Correction of vital statistics based on a proactive search of deaths and live births: evidence from a study of the North and Northeast regions of Brazil

Background

In the last 20 years, Brazil has undergone dramatic changes in terms of socioeconomic development and health care. In the first decade of the 2000s, the Ministry of Health (MoH) developed a series of programs focused on reducing infant mortality, including the Family Health Program as a national policy for primary care. In this paper, we propose a method to correct underreporting of deaths and live births. After vital statistics are corrected, infant mortality trends are analyzed for the period 2000–2010 by macro-geographical region.

Methods

A proactive search of live births and deaths was carried out in the Amazon and Northeast regions in 2010 to find vital events that occurred in 2008 and were not reported to the Ministry of Health. The probabilistic sample of 133 municipalities was stratified by adequacy of vital information reporting. For each municipality, the adequacy analysis was based on the reported age-standardized mortality rate per 1,000 population and the ratio between reported and estimated live births. Correction factors were estimated by strata based on additional vital events found in the proactive search. The procedure was generalized to correct municipal vital statistics for the period 2000–2010.

Results

In the proactive search, 35% of non-reported deaths were found within the health system (hospitals and other health establishments), but 28% were found in non-official sources, like illegal cemeteries. In areas of extreme poverty and unreliable vital information, the estimated completeness of infant death reporting was only 33%. After correction of vital information, the estimated infant mortality rate decreased from 26.1 in 2000 to 16.0 in 2010, with an annual rate of decrease of 4.7%, greater than the required rate to achieve the Millennium Development Goal. Among Brazilian regions, the Northeast showed the largest decrease, from 38.4 to 20.1 per 1,000 live births.

Conclusions

The proactive search for vital events was shown to be a good strategy both in terms of understanding local irregularities and for correcting vital statistics. The methodology could be applied in other countries to routinely assess the pattern and extent of birth and death under-registration in order to improve the utility of these data to inform health policies.

     

How useful are registered birth statistics for health and social policy? A global systematic assessment of the availability and quality of birth registration data

Background

The registration and certification of births has a wide array of individual and societal benefits. While near-universal in some parts of the world, birth registration is less common in many low- and middle-income countries, and the quality of vital statistics vary. We assembled publicly available birth registration records for as many countries as possible into a novel global birth registration database, and we present a systematic assessment of available data.

Methods

We obtained 4918 country-years of data from 145 countries covering the period 1948–2015. We compared these to existing estimates of total births to assess completeness of public data and adapted existing methods to evaluate the quality and timeliness of the data.

Results

Since 1980, approximately one billion births were registered and shared in public databases. Compared to estimates of fertility, this represents only 40.0% of total births in the peak year, 2011. Approximately 74 million births (53.1%) per year occur in countries whose systems do not systematically register them and release the aggregate records. Considering data quality, timeliness, and completeness in country-years where data are available, only about 12 million births per year (8.6%) occur in countries with high-performing registration systems.

Conclusions

This analysis highlights the gaps in available data. Our objective and low-cost approach to assessing the performance of birth registration systems can be helpful to monitor country progress, and to help national and international policymakers set targets for strengthening birth registration systems.

     

Association between body mass index and all-cause mortality among oldest old Chinese

Objectives

To examine the association between BMI and all-cause mortality in the oldest old (≥80 years).

Design

The study used a prospective cohort study design.

Setting

Chinese Longitudinal Healthy Longevity Survey (CLHLS) between 1998/99 and 2011.

Population

8026 participants aged 80 years and older were followed every two to three years.

Measurements

Body weight and knee height were measured. Height was calculated based on knee height using a validated equation. Deaths were ascertained from family members during follow-up.

Results

The mean BMI was 19.8 (SD 4.5) kg/m². The prevalence of underweight, overweight and obese was 37.5%, 10.2% and 4.4%, respectively. There were 5962 deaths during 29503 person-years of follow-up. Compared with normal weight, underweight was associated with a higher mortality risk (HRs: 1.20 (95%CI 1.13-1.27) but overweight (HR 0.89 (95%CI 0.81-0.99)) were associated with a lower risk. Obesity had a HR 0.91 (95%CI 0.78-1.05) for mortality.

Conclusion

Among oldest old Chinese, underweight is associated with an increased risk of all-cause mortality but overweight is associated with a reduced risk. Interventions to reduce undernutrition should be given priority among the oldest old Chinese.

     

Population-based survey regarding factors contributing to expectation for death at home

Background

In 2015 in Japan 12.7% of people die at home. Since the government has no policy to increase the number of hospital beds, at-home deaths should inevitably increase in the near future. Previous researches regarding expected place of death have focused on end-of-life patients. The aim of this study is to clarify the percentage and factors of senior people who expect at-home deaths whether they are end-of-life or not.

Methods

Using cross-sectional questionnaire survey data which had been taken by a research group with the support from Tama City Medical Association (Tokyo) in 2014, univariable and multivariable logistic regression analyses were conducted to identify associations among factors. The dependent variable was the expected site of death and other factors were set as independent variables.

Results

Of 1781 respondents, 46.5% expected at-home deaths. Data from 1133 people were analyzed and 46.5% of those wanted at-home deaths. Factors significantly associated with expectation of at-home death were men, stand-alone houses for dwelling, expectation to continue life in Tama city, twosome life with the spouse, healthiness, and economic challenge.

Conclusion

Percentage of those who expected at-home deaths was much higher than the latest percentage of at-home deaths. Some factors associated with expectation of at-home deaths in this study have never been discussed.

     

Evaluation of record linkage of mortality data between a health and demographic surveillance system and national civil registration system in South Africa

Background

Health and Demographic Surveillance Systems (HDSS) collect independent mortality data that could be used for assessing the quality of mortality data in national civil registration (CR) systems in low- and middle-income countries. However, the use of HDSS data for such purposes depends on the quality of record linkage between the two data sources. We describe and evaluate the quality of record linkage between HDSS and CR mortality data in South Africa with HDSS data from Agincourt HDSS.

Methods

We applied deterministic and probabilistic record linkage approaches to mortality records from 2006 to 2009 from the Agincourt HDSS and those in the CR system. Quality of the matches generated by the probabilistic approach was evaluated using sensitivity and positive predictive value (PPV) calculated from a subset of records that were linked using national identity number. Matched and unmatched records from the Agincourt HDSS were compared to identify characteristics associated with successful matching. In addition, the distribution of background characteristics in all deaths that occurred in 2009 and those linked to CR records was compared to assess systematic bias in the resulting record-linked dataset in the latest time period.

Results

Deterministic and probabilistic record linkage approaches combined linked a total of 2264 out of 3726 (60.8%) mortality records from the Agincourt HDSS to those in the CR system. Probabilistic approaches independently linked 1969 (87.0%) of the linked records. In a subset of 708 records that were linked using national identity number, the probabilistic approaches yielded sensitivity of 90.0% and PPV of 98.5%. Records belonging to more vulnerable people, including poorer persons, young children, and non-South Africans were less likely to be matched. Nevertheless, distribution of most background characteristics was similar between all Agincourt HDSS deaths and those matched to CR records in the latest time period.

Conclusion

This study shows that record linkage of mortality data from HDSS and CR systems is possible and can be useful in South Africa. The study identifies predictors for death registration and data items and registration system characteristics that could be improved to achieve more optimal future matching possibilities.

     

Increased Mortality Despite Successful Multifactorial Cardiovascular Risk Reduction in Healthy Men: 40-Year Follow-Up of the Helsinki Businessmen Study Intervention Trial

Objectives

In a 5-year multifactorial risk reduction intervention for healthy men with at least one cardiovascular disease (CVD) risk factor, mortality was unexpectedly higher in the intervention than the control group during the first 15-year follow-up. In order to find explanations for the adverse outcome, we have extended mortality follow-up and examined in greater detail baseline characteristics that contributed to total mortality.

Design

Long-term follow-up of a controlled intervention trial.

Setting

The Helsinki Businessmen Study Intervention Trial.

Participants and Intervention

The prevention trial between 1974–1980 included 1,222 initially healthy men (born 1919–1934) at high CVD risk, who were randomly allocated into intervention (n=612) and control groups (n=610). The 5-year multifactorial intervention consisted of personal health education and contemporary drug treatments for dyslipidemia and hypertension. In the present analysis we used previously unpublished data on baseline risk factors and lifestyle characteristics.

Main outcome measures

40-year total and cause-specific mortality through linkage to nation-wide death registers.

Results

The study groups were practically identical at baseline in 1974, and the 5-year intervention significantly improved risk factors (body mass index, blood pressure, serum lipids and glucose), and total CVD risk by 46% in the intervention group. Despite this, total mortality has been consistently higher up to 25 years post-trial in the intervention group than the control group, and converging thereafter. Increased mortality risk was driven by CVD and accidental deaths. Of the newly-analysed baseline factors, there was a significant interaction for mortality between intervention group and yearly vacation time (P=0.027): shorter vacation was associated with excess 30-year mortality in the intervention (hazard ratio 1.37, 95% CI 1.03–1.83, P=0.03), but not in the control group (P=0.5). This finding was robust to multivariable adjustments.

Conclusion

After a multifactorial intervention for healthy men with at least one CVD risk factor, there has been an unexpectedly increased mortality in the intervention group. This increase was especially observed in a subgroup characterised by shorter vacation time at baseline. Although this adverse response to personal preventive measures in vulnerable individuals may be characteristic to men of high social status with subclinical CVD, it clearly deserves further investigation.

     

Correcting and estimating HIV mortality in Thailand based on 2005 verbal autopsy data focusing on demographic factors, 1996-2009

Background

It is known that death registry (DR) underestimates HIV deaths. The objectives of this study were to examine under-reporting/misclassification and to estimate HIV mortality in Thailand during 1996-2009 from a model based on 2005 verbal autopsy (VA) data.

Methods

Logistic regression was used to predict HIV deaths from the VA dataset with and without demographic covariates. This full model was then used to predict individual HIV deaths from the DR dataset of provinces in which VA was conducted. The proportions in the remaining provinces were predicted from spatial interpolation based on coefficients of the VA provinces.

Results

Area under Receiver Operating Characteristic curve of the full model was 0.969 compared to 0.879 of the simple cross-referencing model when demographic covariates were not included. DR-reported HIV deaths accounted for only one-third of all VA-estimated HIV deaths. The most misclassified HIV deaths were those registered as tuberculosis and mental and nervous system. Under-reporting was most common among females and people aged 20-39 years, and effect of province was highest in the upper north and upper south regions.

Conclusions

For approximately two-thirds of all HIV deaths estimated by the full model, the causes were reported under other categories, not HIV. Demographic variables are essential for accurately correcting causes of death from death registries.

     

Assessing the quality of medical death certification: a case study of concordance between national statistics and results from a medical record review in a regional hospital in the Philippines

Background

Medical certificates of cause of death (MCCOD) issued by hospital physicians are a key input to vital registration systems. Deaths certified by hospital physicians have been implicitly considered to be of high quality, but recent evidence suggests otherwise. We conducted a medical record review (MRR) of hospital MCCOD in the Philippines and compared the cause of death concordance with certificates coded by the Philippines Statistics Authority (PSA).

Methods

MCCOD for adult deaths in Bohol Regional Hospital (BRH) in 2007–2008 and 2011 were collected and reviewed by a team of study physicians. Corresponding MCCOD coded by the PSA were linked by a hospital identifier. The study physicians wrote a new MCCOD using the patient medical record, noted the quality of the medical record to produce a cause of death, and indicated whether it was necessary to change the underlying cause of death (UCOD). Chance-corrected concordance, cause-specific mortality fraction (CSMF) accuracy, and chance-corrected CSMF were used to examine the concordance between the MRR and PSA.

Results

A total of 1052 adult deaths were linked between the MRR and PSA. Median chance-corrected concordance was 0.73, CSMF accuracy was 0.85, and chance-corrected CSMF accuracy was 0.58. 74.8% of medical records were deemed to be of high enough quality to assign a cause of death, yet study physicians indicated that it was necessary to change the UCOD in 41% of deaths, 82% of which required addition of a new UCOD.

Conclusions

Medical records were generally of sufficient quality to assign a cause of death and concordance between the PSA and MRR was reasonably high, suggesting that routine mortality statistics data are reasonably accurate for describing population level causes of death in Bohol. While overall agreement between the PSA and MRR in major cause groups was sufficient for public health purposes, improvements in death certification practices are recommended to help physicians differentiate between treatable (immediate) COD and COD that are important for public health surveillance.

     

The effects of weight and waist change on the risk of long-term mortality in older adults- The Bambuí (Brazil) Cohort Study of Aging

Objective

We aimed to investigate the risk of long-term mortality associated with weight and waist circumference (WC) change among older adults, particularly the overweight and obese ones.

Design

Cohort Study.

Setting

The Bambuí (Brazil) Cohort Study of Aging.

Participants

Community-dwelling elderly (n=1138).

Measurements

Weight and WC were reassessed three years after baseline. Mortality risk associated with a 5% weight/WC loss and gain was compared to that of weight/WC stability by Cox models adjusted for clinical, behavioral and social known risk factors for death (age, gender, BMI, smoking, diabetes, total cholesterol, hypertension, Chagas disease, major electrocardiographic changes, physical activity, B-type natriuretic peptide, C-reactive protein, creatinine, education and household income).

Results

Female sex was predominant (718; 63.1%). Mean age was 68 (6.7) years. Weight stability (696; 61.1%) was more common than weight loss (251; 22.1%) or gain (191; 16.8%). WC remained stable in 422 (37.3%), decreased in 418 (37.0%) and increased in 291 (25.7%) participants. There were 334 (29.3%) deaths over a median follow-up time of 8.0 (6.4-8.0) years from weight/WC reassessment. Weight loss (HR 1.69; 95% CI 1.30-2.21) and gain (HR 1.37; 95% CI 1.01-1.85) were associated with increased mortality, except in those who were physically active in which weight gain was associated with decreased mortality. Results were similar for participants who were overweight/ obese or with abdominal obesity at baseline (HR 1.41; 95%CI 1.02-1.97 and HR 2.01; 95%CI 1.29-3.12, for weight loss and gain, respectively). WC change was not significantly associated with mortality.

Conclusion

Although weight loss has been recommended for adults with excessive weight regardless of age, weight change might be detrimental in older adults. Rather than weight loss, clinical interventions should target healthy lifestyle behaviors that contribute to weight stability, particularly physical activity in overweight and obese older adults.

     

The incomparability of cause of death statistics under “one country,two systems”: Shanghai versus Hong Kong

Background

Valid and comparable cause of death (COD) statistics are crucial for health policy analyses. Variations in COD assignment across geographical areas are well-documented while socio-institutional factors may affect the process of COD and underlying cause of death (UCD) determination. This study examines the comparability of UCD statistics in Hong Kong and Shanghai, having two political systems within one country, and assesses how socio-institutional factors influence UCD comparability.

Methods

A mixed method was used. Quantitative analyses involved anonymized official mortality records. Mortality rates were analyzed by location of death. To analyze the odds ratio of being assigned to a particular UCD, logistic regressions were performed. Qualitative analyses involved literature reviews and semi-structural interviews with key stakeholders in death registration practices. Thematic analysis was used.

Results

Age-standardized death rates from certain immediate conditions (e.g., septicemia, pneumonia, and renal failure) were higher in Hong Kong. Variations in UCD determination may be attributed to preference of location of death, procedures of registering deaths outside hospital, perceptions on the causal chain of COD, implications of the selected UCD for doctors’ professional performance, and governance and processes of data quality review.

Conclusions

Variations in socio-institutional factors were related to the process of certifying and registering COD in Hong Kong and Shanghai. To improve regional data comparability, health authorities should develop standard procedures for registering deaths outside hospital, provide guidelines and regular training for doctors, develop a unified automated coding system, consolidate a standard procedure for data review and validity checks, and disseminate information concerning both UCD and multiple causes of death.

     

Tuberculosis and HIV are the leading causes of adult death in northwest Ethiopia: evidence from verbal autopsy data of Dabat health and demographic surveillance system, 2007–2013

Background

Reliable data on causes of death form the basis for building evidence on health policy, planning, monitoring, and evaluation. In Ethiopia, the majority of deaths occur at home and civil registration systems are not yet functional. The main objective of verbal autopsy (VA) is to describe the causes of death at the community or population level where civil registration and death certification systems are weak and where most people die at home without having had contact with the health system.

Methods

Causes of death were classified and prepared based on the International Classification of Diseases (ICD-10). The cause of a death was ascertained based on an interview with next of kin or other caregivers using a standardized questionnaire that draws information on signs, symptoms, medical history, and circumstances preceding death. The cause of death, or the sequence of causes that led to death, is assigned based on the data collected by the questionnaire. The complete VA questionnaires were given to two blinded physicians and reviewed independently. A third physician was assigned to review the case when disagreements in diagnosis arose.

Results

Communicable diseases (519 deaths [48.0%]), non-communicable diseases (377 deaths [34.8%]), and external causes (113 deaths [10.4%]) were the main causes of death between 2007 and 2013. Of communicable diseases, tuberculosis (207 deaths [19.7%]), HIV/AIDS (96 deaths [8.9%]) and meningitis (76 deaths [7.0%]) were the most common causes of death.

Conclusion

Tuberculosis, HIV/AIDS, and meningitis were the most common causes of deaths among adults. Death due to non-communicable diseases showed an increasing trend. Increasing community awareness of infections and their interrelationships, tuberculosis case finding, effective local TB programs, successful treatment, and interventions for HIV are supremely important.

     

Overweight and abdominal obesity association with all-cause and cardiovascular mortality in the elderly aged 80 and over: A cohort study

Objective

To evaluate the association between overweight and abdominal obesity with all-cause and cardiovascular mortality in the elderly aged 80 and over.

Design

A prospective cohort study.

Setting

A population-based study of community-dwelling very elderly adults in a city in southern Brazil.

Participants

236 very elderly adults, number that represents 85% of the population aged 80 and over living in the city in the period (mean age 83.4 ± 3.2).

Measurements

Overweight and abdominal obesity were assessed using recommended cut-off points for body mass index (BMI), waist circumference (WC), waist-hip ratio (WHR) and waist-height ratio (WHtR). The association between these anthropometric measurements and all-cause and cardiovascular mortality were independently estimated by Cox proportional hazards model. Kaplan-Meier was used to assess survival time.

Results

Increased WC (>80cm F and >94cm M) and WHtR (>0.53 F and >0.52 M) were associated with lower all-cause mortality, but only WHtR remained associated even after controlling for residual confounding (HR 0.55 CI95% 0.36-0.84; p<0.001). Additionally increased WC was independently associated with lower mortality from cardiovascular diseases (HR 0.57 CI95% 0.34-0.95; p<0.030). BMI and WHR did not show significant independent association with mortality in the main analysis.

Conclusion

Greater abdominal fat accumulation, as estimated by WC and WHtR, presented an association with lower allcause and cardiovascular mortality in the elderly aged 80 and over, but not by BMI and WHR.

     

Mortality after discharge from long-term psychiatric care in Scotland, 1977 – 94: a retrospective cohort study

Background

Recent United Kingdom strategies focus on preventable suicide deaths in former psychiatric in-patients, but natural causes of death, accidents and homicide may also be important. This study was intended to find the relative importance of natural and unnatural causes of death in people discharged from long-term psychiatric care in Scotland in 1977 –1994.

Methods

People discharged alive from psychiatric hospitals in Scotland in 1977 – 94 after a stay of one year or longer were identified using routine hospital records. Computer record linkage was used to link hospital discharges to subsequent death records. Mortality was described using a person-years analysis, and compared to the general population rates.

Results

6,776 people were discharged in the time period. 1,994 people (29%) died by the end of follow-up, 732 more deaths than expected. Deaths from suicide, homicide, accident and undetermined cause were increased, but accounted for only 197 of the excess deaths. Deaths from respiratory disease were four times higher than expected, and deaths from other causes, including cardiovascular disease, were also elevated.

Conclusion

Suicide is an important cause of preventable mortality, but natural causes account for more excess deaths. Prevention activities should not focus only on unnatural causes of death.

     

Rural-urban differentials in pregnancy-related mortality in Zambia: estimates using data collected in a census

Background

The use of census data to measure maternal mortality is a recent phenomenon, implemented in settings with non-functional vital registration systems and driven by needs for trend data. The 2010 round of population and housing censuses recorded a significant increase in the number of countries collecting maternal mortality data. The objective of this study was to estimate rural-urban differentials in pregnancy-related mortality in Zambia using census data.

Methods

We used data from the Zambia 2000 and 2010 censuses. Both censuses recorded the female population by age, the number of children ever born, and live births 12 months prior to the census. The 2010 census further recorded, by age, household, and pregnancy-related deaths 12 months prior to the census. We evaluated and adjusted recorded live births using the cohort Parity Fertility ratio method, and household deaths using deaths distribution methods (General Growth Balance and Synthetic Extinct Generation). Adult female mortality and pregnancy-related mortality for rural and urban areas were estimated for the period October 2009 to October 2010.

Results

Data evaluation showed errors in recorded population age, age-at-death, live births, and deaths, and appropriate adjustments were made. Adjusted adult female mortality was high; an adolescent aged 15 years had a one-in-three chance of dying before her 50th birthday in rural areas and one-in-four chance in urban areas. Pregnancy-related deaths comprised 15.3 % of all deaths among reproductive-age women overall; 17.9 % in rural areas and 9.8 % in urban areas. The pregnancy-related mortality ratio for the period was 789 deaths/100,000 live births overall: 960/100,000 live births in rural areas and 470/100,000 live births in urban areas.

Conclusions

Census-based estimates show very high adult female mortality and particularly high pregnancy-related mortality in both rural and urban areas of Zambia 12 months prior to the 2010 census. Future censuses should pay greater attention to strategies for improving data quality.

     

A composite metric for assessing data on mortality and causes of death: the vital statistics performance index

Background

Timely and reliable data on causes of death are fundamental for informed decision-making in the health sector as well as public health research. An in-depth understanding of the quality of data from vital statistics (VS) is therefore indispensable for health policymakers and researchers. We propose a summary index to objectively measure the performance of VS systems in generating reliable mortality data and apply it to the comprehensive cause of death database assembled for the Global Burden of Disease (GBD) 2013 Study.

Methods

We created a Vital Statistics Performance Index, a composite of six dimensions of VS strength, each assessed by a separate empirical indicator. The six dimensions include: quality of cause of death reporting, quality of age and sex reporting, internal consistency, completeness of death reporting, level of cause-specific detail, and data availability/timeliness. A simulation procedure was developed to combine indicators into a single index. This index was computed for all country-years of VS in the GBD 2013 cause of death database, yielding annual estimates of overall VS system performance for 148 countries or territories.

Results

The six dimensions impacted the accuracy of data to varying extents. VS performance declines more steeply with declining simulated completeness than for any other indicator. The amount of detail in the cause list reported has a concave relationship with overall data accuracy, but is an important driver of observed VS performance. Indicators of cause of death data quality and age/sex reporting have more linear relationships with simulated VS performance, but poor cause of death reporting influences observed VS performance more strongly. VS performance is steadily improving at an average rate of 2.10% per year among the 148 countries that have available data, but only 19.0% of global deaths post-2000 occurred in countries with well-performing VS systems.

Conclusions

Objective and comparable information about the performance of VS systems and the utility of the data that they report will help to focus efforts to strengthen VS systems. Countries and the global health community alike need better intelligence about the accuracy of VS that are widely and often uncritically used in population health research and monitoring.

     

Mini nutritional assessment and mortality after hip fracture surgery in the elderly

Background

Hip fracture surgery in elderly patients is associated with a poor postoperative outcome and a high mortality. Malnutrition is a frequent problem in elderly patients and may be associated with mortality after hip fracture surgery. The Mini Nutritional Assessment (MNA) is a valuable tool to identify malnourished patients and those at risk for malnutrition.

Objective

To evaluate the association between the preoperative MNA score and mortality after surgery for hip fractures in elderly patients.

Methods

Patients with a hip fracture and an indication for surgery were included in our study. This study was part of a randomized trial on the effect of taurine on postoperative outcome in elderly hip fracture patients. The MNA was assessed on admission before surgery. Length of stay, postoperative complications and mortality were documented. The association of the MNA score on postoperative outcome and mortality was analyzed using Cox regression analysis.

Results

The one-year survival rate in 226 elderly hip fracture patients was 79%. In-hospital mortality rates and 1-year mortality were 27% and 46% in malnourished patients, 12% and 26% in patients at risk for malnutrition and 7% and 17% in well-nourished patients as assessed by MNA.

Conclusion

Preoperative malnutrition measured by the MNA is associated with mortality in elderly hip fracture patients.

     

Association between dietary zinc intake and mortality among Chinese adults: findings from 10-year follow-up in the Jiangsu Nutrition Study

Purpose

Population studies of the association between zinc intake and mortality yield inconsistent findings. Using data from Jiangsu Nutrition Study, we aimed to assess the association between zinc intake and mortality among Chinese adults.

Methods

We prospectively studied 2832 adults aged 20 years and older with a mean follow-up of 9.8 years. At baseline, food intake was measured by 3-day weighed food record (WFR) between September and December in 2002. Death occurrence was assessed in 2012 during a household visit as well as by data linkage with the regional death registry. Hazard ratios (HRs) and 95% CI were calculated using competing risks regression (CVD and cancer mortality) and Cox proportional hazards analysis (all-cause mortality).

Results

During 27,742 person-years of follow-up, there were 184 deaths [63 cancer deaths and 70 cardiovascular disease (CVD) deaths]. Dietary zinc to energy ratio was positively associated with cancer and all-cause mortality. Across quartiles of the zinc to energy ratio from low to high, the HR (95% CI) for all-cause mortality was 1.00, 1.80 (95% CI 1.10–2.95), 1.55 (95% CI 0.96–2.50), and 1.85 (95% CI 1.11–3.07), respectively. Comparing the extreme quartiles of the zinc to energy ratio, the HR for cancer mortality was 2.28 (95% CI 1.03–5.04).

Conclusion

Zinc intake was positively related to all-cause mortality and cancer mortality.

     

Verbal autopsy of 80,000 adult deaths in Tamilnadu,South India

Background

Registration of the fact of death is almost complete in the city of Chennai and not so in the rural Villupuram district in Tamilnadu, India. The cause of death is often inadequately recorded on the death certificate in developing countries like India. A special verbal autopsy (VA) study of 48 000 adult (aged ≥ 25 yrs) deaths in the city of Chennai (urban) during 1995–97 and 32 000 in rural Villupuram during 1997–98 was conducted to arrive at the probable underlying cause of death to estimate cause specific mortality.

Methods

A ten day training on writing verbal autopsy (VA) report for adult deaths was given to non-medical graduates with at least 15 years of formal education. They interviewed surviving spouse/close associates of the deceased to write a verbal autopsy report in local language (Tamil) on the complaints, symptoms, signs, duration and treatment details of illness prior to death. Each report was reviewed centrally by two physicians independently. Random re-interviewing of 5% of the VA reports was done to check the reliability and reproducibility of the VA report. The validity of VA diagnosis was assessed only for cancer deaths.

Results

Verbal autopsy reduced the proportion of deaths attributed to unspecified and unknown causes from 54% to 23% (p < 0.0001) in urban and from 41% to 26% (p < 0.0001) in rural areas in Tamilnadu for adult deaths (≥ 25). The sensitivity of VA to identify cancer was 95% in the age group 25–69.

Conclusion

A ten day training programme to write verbal autopsy report with adequate feed back sessions and random sampling of 5% of the verbal autopsy reports for re-interview worked very well in Tamilnadu, to arrive at the probable underlying cause of death reliably for deaths in early adult life or middle age (25–69 years) and less reliably for older ages (70+). Thus VA is practicable for deaths in early adult life or middle age and is of more limited value in old age.

     

National mortality burden due to communicable,non-communicable,and other diseases in Ethiopia, 1990–2015: findings from the Global Burden of Disease Study 2015

Background

Ethiopia lacks a complete vital registration system that would assist in measuring disease burden and risk factors. We used the Global Burden of Diseases, Injuries, and Risk Factors Study 2015 (GBD 2015) estimates to describe the mortality burden from communicable, non-communicable, and other diseases in Ethiopia over the last 25 years.

Methods

GBD 2015 mainly used cause of death ensemble modeling to measure causes of death by age, sex, and year for 195 countries. We report numbers of deaths and rates of years of life lost (YLL) for communicable, maternal, neonatal, and nutritional (CMNN) disorders, non-communicable diseases (NCDs), and injuries with 95% uncertainty intervals (UI) for Ethiopia from 1990 to 2015.

Results

CMNN causes of death have declined by 65% in the last two-and-a-half decades. Injury-related causes of death have also decreased by 70%. Deaths due to NCDs declined by 37% during the same period. Ethiopia showed a faster decline in the burden of four out of the five leading causes of age-standardized premature mortality rates when compared to the overall sub-Saharan African region and the Eastern sub-Saharan African region: lower respiratory infections, tuberculosis, HIV/AIDS, and diarrheal diseases; however, the same could not be said for ischemic heart disease and other NCDs. Non-communicable diseases, together, were the leading causes of age-standardized mortality rates, whereas CMNN diseases were leading causes of premature mortality in 2015. Although lower respiratory infections, tuberculosis, and diarrheal disease were the leading causes of age-standardized death rates, they showed major declines from 1990 to 2015. Neonatal encephalopathy, iron-deficiency anemia, protein-energy malnutrition, and preterm birth complications also showed more than a 50% reduction in burden. HIV/AIDS-related deaths have also decreased by 70% since 2005. Ischemic heart disease, hemorrhagic stroke, and ischemic stroke were among the top causes of premature mortality and age-standardized death rates in Ethiopia in 2015.

Conclusions

Ethiopia has been successful in reducing deaths related to communicable, maternal, neonatal, and nutritional deficiency diseases and injuries by 65%, despite unacceptably high maternal and neonatal mortality rates. However, the country’s performance regarding non-communicable diseases, including cardiovascular disease, diabetes, cancer, and chronic respiratory disease, was minimal, causing these diseases to join the leading causes of premature mortality and death rates in 2015. While the country is progressing toward universal health coverage, prevention and control strategies in Ethiopia should consider the double burden of common infectious diseases and non-communicable diseases: lower respiratory infections, diarrhea, tuberculosis, HIV/AIDS, cardiovascular disease, cancer, and diabetes. Prevention and control strategies should also pay special attention to the leading causes of premature mortality and death rates caused by non-communicable diseases: cardiovascular disease, cancer, and diabetes. Measuring further progress requires a data revolution in generating, managing, analyzing, and using data for decision-making and the creation of a full vital registration system in the country.