups 29 and above. The gap in estimated fertility between direct and indirect methods decreased with age.ConclusionThe indirect method is an invaluable tool in situations where direct measurement of fertility rates is challenging or impossible. By utilizing this method, policymakers can gain important insights into the fertility patterns and trends of a population, which is crucial for making informed decisions on fertility planning.

Burden of disease and barriers to comprehensive care for rheumatic heart disease in South Africa: an updated systematic review protocol

IntroductionRheumatic heart disease (RHD) is responsible for a significant burden of cardiovascular morbidity and mortality, and remains the most common cause of acquired heart disease among children and young adults...

LINKS. A System for Historical Family Reconstruction in the Netherlands

LINKS stands for 'LINKing System for historical family reconstruction' and is a software system to link nominal data from the Dutch archives and ultimately reconstruct historical individuals and families. We present the background and philosophy of this matching system and explain its data structure and functioning. Currently the core data of the LINKS system consists of indexed civil certificates. These certificates are available from 1812 — the start of the Dutch Vital Registration — until the year they are confidential based on privacy laws. For more than 20 years, thousands of volunteers have been working to build this index, which contains not only the names of newborn, married and deceased persons, but also the names of their parents, places of birth, ages and sometimes their occupational titles. The software system LINKS includes the standardization of all input before linking, nominal record linkage procedures and identification of all unique persons involved in the system. All processes are repeatable and a strict distinction is maintained between source data, standardized, linked and enriched data and released data. Moreover, LINKS also informs archives about all kinds of errors and inconsistencies found during the cleaning and matching process. We will discuss two matching systems, the first is the original querying system that runs within a MySQL database environment and the second is a newly developed system, called burgerLinker, which is based on knowledge graphs and which is designed as a system that can be used independently from LINKS and is made available as open source software. Finally, we present the most important releases of LINKS data so far: two national releases that link birth and parental marriage certificates, creating families and pedigrees and an integrated dataset of persons, families and family trees in four provinces.

The Casualties of War: An Excess Mortality Estimate of Lives Lost in the 2020 Nagorno-Karabakh Conflict

Who and how many died in the 2020 Karabakh War? With limited evidence provided by authorities, media outlets, and human rights organizations, still little is known about the death toll caused by the 44-day conflict in and around Nagorno-Karabakh. This paper provides a first assessment of the human cost of the war. Using age–sex vital registration data from Armenia, Azerbaijan, and the de facto Republic of Artsakh/Nagorno-Karabakh, we difference the 2020 observed mortality values from expected deaths based on trends in mortality between 2015 and 2019 to offer sensible estimates of excess mortality resulting from the conflict. We compare and contrast our findings with neighboring peaceful countries with similar mortality patterns and socio-cultural background and discuss them against the backdrop of the concurrent first wave of Covid-19. We estimate that the war led to almost 6,500 excess deaths among people aged 15–49. Nearly 2,800 excess losses occurred in Armenia, 3,400 in Azerbaijan, and 310 in de facto Artsakh. Deaths were highly concentrated among late adolescent and young adult males, suggesting that most excess mortality was directly related to combat. Beyond the human tragedy, for small countries like Armenia and Azerbaijan, such loss of young men represents a considerable long-term cost for future demographic, economic, and social development.

Effect of Age and Sex on Stroke Mortality of Young and Middle-aged Adults in China, 2002–2019, and Predictions to 2030

ObjectiveThis study aimed to examine the trends in stroke mortality among young and middle-aged adults in China. MethodsData were obtained from the China national vital registration system. Significant changes in mortality were assessed by Joinpoint regression. Age-period-cohort analysis was used to explain the reasons for the changes. Future mortality and counts were predicted by the Bayesian age-period-cohort model. ResultsBetween 2002 and 2019, a total of 6,253,951 stroke mortality in young and middle-aged adults were recorded. The age-adjusted mortality rates (AAMRs) of women showed a downward trend. The annual percent changes (APC) were –3.5% (–5.2%, –1.7%) for urban women and –2.8% (–3.7%, –1.9%) for rural women. By contrast, the AAMRs per 100,000 for rural men aged 25–44 years continued to rise from 9.40 to 15.46. The AAMRS for urban men aged 25–44 years and urban and rural men aged 45–64 years did not change significantly. Between 2020 and 2030, the projected stroke deaths are 1,423,584 in men and 401,712 in women. ConclusionSignificant sex and age disparities in the trends of stroke mortality among young and middle-aged adults were identified in China. Targeted health policy measures are needed to address the burden of stroke in the young generation, especially for rural men, with a focus on the prevention and management of high risk factors.

Relationship between clinic and ambulatory blood pressure and mortality: an observational cohort study in 59 124 patients

Ambulatory blood pressure provides a more comprehensive assessment than clinic blood pressure, and has been reported to better predict health outcomes than clinic or home pressure. We aimed to examine associations of clinic and 24-h ambulatory blood pressure with all-cause and cardiovascular mortality in a large cohort of primary care patients referred for assessment of hypertension. We did an observational cohort study using clinic and ambulatory blood pressure data obtained from March 1, 2004, to Dec 31, 2014, from the Spanish Ambulatory Blood Pressure Registry. This registry included patients from 223 primary care centres from the Spanish National Health System in all 17 regions of Spain. Mortality data (date and cause) were ascertained by a computerised search of the vital registry of the Spanish National Institute of Statistics. Complete data were available for age, sex, all blood pressure measures, and BMI. For each study participant, follow-up was from the date of their recruitment to the date of death or Dec 31, 2019, whichever occurred first. Cox models were used to estimate associations between usual clinic or ambulatory blood pressure and mortality, adjusted for confounders and additionally for alternative measures of blood pressure. For each measure of blood pressure, we created five groups (ie, fifths) defined by quintiles of that measure among those who subsequently died. During a median follow-up of 9·7 years, 7174 (12·1%) of 59 124 patients died, including 2361 (4·0%) from cardiovascular causes. J-shaped associations were observed for several blood pressure measures. Among the top four baseline-defined fifths, 24-h systolic blood pressure was more strongly associated with all-cause death (hazard ratio [HR] 1·41 per 1 - SD increment [95% CI 1·36-1·47]) than clinic systolic blood pressure (1·18 [1·13-1·23]). After adjustment for clinic blood pressure, 24-h blood pressure remained strongly associated with all-cause deaths (HR 1·43 [95% CI 1·37-1·49]), but the association between clinic blood pressure and all-cause death was attenuated when adjusted for 24-h blood pressure (1·04 [1·00-1·09]). Compared with the informativeness of clinic systolic blood pressure (100%), night-time systolic blood pressure was most informative about risk of all-cause death (591%) and cardiovascular death (604%). Relative to blood pressure within the normal range, elevated all-cause mortality risks were observed for masked hypertension (HR 1·24 [95% CI 1·12-1·37]) and sustained hypertension (1·24 [1·15-1·32]), but not white-coat hypertension, and elevated cardiovascular mortality risks were observed for masked hypertension (1·37 [1·15-1·63]) and sustained hypertension (1·38 [1·22-1·55]), but not white-coat hypertension. Ambulatory blood pressure, particularly night-time blood pressure, was more informative about the risk of all-cause death and cardiovascular death than clinic blood pressure. Spanish Society of Hypertension, Lacer Laboratories, UK Medical Research Council, Health Data Research UK, National Institute for Health and Care Research Biomedical Research Centres (Oxford and University College London Hospitals), and British Heart Foundation Centre for Research Excellence.

Completeness and Factors Affecting Community Workers' Reporting of Births and Deaths in the Countrywide Mortality Surveillance for Action in Mozambique.

Since March 2018, the Countrywide Mortality Surveillance for Action project, implemented as a national sample registration system by the Mozambique Instituto Nacional de Saude and the Instituto Nacional de Estatistica in 700 geographic clusters randomly distributed across the 11 provinces, has trained and deployed community surveillance agents (CSAs) to report births and deaths in each cluster prospectively. An independent, retrospective data collection was conducted to assess the completeness of surveillance data. Record linkage procedures were used to match households and vital events reported in the two data sources. We calculated birth and death reporting rates and used a regression model to determine factors associated with the likelihood of vital events being reported by the CSAs. Between March 2018 and December 2019, CSAs reported 54% of births (8,787/16,421) and 45% of deaths (1,726/3,867). Births of smaller cluster sizes (< 1,000 people) were more likely to be reported (adjusted odds ratio [aOR] = 1.45; 95% CI = 1.15-1.83) compared with those of larger cluster sizes (> 1,500 people). Deaths of rural clusters were more likely to be reported (aOR = 1.41; 95% CI = 1.07-1.85) than those of urban clusters. Adult deaths were more likely to be reported (aOR = 1.49; 95% CI = 1.10-2.02) than child deaths. Our findings suggest that a fully functioning sample vital registration system must adopt a dual system with high-quality surveys or other ways to estimate underregistration periodically, consider a smaller cluster size manageable by a community worker, and pay special attention to urban clusters as underreporting is larger.

A Qualitative Assessment of Community Acceptability and Its Determinants in the Implementation of Minimally Invasive Tissue Sampling in Children in Quelimane City, Mozambique.

The Countrywide Mortality Surveillance for Action project aims to implement a child mortality surveillance program through strengthening vital registration event reporting (pregnancy, birth, and death) and investigating causes of death (CODs) based on verbal autopsies. In Quelimane (central Mozambique), Minimally Invasive Tissue Sampling (MITS) procedures were added to fine-tune the COD approaches. Before the implementation of MITS, an evaluation of the acceptability and ethical considerations of child mortality surveillance was considered fundamental. A socio-anthropological study was conducted in Quelimane, using observations, informal conversations, semi-structured interviews, and focus group discussions with healthcare providers, nharrubes (traditional authorities who handle bodies before the funeral), community and religious leaders, and traditional birth attendants to understand the locally relevant potential facilitators and barriers to the acceptability of MITS. Audio materials were transcribed, systematically coded, and analyzed using NVIVO12®. The desire to know the COD, intention to discharge the elders from accusations of witchcraft, involvement of leaders in disseminating project information, and provision of transport for bodies back to the community constitute potential facilitators for the acceptability of MITS implementation. In contrast, poor community mobilization, disagreement with Islamic religious practices, and local traditional beliefs were identified as potential barriers. MITS was considered a positive innovation to determine the COD, although community members remain skeptical about the procedure due to tensions with religion and tradition. Therefore, the implementation of MITS in Quelimane should prioritize the involvement of a variety of influential community and religious leaders.

Temporal trends in acute myocardial infarction-related mortality in Italy (2007-2017)

Update data regarding acute myocardial infarction (AMI)-related mortality in Italy remain scant. We assessed AMI-related mortality and time trends in Italy from 2007 to 2017 by using the Eurostat Mortality Database. The vital registration data of Italy from the publicly free-available OECD Eurostat website database were analyzed for the period between January 1, 2007 and December 31, 2017. Deaths reporting the codes I21 and I22 were extracted and analyzed according to the International Classification of Diseases 10th revision (ICD-10) coding system. Joinpoint regression was used to calculate nationwide annual trends in AMI-related mortality, determining the average annual percent change with 95% confidence intervals (CIs). During the study period, 300 862 (132 368 men and 168 494 women) AMI-related deaths were recorded in Italy. Among 5-year age groups, AMI-related mortality increased with a seemingly exponential distribution. However, joinpoint regression analysis demonstrated a statistically significant linear decrease in age-standardized AMI-related mortality of -5.3 (95% CI -5.6, -4.9, p<0.0001) deaths per 100 000 individuals. A further sub-analysis, stratifying the population by gender, confirmed yielded results both in men (-5.7; 95% CI -6.3, -5.2, p<0.0001) and in women (-5.4; 95% CI -5.7, -4.8, p<0.0001). The Italian age-adjusted mortality rates for AMI decreased over time, both in men and women.

Short sleep duration associated with the incidence of cardio-cerebral vascular disease: a prospective cohort study in Shanghai, China

ImportanceSleep duration plays an important role in predicting CCVD incidence, and have implications for reducing the burden of CCVD. However, the association between sleep duration and predicted cardio-cerebral vascular diseases (CCVD) risk remains to be fully understood.ObjectiveTo investigate the effects of sleep duration on the development of CCVD among Chinese community residents.DesignA prospective cohort study. The baseline survey was conducted from January 2013 to July 2013. The cohort has been followed until December 31, 2016 using a combination of in-person interviews and record linkages with the vital registry of Pudong New Area, Shanghai, China.SubjectsA total of 8245 Chinese community residents were initially enrolled in the cohort. Of those, 6298 underwent the follow-up examination.ExposureSelf-reported sleep duration and sleep quality were obtained via the questionnaire. Sleep duration was divided into five categories: ≤5, 6, 7, 8, or ≥ 9 h per day.Main Outcome(s) and Measure(s)CCVD, Coronary heart disease (CHD) and Stroke occurrence, Hazard ratios (HRs) and 95% confidence intervals (95% CIs) were calculated using Fine-Gray proportional subdistribution hazards models.ResultsDuring a median follow-up of 3.00 years (IQR 2.92–3.08), we observed 370 participants have had incident CCVD events, of whom 230 had CHDs, 169 had strokes, and 29 had both. After adjustment for relevant confounders, short sleepers (≤ 5 h) had 83% higher risk of total CCVD incidence (HR: 1.83; 95% CI: 1.32–2.54), 82% higher risk of CHD incidence (HR: 1.82; 95% CI: 1.21–2.75), and 82% higher risk of stroke incidence (HR: 1.82; 95% CI: 1.12–2.98) in contrast to the reference group (7 h). Some of these U-shaped relationships varied by age, and were more pronounced in individuals aged < 65 years. Individuals who slept ≤ 5 h per day with baseline hypertension had the highest risk of CCVD incidence (HR: 3.38, 95% CI 2.08–5.48), CHD incidence (HR: 3.11, 95% CI 1.75–5.53), and stroke incidence (HR: 4.33, 95% CI 1.90–9.86), compared with those sleep 7 h and without baseline hypertension.ConclusionsShort sleep duration is independently associated with greater incidence of CCVD, CHD and stroke.

State-Level Cardiovascular Mortality Rates Among Hispanic, Non-Hispanic Black, and Non-Hispanic White Populations, 1990 to 2019

Cardiovascular disease (CVD) is the leading cause of death in the US, with considerable variation by both state and race and ethnicity group. Consistent, comparable measures of mortality by specific CVD cause at the state level and by race and ethnicity have not previously been available and are necessary for supporting policy decisions aimed at reducing health inequities. To quantify and describe levels and trends of mortality due to overall CVD and its component causes for 3 mutually exclusive race and ethnicity groups and by state. This cross-sectional study used Census data, population surveys, and US vital registration records to estimate cause-specific cardiovascular mortality by state and by the following race and ethnicity groups, defined by the US Office of Management and Budget: Hispanic of any race, non-Hispanic Black (hereafter, Black), and non-Hispanic White (hereafter, White). Data were analyzed from January 2020 to September 2022. State of residence at time of death; Hispanic ethnicity and Black or White race. CVD death counts and mortality rates. An estimated 25 397 029 persons died of cardiovascular diseases from 1990 to 2019. The mean (SD) age of individuals was 78.20 (14.01); 13 087 290 individuals (51.53%) were female and 12 309 739 (48.47%) were male; 2 921 650 (11.50%) were Black, 1 159 498 (4.57%) were Hispanic, and 21 315 880 (83.93%) were White. Age-standardized CVD mortality per 100 000 persons in 2019 was 194.4 (95% uncertainty interval [UI], 172.7 to 207.4), 107.7 (95% UI, 92.9 to 121.4), and 153.8 (95% UI, 133.8 to 163.8) among Black, Hispanic, and White populations, respectively. The median (IQR) percentage change across states was smaller for 2010 to 2019 compared with 1990 to 2000 for both White female and White male populations (-6.8 [-10.1 to -4.3] vs -10.2 [-12.9 to -5.9] and -4.6 [-8.6 to -2.5] vs -16.5 [-19.3 to -15.4]). For the Black and Hispanic groups, the percentage change (IQR) was larger for the female populations for the latter time period (-15.1 [-18.9 to -11.7] vs -12.6 [-19.6 to -7.8] and -23.5 [-29.2 to -18.5] vs -8.2 [-17.8 to 5.96]). The converse was observed among male individuals in both groups, with smaller percentage change (IQR) values in 2010 to 2019 compared with 1990 to 2000 (-13.1 [-18.7 to -8.6] vs -18.6 [-25.5 to -14.7] among the Black male population and -20.4 [-25.6 to -15.6] vs -21.5 [-31.1 to -5.7] among the Hispanic male population). There was substantial variability at the state level for death due to total CVD and component causes in 2019 and changes in CVD mortality from 1990 through 2019. The findings of this study indicate that CVD mortality varied widely by state and race and ethnicity group. Changes over the time period were not consistent for all groups and varied by cardiovascular subcause. These results highlight ongoing health disparities in cardiovascular mortality.

Global, Regional, and National Burden of Mesothelioma 1990-2019: A Systematic Analysis of the Global Burden of Disease Study 2019.

Rationale: Mesothelioma has become a major health burden since World War II because of the use of asbestos. Although many countries have imposed bans on asbestos, there remain significant mortality and morbidity from mesothelioma because of its long latent period and aggressiveness. Also, the use of asbestos is increasing in low-income countries, potentiating risk of mesothelioma in the coming decades. Assessment of the global burden of mesothelioma is required to take proper measures against the disease. Objectives: To assess the burden of mesothelioma from 1990 to 2019 at the global, regional, and national levels and to investigate patterns according to sex, age, sociodemographic index, and risk factors. Methods: The numbers, rates, and age-standardized rates of incidence, death, and disability-adjusted life years (DALYs) of mesothelioma in 204 countries and territories from 1990 to 2019 were estimated using vital registration and cancer registry data. The relationship between sociodemographic index and age-standardized DALY rate was determined, and DALYs attributable to occupational exposure to asbestos were calculated. Results: In 2019, there were 34,511 (95% uncertainty interval [UI], 31,199 to 37,771) incident cases of mesothelioma globally, with an age-standardized rate of 0.43 per 100,000 persons (95% UI, 0.38 to 0.47), which decreased between 1990 and 2019 by -12.6% (95% UI, -21.8% to -2.3%). Mesothelioma was responsible for 29,251 (95% UI, 26,668 to 31,006) deaths in 2019, with an age-standardized rate of 0.36 deaths per 100,000 persons (95% UI, 0.33 to 0.39), which decreased between 1990 and 2019 by -9.6% (95% UI, -17.8% to -1.1%). The age-standardized incidence rate increased in central Europe between 1990 and 2019 by 46.1% (95% UI, 16.6% to 72.4%). The Netherlands, Australia, and the United Kingdom had the highest age-standardized incidence rates. Incidence rates were higher in men than in women ages 45-49 to 90-94 years, peaking at 85-89 years. Occupational exposure to asbestos contributed to 85.2% (95% UI, 82.1% to 88.1%) of DALYs. Conclusions: The global burden of mesothelioma is decreasing in terms of age-standardized incidence and mortality rates. Mesothelioma remains a substantial public health challenge in many parts of the world.

Time-Varying Effect of Physical Activity on Mortality Among Myocardial Infarction Survivors: A Nationwide Population-Based Cohort Study.

Physical activity (PA) is an important component of secondary prevention after myocardial infarction (MI). The mortality risk of MI survivors varies at different post-MI periods, yet the time-varying effect of total PA is unclear. We aimed to investigate the association between different volumes and patterns of total PA and mortality at different post-MI periods. Using data from the China Patient-centered Evaluative Assessment of Cardiac Events Million Persons Project, we divided the screened MI survivors into within-1-year and beyond-1-year groups based on the duration between their baseline interview and MI onset. Total PA was divided into insufficient ( 3000 metabolic equivalent of task [MET] minutes/week) and sufficient PA. Sufficient PA was further categorized as moderate and high (3000-4500 and 4500 MET minutes/week) volumes; leisure ( 50%) and non-leisure ( 50%) patterns. Data on mortality were derived from the National Mortality Surveillance System and Vital Registration of the Chinese Center for Disease Control and Prevention. Cox proportional hazard models were fitted to estimate hazard ratios (HRs) and 95% confidence intervals (CIs). Restricted cubic spline regression analyses were performed to examine the dose-response association between PA and mortality. During the follow-up (median 3.7 years) of the 20,653 post-MI patients, 751 patients died. In the within-1-year group, moderate (HR: 0.59, 95% CI: 0.40 to 0.88) and high (0.63, 0.45 to 0.88) volumes and both patterns (leisure: 0.52, 0.29 to 0.94; non-leisure: 0.64, 0.46 to 0.88) of PA were all associated with significantly lower risk of mortality, compared with insufficient PA. In the beyond-1-year group, the association was observed in high volume (0.69, 0.56 to 0.86) and both patterns (leisure: 0.64, 0.48 to 0.87; non-leisure: 0.79, 0.65 to 0.97). A non-linear relationship between PA and mortality was found in the within-1-year group (p for non-linearity 0.001), while a linear relationship was demonstrated in the beyond-1-year group (p for non-linearity = 0.107). Sufficient total PA was associated with mortality risk reduction after MI, either leisure or non-leisure pattern. Different dose-response associations between PA and mortality were found at different post-MI periods. These results could promote individualized and scientifically derived secondary prevention strategies for MI.

Population cause of death estimation using verbal autopsy methods in large-scale field trials of maternal and child health: lessons learned from a 20-year research collaboration in Central Ghana

Low and middle-income countries continue to use Verbal autopsies (VAs) as a World Health Organisation-recommended method to ascertain causes of death in settings where coverage of vital registration systems is not yet comprehensive. Whilst the adoption of VA has resulted in major improvements in estimating cause-specific mortality in many settings, well documented limitations have been identified relating to the standardisation of the processes involved. The WHO has invested significant resources into addressing concerns in some of these areas; there however remains enduring challenges particularly in operationalising VA surveys for deaths amongst women and children, challenges which have measurable impacts on the quality of data collected and on the accuracy of determining the final cause of death. In this paper we describe some of our key experiences and recommendations in conducting VAs from over two decades of evaluating seminal trials of maternal and child health interventions in rural Ghana. We focus on challenges along the entire VA pathway that can impact on the success rates of ascertaining the final cause of death, and lessons we have learned to optimise the procedures. We highlight our experiences of the value of the open history narratives in VAs and the training and skills required to optimise the quality of the information collected. We describe key issues in methods for ascertaining cause of death and argue that both automated and physician-based methods can be valid depending on the setting. We further summarise how increasingly popular information technology methods may be used to facilitate the processes described. Verbal autopsy is a vital means of increasing the coverage of accurate mortality statistics in low- and middle-income settings, however operationalisation remains problematic. The lessons we share here in conducting VAs within a long-term surveillance system in Ghana will be applicable to researchers and policymakers in many similar settings.

Prehospital vital sign monitoring in paediatric patients: an interregional study of educational interventions

BackgroundPrehospital vital sign documentation in paediatric patients is incomplete, especially in patients ≤ 2 years. The aim of the study was to increase vital sign registration in paediatric patients through specific educational initiatives.MethodsProspective quasi-experimental study with interrupted time-series design in the North Denmark and South Denmark regions. The study consecutively included all children aged < 18 years attended by the emergency medical service (EMS) from 1 July 2019 to 31 December 2021. Specific educational initiatives were conducted only in the North Denmark EMS and included video learning and classroom training based on the European Paediatric Advanced Life Support principles. The primary outcome was the proportion of patients who had their respiratory rate, peripheral capillary oxygen saturation, heart rate and level of consciousness recorded at least twice. We used a binomial regression model stratified by age groups to compare proportions of the primary outcome in the pre- and post-intervention periods in each region.ResultsIn North Denmark, 7551 patients were included, while 15,585 patients from South Denmark were used as a reference. Virtually all of the North Denmark EMS providers completed the video learning (98.7%). The total study population involved patients aged ≤ 2 months (5.5%), 3–11 months (7.4%), 1–2 years (18.8%), 3–7 years (16.2%) and ≥ 8 years (52.1%). In the intervention region, the primary outcome increased from the pre- to the post-intervention period from 35.3% to 40.5% [95% CI for difference 3.0;7.4]. There were large variations in between age groups with increases from 18.8% to 27.4% [95% CI for difference 5.3;12.0] among patients aged ≤ 2 years, from 33.5% to 43.7% [95% CI for difference 4.9;15.5] among patients aged 3–7 years and an insignificant increase among patients aged ≥ 8 years (from 46.4% to 47.9% [95% CI for difference − 1.7;4.7]). In the region without the specific educational interventions, proportions were steady for all age groups throughout the entire study period.ConclusionsMandatory educational initiatives for EMS providers were associated with an increase in the extent of vital sign registration in paediatric patients ≤ 7 years. Incomplete vital registration was associated with, but not limited to non-urgent cases.

Trends of suicide rates by gender and residence in China from 2002 to 2019

ObjectiveChina has undergone tremendous social changes in the last few decades. This study aimed to research the trends of the suicide rates from 2002 to 2019, and to differentiate effects attributable to age, period, and cohort by gender and residence in China. MethodsSuicide mortality data were obtained from China's Ministry of Health Vital Registration System. Joinpoint regression model was used to estimate the average annual percentage change (AAPC) of the suicide rates and ratios by gender and residence. The age-period-cohort framework was performed to analyze the underlying mechanisms for suicide mortality trends. ResultsOver the observation period, the significant decrease in suicide mortality rates in China for the economic development and urbanization was observed but to different degrees across gender and regional subgroups. The male-to-female ratio of suicide rates increased year by year (AAPC: 1.9%, 95% CI: 0.2% to 3.7%) while the urban-rural ratio changed little (AAPC: 0.9%, 95% CI: −1.8% to 3.7%). The age-period-cohort analysis revealed a marked increased effect of age and overall decreased effect of both period and cohort on suicide mortality rates. However, the recent cohort has presented an inversely increasing effect. ConclusionThe suicide rate has fallen sharply in China which has undergone tremendous socioeconomic changes. The varied changes in the suicide rate of different residence-, gender-, and age-groups as well as the age, period, and cohort effect on suicide risk further indicate the relationship of development and the suicide rates may be neither static nor identical on different subgroups in a rapidly changing society.

S-31-3: BURDEN OF HYPERTENSIVE HEART DISEASE AND HIGH SYSTOLIC BLOOD PRESSURE IN AUSTRALIA FROM 1990–2019: RESULTS FROM THE GBD STUDY

Background: There is a dearth of comprehensive studies on the burden of hypertensive heart disease (HHD) and high systolic blood pressure (SBP) among the Australian population over time. We aimed to explore the burden of HHD and SBP, and how it changed over time from 1990 to 2019. Methods: We analysed the 2019 Global Burden of Disease data with a focus on Australia. We assessed the prevalence, mortality, disability-adjusted life-years (DALY), years lived with disability (YLD) and years of life lost (YLL) attributable to HHD and high SBP between 1990 and 2019 in Australia. GBD data sources included surveillance and survey data, published, and unpublished research articles and reports, vital registration and hospital data. Data were presented as point estimates with their corresponding 95% uncertainty intervals (UI). Results: From 1990 to 2019, the burden of HHD and SBP in Australia decreased. Age standardized prevalence rate of HHD was 119.3 cases per 100,000 people (95% UI 86.6 to 161.0) in 1990, compared to 80.1 cases (95% UI 57.4 to 108.1) in 2019. HHD death stood at 3.4 cases per 100,000 population (95% UI 2.6 to 3.8) in 1990, compared to 2.5 (95% UI 1.9 to 3.0), 32.0 cases (95% UI 26.1 to 38.8) in 2019. HHD contributed to 57.2 cases per 100,000 population (95% UI 46.6 to 64.7) of DALYs in 1990 compared to 38.4 cases per 100,000 population (95% UI 32.0 to 45.2) in 2019. Death rates per 100,000 population attributable to high SBP declined significantly over time for both sexes from 1990 (155.6 cases; 95% UI 131.2 to 177.0) to approximately one third in 2019 (53.8 cases; 95% UI 43.4 to 64.4). Conclusion: Over the past three decades, the burden of HHD and high SBP in Australia reduced, but remains relatively high, particularly HHD. The contribution of HHD and high SBP to mortality, DALYs, and YLLs reduced significantly from 1990 to 2019. Efforts to identify people with high blood pressure early and population level measures for improving the management of blood pressure should be a priority for Australia.

PS-BPP04-5: BURDEN AND TRENDS OF HYPERTENSIVE HEART DISEASES IN SOUTH ASIA, 1990 TO 2019: ANALYSIS FROM THE GLOBAL BURDEN OF DISEASES

Background: There is lack of comprehensive population based studies on the burden of hypertensive heart diseases (HHD) in South Asia and its trends over time. We aimed to explore the burden of HHD, and how it changed over time from 1990 to 2019 in South Asia. Methods: We performed a systematic analysis of burden of hypertensive heart disease using the Global Burden of Disease (GBD) study data from South Asia, including Bangladesh, Bhutan, India, Pakistan, and Nepal. GBD data sources included surveillance and survey data, published, and unpublished research articles and reports, vital registration and hospital data. We assessed the prevalence, mortality, disability adjusted life years (DALY), years lived with disability (YLD) and years of life lost (YLL) attributable to HHD between 1990 and 2019 in South Asia. Data were presented as point estimates with their corresponding 95% uncertainty intervals (UI). Results: From 1990 to 2019 the age standardized prevalence for HHD in South Asia increased from 110.2 (95% UI, 77.4 - 156.8) to 111.8 (78.3 - 159.0) per 100,000 population, and from 8.7 (5.2 - 13.7) to 8.8 (5.2 - 13.9) for YLDs, in both genders, respectively. The prevalence increased with age and was higher among females. The age standardized rate decreased from 334.1 (206.3 - 452.4) to 229.2 (166.1 - 296.9) for DALYs, and from 19.0 (12.1 - 26.7) to 13.2 (9.3 - 17.4) for death, respectively. In 2019, HHD prevalence was highest in Pakistan (138.6, 95% UI, 96.2 to 196.9), and lowest in Nepal (69.9, 49.5 to 98.3). Countries with the biggest increase in YLDs were Bangladesh (8.3%, 95% UI, -3.9% to 22.8%), followed by India (5.0%, 2.4% to 7.7%), Bhutan (4.0%, -8.7% to 18.3%), Pakistan (3.4%, -3.5% to 10.8%), and Nepal (1.0%, -11.5% to 15.5%). The age standardized DALYs decreased from 334.1 (95% UI, 206.3 to 452.4) in 1990 to 229.2 (95% UI, 166.1 to 296.9) in 2019 with the highest significant percentage change in the India (-34.1%, 95% UI, -48.3% to -9.5%), followed by Bangladesh, Bhutan and Nepal. Deaths due to HHD significantly declined in all countries except Pakistan with a small increase (0.3%, -24.6% to 26.8%) and in Nepal with a decrease (-8.6, -38.8% to 36.8%), respectively. Conclusion: HHD remains a significant cause of disease burden in South Asian countries. The increased prevalence amongst older people and females warrants particular attention. Policies focusing on preventing modifiable risk factors and access to essential medicines is warranted.