Vital Registration Research Articles

Inequality in Life Expectancy-Acceleration due to COVID-19

The study of inequality in life expectancy by socio-economic groups has been receiving more and more attention with the rise in inequality. The present study investigates the prevailing situation in Bangladesh by using the age-specific mortality data available from various sources like the Sample Vital Registration System(SVRS) of the BBS and the Bangladesh Maternal Mortality Survey. The BBS, however, has been presenting a life table by sex, and there is a disparity in life expectancy in favour of females presently by three years. Rural life expectancy was lower in Bangladesh from 1981-to 2014, after which it exhibited that the difference in rural and urban life expectancy is being narrowed down. In India, the life expectancy at birth is slightly more than one year higher in urban areas than in rural areas. Life expectancy at birth was computed for seven regions (administrative divisions) using the age-specific mortality rates given in SVRS reports. For the year 2016, the highest value of life expectancy at birth (73.9 years) was found for the Rajshahi division, followed by Khulna division(73.5 years), Rangpur(73.0 years), Barisal(72.8 years), Sylhet(72.6 years) and the lowest for Chattogram division(72.1 years). We also compared the life expectancy and Household average income of the administrative divisions as obtained in the HIES 2016. No systematic relationship between household income and life expectancy was observed. Analysing the mortality of BMMCHS between 2010 and 2016, the life expectancy increased with the increase in wealth quintile for both males and females. The difference in life expectancy between the richest and poorest quintile of the male was 3.37 years, and for females, it was 1.34 years. But the much higher difference in life expectancy at birth between the richest and poorest quintile has been observed in other countries like India, the United Kingdom, the United States and Norway.

Culture, tradition, and the registration of deaths: The case of Kosovo

Population statistics for Kosovo show an unusually high share of male deaths (SMD) among all deaths. Women have a very low status in traditional parts of Kosovo – a direct consequence of the so-called Kanun of Lekë Dukagjini. This set of behavioural rules, practiced in Northern Albania and Kosovo, is strongly associated with a patriarchal culture. According to the code, a woman cannot own immovable property. Thus, to register the death of a family member at the office for civil registration is less urgent for women than for men. We assume that female deaths are under-registered. (i) A high SMD is more prevalent among the population with primary education, compared to secondary or tertiary education. (ii) More women aged 65+ receive the basic pension than there are resident women in that age group. (iii) Islamic societies report SMDs in 2017–2019 that are markedly lower than SMDs from vital registration. Registration of a death at the Islamic society is required before the funeral can take place. Other factors could also explain the high SMD: under-registration of deaths among Serbs in Kosovo, violent deaths and smoking among men, and bad physical and mental health among veterans of the war of 1999.

Abstract 13165: Increasing Incidence Rates and High Case Fatality Rates for Acute Myocardial Infarction in the Caribbean Island of Barbados

Introduction: The Caribbean sub-region has the highest rates of cardiovascular disease in the Region of the Americas. We present data from one of the few population-based registries in the region - the Barbados National Registry for NCDs (BNR). We describe trends in incidence and case fatality rates for acute myocardial infarction(MI) in the high income small island developing state of Barbados. Hypothesis: Myocardial infarction age-standardized incidence rates (ASIRs) are increasing. Methods: Data from the BNR were collected prospectively from charts of patients diagnosed with acute myocardial infarction from all private and public hospitals for the period 2010-2019. Out-of-hospital deaths and in-hospital deaths within 24 hours, were identified through the national vital registration department. Cases are defined in accordance with the Universal Definition of Myocardial Infarctions published by the American Heart Association. Population estimates were obtained from the United Nation World Population Prospects. We calculated incidence rates by sex, age-standardized to the World Health Organization 2000 population and assessed trends in case fatality rates for those admitted to hospital. Results: For the period 2010-2019, 4065 cases of as myocardial infarction (MI) were registered by BNR. Numbers of cases ranged from 294 in 2011 to 547 in 2019. The 3-year average for 2014 - 2016 is 391 cases versus 499 cases for 2017 - 2019 - a 28% increase in new cases. ASIRs increased from 67 per 100,000 (95%UI 59 to 75) in 2011 to 123 per 100,000 (95%UI 113 to 135) in 2019. ASIRs were consistently higher in men ranging from 83 per 100,00 (95% UI 71 - 98) to 120 (95% UI 106 to 136) while rates in women ranged from 43 per 100,000 95% CI (35 - 53) to 83 per 100,000 (73 - 95). The in-hospital case fatality rate (CFR) was 25% in 2019, ranging from 15% in 2011 to 31% in 2014. Overall, CFR was higher in women (24%) versus men (19%) and this was true in 9/10 years. Conclusions: Despite its status as a high income country, ASIRs for MIs in Barbados are increasing while case fatality rates are more than twice as high as rates found in developed countries.

Impact of Inherited Bleeding Disorders on Maternal Bleeding and Other Pregnancy Outcomes: A Population-Based Cohort Study

▪Introduction: Increasing rate of postpartum hemorrhage (PPH) has been observed between 2003 and 2010 in Canada. Given that bleeding disorders contribute to the risk of PPH, it is important to identify the current trend in PPH in the last decade and assess the impact of inherited bleeding disorders on maternal bleeding and other pregnancy outcomes.Methods: This is a retrospective population-based cohort study using the Alberta Pregnancy Birth Cohort. The creation of this cohort using multiple linked administrative databases has been previously described. Number of deliveries per year in Alberta, Canada was determined by Vital Statistics birth registry from 2010 to 2018 and was linked with Discharge Abstract Database (DAD) to identify cases of PPH and other pregnancy outcomes. PPH was defined as a blood loss of ≥500 ml following vaginal delivery or ≥1000 ml following Caesarean section, or as a diagnosis noted by a health care provider. All diagnoses and procedures were identified by International Classification of Diseases (ICD)-10 codes and Canadian Classification of Interventions (CCI) codes, respectively. Previous validation study of diagnostic code for PPH in DAD showed high sensitivity and specificity. Inherited bleeding disorders including von Willebrand disease, hemophilia carriers, platelet function disorder, and hereditary deficiencies of other coagulation factors were identified by presence of at least two ICD codes. All analyses were restricted to hospitalized deliveries with live births. Temporal trend of PPH rate was assessed by Mann-Kendall test. Univariate logistic regression analyses were used to compute odds of pregnancy outcomes among women with inherited bleeding disorders compared with those without at their index pregnancies during the study period.Results: Between 2010 to 2018, 311,657 women had a total of 452,846 pregnancies with live births. The mean age of the study cohort was 29 years. Most (90%) of them reached term pregnancies. The total number of PPH was 47,602 (10.5 per 100 deliveries). The rate of PPH did not have any significant change from 10.3 in 2010 (95% confidence interval [CI] 10.0-10.6) to 10.8 (95% CI 10.6 -11.1) in 2018 (P for trend =0.28) [Figure 1]. Among 311,657 women, 345 (0.1%) had a diagnosis of inherited bleeding disorders [Table 1]. Women with bleeding disorders were more likely to experience PPH (odds ratio [OR] 1.4; 95% CI 1.1-1.9), antepartum hemorrhage (OR 4.3; 95% CI 2.9-6.4) and had a 3-fold increased risk of undergoing hysterectomy (OR 3.1; 95% CI 1.8-5.2). The bleeding cohort had 3.8 (95% CI: 2.4-6.0) times greater risk of being transfused with blood products. We observed a trend towards higher odds of caesarean delivery in women with bleeding disorders compared with those without (OR 1.2, 95% CI 0.9-1.5), albeit not statistically significant. However, there was no significant difference in prolonged labor, obstetric hematoma, low birth weight baby and induced labour.Conclusion: Despite a rise in the rate of PPH between 2003-2010, we observed no significant change in the rate of PPH in Alberta between 2010-2018. Women with inherited bleeding disorders are at an increased risk of bleeding events during pregnancy and childbirth. Further investigation into quality of care among this patient population is ongoing to identify areas for improvement. [Display omitted] DisclosuresWu: BMS-Pfizer: Honoraria, Research Funding; Leo Pharma: Honoraria; Pfizer: Honoraria; Servier: Honoraria; Bayer: Research Funding; Daiichi-Sankyo: Research Funding. Sun: Pfizer: Consultancy; Novo Nordisk: Consultancy; Bayer: Consultancy; Octapharma: Consultancy, Research Funding; Shire: Consultancy.

Estimating the infant mortality rate from DHS birth histories in the presence of age heaping.

BackgroundThe infant mortality rate (IMR) is a critical indicator of population health, but its measurement is subject to response bias in countries without complete vital registration systems who rely instead on birth histories collected via sample surveys. One of the most salient bias is the fact that child deaths in these birth histories tend to be reported with a large amount of heaping at age 12 months. Because of this issue, analysts and international agencies do not directly use IMR estimates based on surveys such as Demographic and Health Surveys (DHS); they rely instead on mortality models such as model life tables. The use of model life tables in this context, however, is arbitrary, and the extent to which this approach appropriately addresses bias in DHS-based IMR estimates remains unclear. This hinders our ability to monitor IMR levels and trends in low-and middle-income countries. The objective of this study is to evaluate age heaping bias in DHS-based IMR estimates and propose an improved method for adjusting this bias.Methods and findingsOur method relies on a recently-developed log-quadratic model that can predict age-specific mortality by detailed age between 0 and 5. The model’s coefficients were derived from a newly constituted database, the Under-5 Mortality Database (U5MD), that represents the mortality experience of countries with high-quality vital registration data. We applied this model to 204 DHS surveys, and compared unadjusted IMR values to IMR values adjusted with the log-quadratic model as well as with the classic model life table approach. Results show that contrary to existing knowledge, age heaping at age 12 months rarely generates a large amount of bias in IMR estimates. In most cases, the unadjusted IMR values were not deviating by more than +/- 5% from the adjusted values. The model life table approach, by contrast, introduced an unwarranted, downward bias in adjusted IMR values. We also found that two regions, Sub-Saharan Africa and South Asia, present age patterns of under-5 mortality that strongly depart from the experience represented in the U5MD. For these countries, neither the existing model life tables nor the log-quadratic model can produce empirically-supported IMR adjustments.ConclusionsAge heaping at age 12 months produces a smaller amount of bias in DHS-based IMR estimates than previously thought. If a large amount of age heaping is present in a survey, the log-quadratic model allows users to evaluate, and whenever necessary, adjust IMR estimates in a way that is more informed by the local mortality pattern than existing approaches. Future research should be devoted to understanding why Sub-Saharan African and South Asian countries have such distinct age patterns of under-five mortality.

Investigating regional excess mortality during 2020 COVID-19 pandemic in selected Latin American countries

In this paper, we measure the effect of the 2020 COVID-19 pandemic wave at the national and subnational levels in selected Latin American countries that were most affected: Brazil, Chile, Ecuador, Guatemala, Mexico, and Peru. We used publicly available monthly mortality data to measure the impacts of the pandemic using excess mortality for each country and its regions. We compare the mortality, at national and regional levels, in 2020 to the mortality levels of recent trends and provide estimates of the impact of mortality on life expectancy at birth. Our findings indicate that from April 2020 on, mortality exceeded its usual monthly levels in multiple areas of each country. In Mexico and Peru, excess mortality was spreading through many areas by the end of the second half of 2020. To a lesser extent, we observed a similar pattern in Brazil, Chile, and Ecuador. We also found that as the pandemic progressed, excess mortality became more visible in areas with poorer socioeconomic and sanitary conditions. This excess mortality has reduced life expectancy across these countries by 2–10 years. Despite the lack of reliable information on COVID-19 mortality, excess mortality is a useful indicator for measuring the effects of the coronavirus pandemic, especially in the context of Latin American countries, where there is still a lack of good information on causes of death in their vital registration systems.

SARS-CoV-2 testing, infections, and hospital admissions with COVID-19 in children and young people in Scotland: a birth cohort study

BackgroundA strong association between deprivation and severe COVID-19 outcomes has been reported among adults. We estimated population-based rates of SARS-CoV-2 testing, laboratory-confirmed infections, and hospital admissions with COVID-19 in children and young people (aged 0–23 years) in Scotland according to sociodemographic risk factors. MethodsWe used a birth cohort of all children and young people born in Scotland in 1997–2020, consisting of linked vital registration, maternity, hospital admissions, and SARS-CoV-2 PCR testing data. Participants were followed from birth or Jan 1, 2020 (whichever occurred last) until Dec 31, 2020, death, or emigration. Admissions with COVID-19 were defined as participants with a positive SARS-CoV-2 test during or up to 28 days before admission to hospital, or a relevant International Classification of Diseases version 10 code recorded (U07.1/U07.2). We calculated crude rates of tests, laboratory-confirmed infections, and admissions, by age group, sex, and Scottish Index of Multiple Deprivation (SIMD) quintiles with 95% CIs. FindingsThe cohort included 1 230 290 children and young people living in Scotland during 2020. By Dec 31, 2020, 243 958 (19·8%) were tested for SARS-CoV-2 at least once, and 17 709 (7·3%) had tested positive. Infants (aged <2 years) and 18–23-year-olds were most likely to be tested; there was no clear trend in testing rates by SIMD quintile. 18–23-year-olds, females, and those from the most deprived SIMD quintile were most likely to test positive. 379 participants had an admission with COVID-19, corresponding to a rate of 32·0 per 100 000 person-years (95% CI 28·9–35·4). Females (admission rate 35·4 per 100 000 person-years [95% CI 30·9–40·6]) and infants (143·5 per 100 000 person-years [113·3–181·7]) were most likely to be admitted to hospital. There was a clear gradient in hospital admissions by SIMD, with participants in the most deprived quintile (42·9 per 100 000 person-years [36·1–50·8]) experiencing 1·9 times (95% CI 1·3–2·6) the admission rate compared with those in the least deprived (22·6 per 100 000 person-years [16·9–30·3]). InterpretationRates of infection and admissions with COVID-19 were associated with area-level deprivation among children and young people. Infants had a relatively low infection rate but the highest admission rate. Analyses examining risk factors, including ethnic group and long-term conditions are underway, to inform the public health response to SARS-CoV-2 in children. Although children and young people in Scotland had low COVID-19-related admission rates versus adults, a socioeconomic gradient was evident, indicating children living in more deprived areas are at increased risk of short-term, and potential long-term, health and education impacts of COVID-19. FundingUKRI Medical Research Council and the Great Ormond Street Biomedical Research Centre.

Global, regional and national burden of bladder cancer and its attributable risk factors in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease study 2019

IntroductionThe current study determined the level and trends associated with the incidence, death and disability rates for bladder cancer and its attributable risk factors in 204 countries and territories, from...

Guideline adherence among prehospital emergency nurses when caring for patients with chest pain: a prospective cohort study

BackgroundThe emergency medical services (EMS) use guidelines to describe optimal patient care for a wide range of clinical conditions and symptoms. The intent is to guide personnel to provide patient care in line with best practice. The aim of this study is to describe adherence to such guidelines among prehospital emergency nurses (PENs) when caring for patients with chest pain.ObjectiveTo describe guideline adherence among PENs when caring for patients with chest pain. To investigate whether guideline adherence is associated with patient age, sex or final diagnosis of acute myocardial infarction on hospital discharge.MethodsGuideline adherence in terms of patient examination and pharmaceutical treatment was analysed in a cohort of 2092 EMS missions carried out in 2018 in Region Halland, Sweden. Multivariate regression was used to describe how guideline adherence is associated with patient age, sex and diagnosis on hospital discharge.ResultsGuideline adherence was high regarding examination of vital signs (93%) and electrocardiogram (ECG) registration (96%) but lower in terms of pharmaceutical treatment (ranging from 28 to 90%). Adherence was increased in cases in which the patient ended up with acute myocardial infarction (AMI) as diagnosis on discharge. Patients with AMI were given acetylsalicylic acid by PENs in 50% of cases. Women were less likely than men to receive treatment with acetylsalicylic acid and oxycodone.ConclusionsGuideline adherence among PENs when caring for patients with chest pain is satisfactory in terms vital signs and ECG registration. Regarding pharmaceutical treatment guideline adherence is defective. Improved adherence is mainly associated with male sex in patients and a diagnosis of AMI on hospital discharge. Defective adherence excludes measures known to improve patients’ prognoses such as treatment with acetylsalicylic acid.

Hepatitis C mortality trends in San Francisco: can we reach elimination targets?

Hepatitis C virus (HCV) is the most common blood-borne infection in the United States, and a leading cause of liver disease, transplant, and mortality. CDC HCV elimination goals include reducing HCV-related mortality by 65% (from 2015) by 2030. We used vital registry data (CDC WONDER) to estimate overall and demographic-specific HCV-related mortality from 1999 to 2019 in San Francisco and then used an exponential model to project progress toward HCV elimination. Local trends were compared to state and national trends. Between 1999 and 2019, there were 1819 HCV-related deaths in San Francisco, representing an overall age-adjusted mortality rate of 9.4 (95% CI 9.0, 9.9) per 100,000 population. The age-adjusted HCV-related mortality rates were significantly higher among males (13.7), persons aged 55 years and older (28.0), Black and/or African Americans (32.2) compared to other racial groups, and Hispanic/Latinos (11.6) compared to non-Hispanic and/or Latinos. Overall and in most subgroups, mortality rates were lowest between 2015 and 2019. Since 2015, San Francisco observed a significantly larger reduction in agbe-adjusted HCV-related mortality than California or the U.S. Projected age-adjusted HCV-related mortality rates for San Francisco for 2020 and 2030 were 4.7 (95% CI 3.5, 6.2) and 1.1 (95% CI 0.7, 1.8), respectively. Based on trends between 2015 and 2019, San Francisco, California, and the U.S. are projected to achieve 65% reduction in HCV-mortality at or before 2030. Based on current trends, San Francisco is projected to achieve this goal earlier.

Date of introduction and epidemiologic patterns of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in Mogadishu, Somalia: estimates from transmission modelling of satellite-based excess mortality data in 2020

Background: In countries with weak surveillance systems, confirmed coronavirus disease 2019 (COVID-19) deaths are likely to underestimate the pandemic’s death toll. Many countries also have incomplete vital registration systems, hampering excess mortality estimation. Here, we fitted a dynamic transmission model to satellite imagery data of cemeteries in Mogadishu, Somalia during 2020 to estimate the date of introduction and other epidemiologic parameters of the early spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in this low-income, crisis-affected setting. Methods: We performed Markov chain Monte Carlo (MCMC) fitting with an age-structured compartmental COVID-19 model to provide median estimates and credible intervals for the date of introduction, the basic reproduction number ( R 0 ) and the effect of non-pharmaceutical interventions (NPIs) up to August 2020. Results: Under the assumption that excess deaths in Mogadishu March-August 2020 were attributable to SARS-CoV-2 infections, we arrived at median estimates of November-December 2019 for the date of introduction and low R 0 estimates (1.4-1.7) reflecting the slow and early rise and long plateau of excess deaths. The date of introduction, the amount of external seeding, the infection fatality rate (IFR) and the effectiveness of NPIs are correlated parameters and not separately identifiable in a narrow range from deaths data. Nevertheless, to obtain introduction dates no earlier than November 2019 a higher population-wide IFR (≥0.7%) had to be assumed than obtained by applying age-specific IFRs from high-income countries to Somalia’s age structure. Conclusions: Model fitting of excess mortality data across a range of plausible values of the IFR and the amount of external seeding suggests an early SARS-CoV-2 introduction event may have occurred in Somalia in November-December 2019. Transmissibility in the first epidemic wave was estimated to be lower than in European settings. Alternatively, there was another, unidentified source of sustained excess mortality in Mogadishu from March to August 2020.

Changes in the pattern of valvular heart disease following the epidemiological transition in Brazil from 1990 to 2019: data from the Global Burden of Disease 2019 study

Abstract Introduction Valvular heart disease is one of the leading causes of cardiovascular death in Brazil, with a great contribution of Rheumatic Heart Disease (RHD), the most socially driven etiology. However, as socioeconomic conditions improved, an increasing contribution of non-rheumatic valvular heart disease (NRVD) is being observed. Objectives We aimed to evaluate the changes in trends of prevalence, mortality and burden of RHD and non-rheumatic valvular heart disease in Brazil from 1990 to 2019, according to the Global Burden of Disease (GBD) 2019 study estimates. Methods We used available vital registration data, epidemiological survey data, and hospital claims data to estimate the cause-specific mortality rate, prevalence, and burden of RHD and NRVD using the GBD modelling framework. Burden estimates in Brazil were estimated for each sex, 5-year age group, federal unit, and year from 1990 to 2019. We also explored the correlation of disease burden and the sociodemographic index (SDI). Results From 1990 to 2019, age-standardized prevalence of RHD increased slightly (2.1% (95%UI 0.2–4.0)) in Brazil, from 899.6 (95%UI 699.8–1119.1) to 918.5 (95%UI 716–1142.5) per 100,000, remaining higher in women in the whole period. In contrast, age-standardized prevalence of NRVD had a marked 54.3% increase from 25.3 (95% UI 22.4–27.8) per 100,000 in 1990 to 39 (95% UI 33.9–44.6) per 100,000 in 2019. The percent change was considerably higher for men compared to women (105.9% vs. 20.9%). For mortality, age-standardized rates attributable to RHD significantly decreased 59.4%, from 2.8 (95%UI 2.7–3.0) to 1.2 (95%UI 1.1–1.2) per 100,000, whereas NRVD had a less pronounced 16.2% decrease in the period. However, crude NRVD mortality increased (51.9% (95%UI 39.8–62.7)), with a considerable contribution of older ages, noticeably over 70 years (17.2% (95%UI 5.4–27.4)), specifically driven by calcific aortic valve disease mortality, with a marked 17% (95%UI 2.0–38.5) increase in the elderly. RHD dropped from 12th to 10th in the mortality ranking, while aortic and mitral degenerative diseases rose in the period (Figure 1). There was a significant negative correlation between the percent change in age-standardized RHD mortality rates and SDI in 1990 (r=−0.41, p=0.03) and in 2019 (r=−0.44, p=0.02), and an opposite trend for NRVD, with positive correlations in 1990 (r=−0.55, p=0.003), and 2019 (r=−0.58, p=0.001), suggesting that SDI was a major driver for the observed trends. Conclusion Mortality and disease burden attributable to RHD decreased significantly in Brazil over the past decades, still with a stable prevalence trend. This contrasts with increasing prevalence and crude mortality estimates for NRVD, especially in older ages, and driven by degenerative conditions. Changes in mortality rates strongly correlated with SDI, depicting the effects of socioeconomic markers of the pattern of valve disease in Brazil. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): This study used data from the Institute of Health Metrics and Evaluation, funded by the Bill &amp; Melinda Gates Foundation. This work was supported by the Brazilian Ministry of Health through resource transfer from the National Health Fund. Figure 1. Ranking of mortality rates.

Date of introduction and epidemiologic patterns of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in Mogadishu, Somalia: estimates from transmission modelling of satellite-based excess mortality data in 2020.

Background: In countries with weak surveillance systems, confirmed coronavirus disease 2019 (COVID-19) deaths are likely to underestimate the pandemic's death toll. Many countries also have incomplete vital registration systems, hampering excess mortality estimation. Here, we fitted a dynamic transmission model to satellite imagery data of cemeteries in Mogadishu, Somalia during 2020 to estimate the date of introduction and other epidemiologic parameters of the early spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in this low-income, crisis-affected setting. Methods: We performed Markov chain Monte Carlo (MCMC) fitting with an age-structured compartmental COVID-19 model to provide median estimates and credible intervals for the date of introduction, the basic reproduction number ( R 0 ) and the effect of non-pharmaceutical interventions (NPIs) up to August 2020. Results: Under the assumption that excess deaths in Mogadishu March-August 2020 were attributable to SARS-CoV-2 infections, we arrived at median estimates of November-December 2019 for the date of introduction and low R 0 estimates (1.4-1.7) reflecting the slow and early rise and long plateau of excess deaths. The date of introduction, the amount of external seeding, the infection fatality rate (IFR) and the effectiveness of NPIs are correlated parameters and not separately identifiable in a narrow range from deaths data. Nevertheless, to obtain introduction dates no earlier than November 2019 a higher population-wide IFR (≥0.7%) had to be assumed than obtained by applying age-specific IFRs from high-income countries to Somalia's age structure. Conclusions: Model fitting of excess mortality data across a range of plausible values of the IFR and the amount of external seeding suggests an early SARS-CoV-2 introduction event may have occurred in Somalia in November-December 2019. Transmissibility in the first epidemic wave was estimated to be lower than in European settings. Alternatively, there was another, unidentified source of sustained excess mortality in Mogadishu from March to August 2020.

Fatal police violence by race and state in the USA, 1980–2019: a network meta-regression

SummaryBackgroundThe burden of fatal police violence is an urgent public health crisis in the USA. Mounting evidence shows that deaths at the hands of the police disproportionately impact people of certain races and ethnicities, pointing to systemic racism in policing. Recent high-profile killings by police in the USA have prompted calls for more extensive and public data reporting on police violence. This study examines the presence and extent of under-reporting of police violence in US Government-run vital registration data, offers a method for correcting under-reporting in these datasets, and presents revised estimates of deaths due to police violence in the USA.MethodsWe compared data from the USA National Vital Statistics System (NVSS) to three non-governmental, open-source databases on police violence: Fatal Encounters, Mapping Police Violence, and The Counted. We extracted and standardised the age, sex, US state of death registration, year of death, and race and ethnicity (non-Hispanic White, non-Hispanic Black, non-Hispanic of other races, and Hispanic of any race) of each decedent for all data sources and used a network meta-regression to quantify the rate of under-reporting within the NVSS. Using these rates to inform correction factors, we provide adjusted estimates of deaths due to police violence for all states, ages, sexes, and racial and ethnic groups from 1980 to 2019 across the USA.FindingsAcross all races and states in the USA, we estimate 30 800 deaths (95% uncertainty interval [UI] 30 300–31 300) from police violence between 1980 and 2018; this represents 17 100 more deaths (16 600–17 600) than reported by the NVSS. Over this time period, the age-standardised mortality rate due to police violence was highest in non-Hispanic Black people (0·69 [95% UI 0·67–0·71] per 100 000), followed by Hispanic people of any race (0·35 [0·34–0·36]), non-Hispanic White people (0·20 [0·19–0·20]), and non-Hispanic people of other races (0·15 [0·14– 0·16]). This variation is further affected by the decedent's sex and shows large discrepancies between states. Between 1980 and 2018, the NVSS did not report 55·5% (54·8–56·2) of all deaths attributable to police violence. When aggregating all races, the age-standardised mortality rate due to police violence was 0·25 (0·24–0·26) per 100 000 in the 1980s and 0·34 (0·34–0·35) per 100 000 in the 2010s, an increase of 38·4% (32·4–45·1) over the period of study.InterpretationWe found that more than half of all deaths due to police violence that we estimated in the USA from 1980 to 2018 were unreported in the NVSS. Compounding this, we found substantial differences in the age-standardised mortality rate due to police violence over time and by racial and ethnic groups within the USA. Proven public health intervention strategies are needed to address these systematic biases. State-level estimates allow for appropriate targeting of these strategies to address police violence and improve its reporting.FundingBill & Melinda Gates Foundation, National Institute on Minority Health and Health Disparities, and National Heart, Lung, and Blood Institute.

Trends of Infant Mortality in Nineveh (2004-2013), A Time Series Analysis

Context: Infant mortality rate is the number of deaths under one year of age in a year divided by total number of live birth in the same year × 1000. It is a standard measure that is not affected by population age structure and therefore suitable to use for comparisons over time and across regions, in addition, it reflects the underlying well-being of communities and the social environment that cultivate health and access to healthpromoting resources. Aim: Determine the trend of infant mortality in Nineveh for 10 year period (2004-2013). Subjects and Methods: Study Design: Descriptive biometric study design. Study Settings: Nineveh Governorate/ North of Iraq. Study Sample: Infant deaths and live births from 2004 to 2013. Data Collection Tool: Death certificates, vital registration system. Outcome Measures: Infant mortality rate in general in addition to the proportions of their mortality by sex and causes with their trends by using various rates, proportions, and Chisquared test for trend. Results: The trend of infant mortality rate fluctuated significantly from 15.36 to 16.93/1000 live births between 2004 and 2013. Most of these deaths were due to respiratory distress syndrome, sepsis, congenital anomalies, infections, birth asphyxia, and pneumonia. Conclusions and Recommendations: Infant mortality was relatively low and most of its causes were preventable, thus; more efforts are still needed to control such causes and improve infants' survival.

Global, regional, and national sex-specific burden and control of the HIV epidemic, 1990-2019, for 204 countries and territories: the Global Burden of Diseases Study 2019.

SummaryBackgroundThe sustainable development goals (SDGs) aim to end HIV/AIDS as a public health threat by 2030. Understanding the current state of the HIV epidemic and its change over time is essential to this effort. This study assesses the current sex-specific HIV burden in 204 countries and territories and measures progress in the control of the epidemic.MethodsTo estimate age-specific and sex-specific trends in 48 of 204 countries, we extended the Estimation and Projection Package Age-Sex Model to also implement the spectrum paediatric model. We used this model in cases where age and sex specific HIV-seroprevalence surveys and antenatal care-clinic sentinel surveillance data were available. For the remaining 156 of 204 locations, we developed a cohort-incidence bias adjustment to derive incidence as a function of cause-of-death data from vital registration systems. The incidence was input to a custom Spectrum model. To assess progress, we measured the percentage change in incident cases and deaths between 2010 and 2019 (threshold >75% decline), the ratio of incident cases to number of people living with HIV (incidence-to-prevalence ratio threshold <0·03), and the ratio of incident cases to deaths (incidence-to-mortality ratio threshold <1·0).FindingsIn 2019, there were 36·8 million (95% uncertainty interval [UI] 35·1–38·9) people living with HIV worldwide. There were 0·84 males (95% UI 0·78–0·91) per female living with HIV in 2019, 0·99 male infections (0·91–1·10) for every female infection, and 1·02 male deaths (0·95–1·10) per female death. Global progress in incident cases and deaths between 2010 and 2019 was driven by sub-Saharan Africa (with a 28·52% decrease in incident cases, 95% UI 19·58–35·43, and a 39·66% decrease in deaths, 36·49–42·36). Elsewhere, the incidence remained stable or increased, whereas deaths generally decreased. In 2019, the global incidence-to-prevalence ratio was 0·05 (95% UI 0·05–0·06) and the global incidence-to-mortality ratio was 1·94 (1·76–2·12). No regions met suggested thresholds for progress.InterpretationSub-Saharan Africa had both the highest HIV burden and the greatest progress between 1990 and 2019. The number of incident cases and deaths in males and females approached parity in 2019, although there remained more females with HIV than males with HIV. Globally, the HIV epidemic is far from the UNAIDS benchmarks on progress metrics.FundingThe Bill & Melinda Gates Foundation, the National Institute of Mental Health of the US National Institutes of Health (NIH), and the National Institute on Aging of the NIH.

Excess mortality during the COVID-19 pandemic: a geospatial and statistical analysis in Mogadishu, Somalia

BackgroundWhile the impact of the COVID-19 pandemic has been well documented in high-income countries, less is known about the health effects in Somalia, where health systems are weak and vital registration is underdeveloped. MethodsWe used remote sensing and geospatial analysis to quantify burial numbers from January 2017 to September 2020 in Mogadishu. We imputed missing grave counts using surface area data. Simple interpolation and a generalised additive mixed growth model were used to predict actual and counterfactual burial rates by cemetery and across Mogadishu during the most likely period of COVID-19 excess mortality and to compute excess burials. We undertook a qualitative survey of key informants to determine the drivers of COVID-19 excess mortality. ResultsBurial rates increased during the pandemic, averaging 1.5-fold and peaking at a 2.2-fold increase on pre-pandemic levels. When scaled to plausible range of baseline crude death rates, the excess death toll between January and September 2020 was 3200–11 800. Compared with Barakaat Cemetery Committee's burial records, our estimates were lower. ConclusionsOur study indicates considerable underestimation of the health effects of COVID-19 in Banadir and an overburdened public health system struggling to deal with the increasing severity of the epidemic in 2020.

Global, regional, and national sex differences in the global burden of tuberculosis by HIV status, 1990–2019: results from the Global Burden of Disease Study 2019

SummaryBackgroundTuberculosis is a major contributor to the global burden of disease, causing more than a million deaths annually. Given an emphasis on equity in access to diagnosis and treatment of tuberculosis in global health targets, evaluations of differences in tuberculosis burden by sex are crucial. We aimed to assess the levels and trends of the global burden of tuberculosis, with an emphasis on investigating differences in sex by HIV status for 204 countries and territories from 1990 to 2019.MethodsWe used a Bayesian hierarchical Cause of Death Ensemble model (CODEm) platform to analyse 21 505 site-years of vital registration data, 705 site-years of verbal autopsy data, 825 site-years of sample-based vital registration data, and 680 site-years of mortality surveillance data to estimate mortality due to tuberculosis among HIV-negative individuals. We used a population attributable fraction approach to estimate mortality related to HIV and tuberculosis coinfection. A compartmental meta-regression tool (DisMod-MR 2.1) was then used to synthesise all available data sources, including prevalence surveys, annual case notifications, population-based tuberculin surveys, and tuberculosis cause-specific mortality, to produce estimates of incidence, prevalence, and mortality that were internally consistent. We further estimated the fraction of tuberculosis mortality that is attributable to independent effects of risk factors, including smoking, alcohol use, and diabetes, for HIV-negative individuals. For individuals with HIV and tuberculosis coinfection, we assessed mortality attributable to HIV risk factors including unsafe sex, intimate partner violence (only estimated among females), and injection drug use. We present 95% uncertainty intervals for all estimates.FindingsGlobally, in 2019, among HIV-negative individuals, there were 1·18 million (95% uncertainty interval 1·08–1·29) deaths due to tuberculosis and 8·50 million (7·45–9·73) incident cases of tuberculosis. Among HIV-positive individuals, there were 217 000 (153 000–279 000) deaths due to tuberculosis and 1·15 million (1·01–1·32) incident cases in 2019. More deaths and incident cases occurred in males than in females among HIV-negative individuals globally in 2019, with 342 000 (234 000–425 000) more deaths and 1·01 million (0·82–1·23) more incident cases in males than in females. Among HIV-positive individuals, 6250 (1820–11 400) more deaths and 81 100 (63 300–100 000) more incident cases occurred among females than among males in 2019. Age-standardised mortality rates among HIV-negative males were more than two times greater in 105 countries and age-standardised incidence rates were more than 1·5 times greater in 74 countries than among HIV-negative females in 2019. The fraction of global tuberculosis deaths among HIV-negative individuals attributable to alcohol use, smoking, and diabetes was 4·27 (3·69–5·02), 6·17 (5·48–7·02), and 1·17 (1·07–1·28) times higher, respectively, among males than among females in 2019. Among individuals with HIV and tuberculosis coinfection, the fraction of mortality attributable to injection drug use was 2·23 (2·03–2·44) times greater among males than females, whereas the fraction due to unsafe sex was 1·06 (1·05–1·08) times greater among females than males.InterpretationAs countries refine national tuberculosis programmes and strategies to end the tuberculosis epidemic, the excess burden experienced by males is important. Interventions are needed to actively communicate, especially to men, the importance of early diagnosis and treatment. These interventions should occur in parallel with efforts to minimise excess HIV burden among women in the highest HIV burden countries that are contributing to excess HIV and tuberculosis coinfection burden for females. Placing a focus on tuberculosis burden among HIV-negative males and HIV and tuberculosis coinfection among females might help to diminish the overall burden of tuberculosis. This strategy will be crucial in reaching both equity and burden targets outlined by global health milestones.FundingBill & Melinda Gates Foundation.

Excess Mortality During the COVID-19 Pandemic in Guatemala.

Objectives. To describe excess mortality during the COVID-19 pandemic in Guatemala during 2020 by week, age, sex, and place of death. Methods. We used mortality data from 2015 to 2020, gathered through the vital registration system of Guatemala. We calculated weekly mortality rates, overall and stratified by age, sex, and place of death. We fitted a generalized additive model to calculate excess deaths, adjusting for seasonality and secular trends and compared excess deaths to the official COVID-19 mortality count. Results. We found an initial decline of 26% in mortality rates during the first weeks of the pandemic in 2020, compared with 2015 to 2019. These declines were sustained through October 2020 for the population younger than 20 years and for deaths in public spaces and returned to normal from July onward in the population aged 20 to 39 years. We found a peak of 73% excess mortality in mid-July, especially in the population aged 40 years or older. We estimated a total of 8036 excess deaths (95% confidence interval = 7935, 8137) in 2020, 46% higher than the official COVID-19 mortality count. Conclusions. The extent of this health crisis is underestimated when COVID-19 confirmed death counts are used. (Am J Public Health. 2021;111(10): 1839-1846. https://doi.org/10.2105/AJPH.2021.306452).

Rapid mortality surveillance using a national population register to monitor excess deaths during SARS-CoV-2 pandemic in South Africa

This paper describes how an up-to-date national population register recording deaths by age and sex, whether deaths were due to natural or unnatural causes, and the offices at which the deaths were recorded can be used to monitor excess death during the SARS-CoV-2 pandemic, both nationally, and sub-nationally, in a country with a vital registration system that is neither up to date nor complete. Apart from suggesting an approach for estimating completeness of reporting at a sub-national level, the application produces estimates of the number of deaths in excess of those expected in the absence of the SARS-CoV-2 epidemic that are highly correlated with the confirmed number of COVID-19 deaths over time, but at a level 2.5 to 3 times higher than the official numbers of COVID-19 deaths. Apportioning the observed excess deaths more precisely to COVID, COVID-related and collateral deaths, and non-COVID deaths averted by interventions with reduced mobility and gatherings, etc., requires access to real-time cause-of-death information. It is suggested that the transition from ICD-10 to ICD-11 should be used as an opportunity to change from a paper-based system to electronic capture of the medical cause-of-death information.