Cost savings associated with 10 years of road safety policies in Catalonia,Spain

Objective

To determine whether the road safety policies introduced between 2000 and 2010 in Catalonia, Spain, which aimed primarily to reduce deaths from road traffic collisions by 50% by 2010, were associated with economic benefits to society.

Methods

A cost analysis was performed from a societal perspective with a 10-year time horizon. It considered the costs of: hospital admissions; ambulance transport; autopsies; specialized health care; police, firefighter and roadside assistance; adapting to disability; and productivity lost due to institutionalization, death or sick leave of the injured or their caregivers; as well as material and administrative costs. Data were obtained from a Catalan hospital registry, the Catalan Traffic Service information system, insurance companies and other sources. All costs were calculated in euros (€) at 2011 values.

Findings

A substantial reduction in deaths from road traffic collisions was observed between 2000 and 2010. Between 2001 and 2010, with the implementation of new road safety policies, there were 26 063 fewer road traffic collisions with victims than expected, 2909 fewer deaths (57%) and 25 444 fewer hospitalizations. The estimated total cost savings were around €18 000 million. Of these, around 97% resulted from reductions in lost productivity. Of the remaining cost savings, 63% were associated with specialized health care, 15% with adapting to disability and 8.1% with hospital care.

Conclusion

The road safety policies implemented in Catalonia in recent years were associated with a reduction in the number of deaths and injuries from traffic collisions and with substantial economic benefits to society.     

Does Temperature Modify the Effects of Rain and Snow Precipitation on Road Traffic Injuries?

Background

There are few data on the interaction between temperature and snow and rain precipitation, although they could interact in their effects on road traffic injuries.

Methods

The integrated database of the Korea Road Traffic Authority was used to calculate the daily frequency of road traffic injuries in Seoul. Weather data included rain and snow precipitation, temperature, pressure, and fog from May 2007 to December 2011. Precipitation of rain and snow were divided into nine and six temperature range categories, respectively. The interactive effects of temperature and rain and snow precipitation on road traffic injuries were analyzed using a generalized additive model with a Poisson distribution.

Results

The risk of road traffic injuries during snow increased when the temperature was below freezing. Road traffic injuries increased by 6.6% when it was snowing and above 0°C, whereas they increased by 15% when it was snowing and at or below 0°C. In terms of heavy rain precipitation, moderate temperatures were related to an increased prevalence of injuries. When the temperature was 0–20°C, we found a 12% increase in road traffic injuries, whereas it increased by 8.5% and 6.8% when it was <0°C and >20°C, respectively. The interactive effect was consistent across the traffic accident subtypes.

Conclusions

The effect of adverse weather conditions on road traffic injuries differed depending on the temperature. More road traffic injuries were related to rain precipitation when the temperature was moderate and to snow when it was below freezing.Key words: injuries, precipitation, snow, traffic accidents, weather     

Local-level mortality surveillance in resource-limited settings: a case study of Cape Town highlights disparities in health

Objective

To identify the leading causes of mortality and premature mortality in Cape Town, South Africa, and its subdistricts, and to compare levels of mortality between subdistricts.

Methods

Cape Town mortality data for the period 2001–2006 were analysed by age, cause of death and sex. Cause-of-death codes were aggregated into three main cause groups: (i) pre-transitional causes (e.g. communicable diseases, maternal causes, perinatal conditions and nutritional deficiencies), (ii) noncommunicable diseases and (iii) injuries. Premature mortality was calculated in years of life lost (YLLs). Population estimates for the Cape Town Metro district were used to calculate age-specific rates per 100 000 population, which were then age-standardized and compared across subdistricts.

Findings

The pattern of mortality in Cape Town reflects the quadruple burden of disease observed in the national cause-of-death profile, with HIV/AIDS, other infectious diseases, injuries and noncommunicable diseases all accounting for a significant proportion of deaths. HIV/AIDS has replaced homicide as the leading cause of death. HIV/AIDS, homicide, tuberculosis and road traffic injuries accounted for 44% of all premature mortality. Khayelitsha, the poorest subdistrict, had the highest levels of mortality for all main cause groups.

Conclusion

Local mortality surveillance highlights the differential needs of the population of Cape Town and provides a wealth of data to inform planning and implementation of targeted interventions. Multisectoral interventions will be required to reduce the burden of disease.     

Road traffic crashes,injury and fatality trends in Sri Lanka: 1938–2013

Objective

To analyse trends in road traffic crashes, injuries and fatalities over 75 years in Sri Lanka.

Methods

Data on road traffic crashes, injuries and fatalities between 1938 and 2013 were obtained from the Police Statistics Unit. Rates per 100 000 population were calculated and trends were analysed using joinpoint regression analysis.

Findings

Road traffic crashes and injuries rose substantially between 1938 and 2013: annual crashes increased from 61.2 to 183.6 per 100 000 people; injuries, from 35.1 to 98.6 per 100 000; and fatalities, from 3.0 to 10.8 per 100 000 people per year. Joinpoint analysis showed large fluctuations in crashes and injuries over time but the fatalities rose almost continuously. These fluctuations paralleled the country’s political and economic development. In some years, better traffic law enforcement and improved public transportation may have been associated with reduced crashes and injuries, whereas rapid growth in vehicle numbers, especially two- and three-wheeled vehicles, may have contributed to increased crashes and injuries. In addition, insurance policies that did not require a police report to claim may have led to underreporting of crashes and allowed drivers to avoid prosecution.

Conclusion

Fluctuations over time in road traffic crashes and injuries in Sri Lanka are associated with changes in political, economic and traffic policy. There is potential for reducing road traffic crashes and injuries through better traffic law enforcement, restrictions on the importation of two- and three-wheeled vehicles and policies to improve road safety and prevent underreporting of crashes.     

Comparing road traffic mortality rates from police-reported data and death registration data in China

Objective

To compare death rates from road traffic injuries in China in 2002–2007 when derived from police-reported data versus death registration data.

Methods

In China, police-recorded data are obtained from police records by means of a standardized, closed-ended data collection form; these data are published in the China statistical yearbook of communication and transportation. Official death registration data, on the other hand, are obtained from death certificates completed by physicians and are published in the China health statistics yearbook. We searched both sources for data on road traffic deaths in 2002–2007, used the χ² test to compare the mortality rates obtained, and performed linear regression to look for statistically significant trends in road traffic mortality over the period.

Findings

For 2002–2007, the rate of death from road traffic injuries based on death registration data was about twice as high as the rate reported by the police. Linear regression showed a significant decrease of 27% (95% confidence interval, CI: 35–19) in the death rate over the period according to police sources but no significant change according to death registration data.

Conclusion

The widely-cited recent drop in road traffic mortality in China, based on police-reported data, may not reflect a genuine decrease. The quality of the data obtained from police reports, which drives decision-making by the Government of China and international organizations, needs to be investigated, monitored and improved.     

Road traffic and childhood leukemia: the ESCALE study (SFCE)

Background

Traffic is a source of environmental exposures, including benzene, which may be related to childhood leukemia.

Objectives

A national registry–based case–control study [ESCALE (Etude Sur les Cancers et les Leucémies de l’Enfant, Study on Environmental and Genetic Risk Factors of Childhood Cancers and Leukemia)] carried out in France was used to assess the effect of exposure to road traffic exhaust fumes on the risk of childhood leukemia.

Methods

Over the study period, 2003–2004, 763 cases and 1,681 controls < 15 years old were included, and the controls were frequency matched with the cases on age and sex. The ESCALE data were collected by a standardized telephone interview of the mothers. Various indicators of exposure to traffic and pollution were determined using the geocoded addresses at the time of diagnosis for the cases and of interview for the controls. Indicators of the distance from, and density of, main roads and traffic nitrogen dioxide (NO₂) concentrations derived from traffic emission data were used. Odds ratios (ORs) were estimated using unconditional regression models adjusted for potential confounders.

Results

Acute leukemia (AL) was significantly associated with estimates of traffic NO₂ concentration at the place of residence > 27.7 μg/m³ compared with NO₂ concentration < 21.9 μg/m³ [OR = 1.2; confidence interval (CI), 1.0–1.5] and with the presence of a heavy-traffic road within 500 m compared with the absence of a heavy-traffic road in the same area (OR = 2.0; 95% CI, 1.0–3.6). There was a significant association between AL and a high density of heavy-traffic roads within 500 m compared with the reference category with no heavy-traffic road within 500 m (OR = 2.2; 95% CI, 1.1–4.2), with a significant positive linear trend of the association of AL with the total length of heavy-traffic road within 500m.

Conclusion

This study supports the hypothesis that living close to heavy-traffic roads may increase the risk of childhood leukemia.     

The formulation and implementation of a national helmet law: a case study from Viet Nam

Problem

Road traffic injuries are a leading cause of death and disability in Viet Nam. In 2008, official data reported 11 243 deaths and 7771 serious injuries on the roads, of which an estimated 60% of fatalities occur in motorcycle riders and passengers. In recognition of this problem, Viet Nam has had partial motorcycle helmet legislation since 1995. However, for a variety of reasons, implementation and enforcement have been limited.

Approach

On 15 December 2007, Viet Nam''s first comprehensive mandatory helmet law came into effect, covering all riders and passengers on all roads nationwide. Penalties increased ten-fold and cohorts of police were mobilized for enforcement.

Local setting

The Viet Nam national helmet legislation was developed and implemented by the National Traffic Safety Committee.

Relevant changes

Despite past barriers to enforcement, increased policing in 2008 led to 680 000 infringements being issued for non-helmet wearing. While changes in helmet wearing were not nationally observed, significant increases were documented in selected provinces in the first six months of the law’s introduction. In Da Nang, helmet wearing increased from 27 to 99%. In the first three months after the law took effect, surveillance data from 20 urban and rural hospitals, found the risk of road traffic head injuries and deaths decreased by 16% and 18% respectively.

Lessons learnt

Political leadership, intensive advanced public education and stringent enforcement have contributed to the successful implementation of the new law. Through continual monitoring of the legislation, loopholes detrimental to the effectiveness of the law have been identified and addressed.     

Effect on road traffic injuries of criminalizing road traffic offences: a time-series study

Objective

To determine the effect of criminalizing some traffic behaviours, after the reform of the Spanish penal code in 2007, on the number of drivers involved in injury collisions and of people injured in traffic collisions in Spain.

Methods

This study followed an interrupted times–series design in which the number of drivers involved in injury collisions and of people injured in traffic collisions in Spain before and after the criminalization of offences were compared. The data on road traffic injuries in 2000–2009 were obtained from the road traffic collision database of the General Traffic Directorate. The dependent variables were stratified by sex, age, injury severity, type of road user, road type and time of collision. Quasi-Poisson regression models were fitted with adjustments for time trend, seasonality, previous interventions and national fuel consumption.

Findings

The overall number of male drivers involved in injury collisions dropped (relative risk, RR: 0.93; 95% confidence interval, CI: 0.89–0.97) after the reform of the penal code, but among women no change was observed (RR: 0.99; 95% CI: 0.95–1.03). In addition, 13 891 men (P < 0.01) were prevented from being injured. Larger reductions were observed among young male drivers and among male motorcycle or moped riders than among the drivers of other vehicles.

Conclusion

The findings suggest that criminalizing certain traffic behaviours can improve road safety by reducing both the number of drivers involved in injury collisions and the number of people injured in such collisions.     

Legislation coverage for child injury prevention in China

Objective

To examine the extent to which effective interventions to prevent unintentional child injury are reflected in the laws and regulations of China.

Methods

We focused on the six common causes of fatal child injuries – drowning, road traffic injury, falls, poisoning, burns and suffocation. We investigated 27 interventions recommended by the United Nations Children’s Fund, the World Health Organization or the European Child Safety Alliance. We searched China National Knowledge Infrastructure and Lawyee for Chinese legislations using keywords and synonyms for the 27 interventions. We reviewed the identified legislations for statements specifying the responsible implementation department.

Findings

Seven national laws, nine regulations of the State Council and 46 departmental regulations were found to relate to at least one of the interventions. Although seven of the 27 internationally recommended interventions were covered by Chinese laws, 10 were not covered by any current Chinese law or regulation. None of the interventions against drowning and falls that we investigated was covered by national laws. The implementation responsibilities for effective interventions were either not specified or were assigned to multiple governmental departments in 11 or 20 legislative documents, respectively.

Conclusion

In Chinese laws and regulations, interventions proven to prevent major causes of unintentional child injuries are underrepresented and the associated implementation responsibilities are often poorly defined. China should include all such interventions in laws and regulations, and assign implementation responsibility for each to a single department of the national government.     

Road injuries and relaxed licensing requirements for driving light motorcycles in Spain: a time-series analysis

Objective

To assess differences between the risk of injury for motorcycle riders before and after the passing of a law allowing licenced car drivers to drive light motorcycles without having to take a special motorcycle driving test.

Methods

We carried out a quasi-experimental study involving comparison groups, and a time-series analysis from 1 January 2002 to 30 April 2008. The study group was composed of people injured while driving or riding a light motorcycle (engine capacity 51–125 cubic centimetres), while the comparison groups consisted of riders of heavy motorcycles (engine capacity > 125 cc), mopeds (engine capacity ≤ 50 cc) or cars who were injured in a collision within the city limits. The “intervention” was a law passed in October 2004 allowing car drivers to drive light motorcycles without taking a special driving test. To detect and quantify changes over time we used Poisson regression, with adjustments for trend and seasonality in road injuries and the existence of a driver’s licence penalty point system.

Findings

The risk of injury among light motorcycle riders was greater after the law than before (relative risk, RR = 1.46; 95% confidence interval, CI: 1.34–1.60). Although less markedly, after the law the risk of injury also increased among heavy motorcycle drivers (RR = 1.15; 95% CI: 1.02–1.29) but remained unchanged among riders of mopeds (RR = 0.92; 95% CI: 0.83–1.01) and cars (RR = 1.06; 95% CI: 0.97–1.16).

Conclusion

Allowing car drivers to drive motorcycles without passing a special test increases the number of road injuries from motorcycle accidents.     

Long-term exposure to traffic-related air pollution and the risk of coronary heart disease hospitalization and mortality

Background

Epidemiologic studies have demonstrated that exposure to road traffic is associated with adverse cardiovascular outcomes.

Objectives

We aimed to identify specific traffic-related air pollutants that are associated with the risk of coronary heart disease (CHD) morbidity and mortality to support evidence-based environmental policy making.

Methods

This population-based cohort study included a 5-year exposure period and a 4-year follow-up period. All residents 45–85 years of age who resided in Metropolitan Vancouver during the exposure period and without known CHD at baseline were included in this study (n = 452,735). Individual exposures to traffic-related air pollutants including black carbon, fine particles [aerodynamic diameter ≤ 2.5 μm (PM_2.5)], nitrogen dioxide (NO₂), and nitric oxide were estimated at residences of the subjects using land-use regression models and integrating changes in residences during the exposure period. CHD hospitalizations and deaths during the follow-up period were identified from provincial hospitalization and death registration records.

Results

An interquartile range elevation in the average concentration of black carbon (0.94 × 10⁻⁵/m filter absorbance, equivalent to approximately 0.8 μg/m³ elemental carbon) was associated with a 3% increase in CHD hospitalization (95% confidence interval, 1–5%) and a 6% increase in CHD mortality (3–9%) after adjusting for age, sex, preexisting comorbidity, neighborhood socioeconomic status, and copollutants (PM_2.5 and NO₂). There were clear linear exposure–response relationships between black carbon and coronary events.

Conclusions

Long-term exposure to traffic-related fine particulate air pollution, indicated by black carbon, may partly explain the observed associations between exposure to road traffic and adverse cardiovascular outcomes.     

Estimated global incidence of Japanese encephalitis: a systematic review

Objective

To update the estimated global incidence of Japanese encephalitis (JE) using recent data for the purpose of guiding prevention and control efforts.

Methods

Thirty-two areas endemic for JE in 24 Asian and Western Pacific countries were sorted into 10 incidence groups on the basis of published data and expert opinion. Population-based surveillance studies using laboratory-confirmed cases were sought for each incidence group by a computerized search of the scientific literature. When no eligible studies existed for a particular incidence group, incidence data were extrapolated from related groups.

Findings

A total of 12 eligible studies representing 7 of 10 incidence groups in 24 JE-endemic countries were identified. Approximately 67 900 JE cases typically occur annually (overall incidence: 1.8 per 100 000), of which only about 10% are reported to the World Health Organization. Approximately 33 900 (50%) of these cases occur in China (excluding Taiwan) and approximately 51 000 (75%) occur in children aged 0–14 years (incidence: 5.4 per 100 000). Approximately 55 000 (81%) cases occur in areas with well established or developing JE vaccination programmes, while approximately 12 900 (19%) occur in areas with minimal or no JE vaccination programmes.

Conclusion

Recent data allowed us to refine the estimate of the global incidence of JE, which remains substantial despite improvements in vaccination coverage. More and better incidence studies in selected countries, particularly China and India, are needed to further refine these estimates.     

Viet Nam��s mandatory motorcycle helmet law and its impact on children

Objective

To measure the use of motorcycle helmets in children and to determine the reasons why children wear helmets less often than adults.

Methods

The frequency of helmet wearing among adults and children was ascertained by trained roadside observers, and randomized road user surveys were completed in four major centres in Viet Nam: Hanoi, Ho Chi Minh City, Can Tho and Da Nang. Survey data on key questions were cross tabulated, and χ² was calculated for significant differences between parents and non-parents (0.05).

Findings

The frequency of helmet use in the four study locations ranged from 90–99% among adults, from 15–53% among children ≤ 7 years of age, and from 38–53% among children > 7 but ≤ 14. Of the parents surveyed, 67% said the fear of neck injury was the most important reason their children did not wear a helmet.

Conclusion

Children wear motorcycle helmets much less often than adults. Legislation to penalize adults whose children do not wear motorcycle helmets has been proposed in Viet Nam. Furthermore, ongoing advocacy and social marketing efforts are being made to disseminate information about the safety benefits of helmets to combat erroneous public perceptions.     

Factors associated with the safety of voluntary medical male circumcision in Nyanza province, Kenya

Objective

To determine factors associated with the incidence of adverse events associated with voluntary medical male circumcision (VMMC) for the prevention of HIV infection in Nyanza province, Kenya.

Methods

Males aged 12 years or older who underwent VMMC between November 2008 and March 2010 in 16 clinics in three districts were followed through passive surveillance to monitor the incidence of adverse events during and after surgery. A subset of clinic participants was randomly selected for active surveillance post-operatively and was monitored for adverse events through a home-based, in-depth interview and a genital exam 28 to 45 days after surgery. Performance indicators were assessed for 167 VMMC providers.

Findings

The adverse event rate was 0.1% intra-operatively and 2.1% post-operatively among clinic system participants (n = 3705), and 7.5% post-operatively among participants under active surveillance (n = 1449). Agreement between systems was moderate (κ: 0.20; 95% confidence interval, CI: 0.09–0.32). Providers who performed more than 100 procedures achieved an adverse event rate of 0.7% and 4.3% in the clinic and active surveillance systems, respectively, and had decreased odds of performing a procedure resulting in an adverse event. With provider experience, the mean duration of the procedure also dropped from 24.0 to 15.5 minutes. Among providers who had performed at least 100 procedures, nurses and clinicians provided equivalent services.

Conclusion

To reduce the adverse event rate, one must ensure that providers achieve a desired level of experience before they perform unsupervised procedures. Adverse events observed by the provider as well as those perceived by the client should both be monitored.     

Influenza-associated mortality in temperate and subtropical Chinese cities, 2003-2008

Objective

To estimate influenza-associated mortality in urban China.

Methods

Influenza-associated excess mortality for the period 2003–2008 was estimated in three cities in temperate northern China and five cities in the subtropical south of the country. The estimates were derived from models based on negative binomial regressions, vital statistics and the results of weekly influenza virus surveillance.

Findings

Annual influenza-associated excess mortality, for all causes, was 18.0 (range: 10.9–32.7) deaths per 100 000 population in the northern cities and 11.3 (range: 7.3–17.8) deaths per 100 000 in the southern cities. Excess mortality for respiratory and circulatory disease was 12.4 (range: 7.4–22.2) and 8.8 (range: 5.5–13.6) deaths per 100 000 people in the northern and southern cities, respectively. Most (86%) deaths occurred among people aged ≥ 65 years. Influenza-associated excess mortality was higher in B-virus-dominant seasons than in seasons when A(H3N2) or A(H1N1) predominated, and more than half of all influenza-associated mortality was associated with influenza B virus.

Conclusion

Between 2003 and 2008, seasonal influenza, particularly that caused by the influenza B virus, was associated with substantial mortality in three cities in the temperate north of China and five cities in the subtropical south of the country.     

Eliminating the category II retreatment regimen from national tuberculosis programme guidelines: the Georgian experience

Problem

The category II retreatment regimen for management of tuberculosis in previously treated patients was first introduced in the early 1990s. It consists of 8 months of total therapy with the addition of streptomycin to standard first-line medications. A review of 6500 patients on category II therapy in Georgia showed poor outcomes and high rates of streptomycin resistance.

Approach

The National Tuberculosis Program used an evidence-based analysis of national data to convince policy-makers that category II therapy should be eliminated from national guidelines in Georgia.

Local setting

The World Health Organization tuberculosis case-notification rate in Georgia is 102 per 100 000 population. All patients receive culture and drug susceptibility testing as a standard part of tuberculosis diagnosis. In 2009, routine surveillance found multidrug-resistant tuberculosis in 10.6% of newly diagnosed patients and 32.5% of previously treated cases.

Relevant changes

Category II retreatment regimen is no longer used in Georgia. Treatment is guided by results of drug susceptibility testing – using rapid, molecular tests where possible – for all previously treated tuberculosis patients.

Lessons learnt

There was little resistance to policy change because the review was initiated and led by the National Tuberculosis Program. This experience can serve as a successful model for other countries to make informed decisions about the use of category II therapy.     

Trends in traffic collisions and injuries in Kyrgyzstan, 2003-2007

Objective

To assess the epidemiological data on motor vehicle collisions, injuries and deaths in Kyrgyzstan to inform evidence-based policy development.

Methods

Data on motor vehicle collision and injury statistics covering 2003–2007 were obtained from official sources provided by the Department of Traffic Safety and the Ministry of Health’s Republican Medical Information Centre. The data were analysed and compared with data derived from studies in other low- and middle-income countries.

Findings

Large heterogeneity between data sources was noted. Motor vehicle collisions caused by drivers increased twofold between 2003 and 2007. Reported motor vehicle collisions, deaths and injuries increased by 34%, 33% and 47%, respectively, over that period. Such increases were proportionately greater than the growth in population or in the number of registered motor vehicles. The proportion of injury attributable to motor vehicle collisions increased by 14% and the collision-related mortality rate increased by 39% in 2003–2007.

Conclusion

In Kyrgyzstan, the number of motor vehicle collisions is rising and so is the number of those who are injured or killed in them. Reversing this trend will call for closer collaboration among relevant agencies and for a comprehensive surveillance system, along with operational improvements in emergency medical care, new and strictly enforced passenger safety laws and improvements to the transportation infrastructure.     

National dengue surveillance in Cambodia 1980�C2008: epidemiological and virological trends and the impact of vector control

Objective

Dengue has been reportable in Cambodia since 1980. Virological surveillance began in 2000 and sentinel surveillance was established at six hospitals in 2001. Currently, national surveillance comprises passive and active data collection and reporting on hospitalized children aged 0–15 years. This report summarizes surveillance data collected since 1980.

Methods

Crude data for 1980–2001 are presented, while data from 2002–2008 are used to describe disease trends and the effect of vector control interventions. Trends in dengue incidence were analysed using the Prais–Winsten generalized linear regression model for time series.

Findings

During 1980–2001, epidemics occurred in cycles of 3–4 years, with the cycles subsequently becoming less prominent. For 2002–2008 data, linear regression analysis detected no significant trend in the annual reported age-adjusted incidence of dengue (incidence range: 0.7–3.0 per 1000 population). The incidence declined in 2.7% of the 185 districts studied, was unchanged in 86.2% and increased in 9.6%. The age-specific incidence was highest in infants aged < 1 year and children aged 4–6 years. The incidence was higher during rainy seasons. All four dengue virus (DENV) serotypes were permanently in circulation, though the predominant serotype has alternated between DENV-3 and DENV-2 since 2000. Although larvicide has been distributed in 94 districts since 2002, logistic regression analysis showed no association between the intervention and dengue incidence.

Conclusion

The dengue burden remained high among young children in Cambodia, which reflects intense transmission. The national vector control programme appeared to have little impact on disease incidence.     

Methodological trends in studies based on verbal autopsies before and after published guidelines

Objective

To report on the uptake of guidelines published in the early 1990s with specific recommendations about the design of future studies based on verbal autopsy conducted for mortality surveillance.

Methods

We conducted a systematic literature search of all verbal autopsy studies published before January 2006 and extracted from the studies a standard set of data. We then compared studies designed before and after the recommendations were issued in terms of seven key methodological indicators.

Findings

We found 102 studies conducted in 39 countries; 60 were designed before and 42 after the guidelines were issued. The methods used in these 102 studies varied considerably. While some encouraging trends were noted, there is no evidence that the design recommendations have been systematically implemented. Specifically, there was no clear increase in the proportion of studies with a combined questionnaire (63% before recommendations versus 74% after; P = 0.3), a trained interviewer (70% versus 70%; P = 1.0), a suitable respondent (98% versus 100%; P = 1.0), an optimal recall period (84% versus 97%; P = 0.2), predefined algorithms (28% versus 38%; P = 0.4), an option for assigning multiple causes of death (30% versus 38%; P = 0.3), or a follow-up validation study (83% versus 72%; P = 0.7).

Conclusion

Expert recommendations for optimal design of verbal autopsy studies have been incompletely implemented to date. Better uptake of design recommendations through enhanced collaboration between research teams is likely to produce better mortality statistics from an increasing number of verbal autopsy studies.