Health policy for sickle cell disease in Africa: experience from Tanzania on interventions to reduce under‐five mortality

Tanzania has made considerable progress towards reducing childhood mortality, achieving a 57% decrease between 1980 and 2011. This epidemiological transition will cause a reduction in the contribution of infectious diseases to childhood mortality and increase in contribution from non‐communicable diseases (NCDs). Haemoglobinopathies are amongst the most common childhood NCDs, with sickle cell disease (SCD) being the commonest haemoglobinopathy in Africa. In Tanzania, 10 313 children with SCD under 5 years of age (U5) are estimated to die every year, contributing an estimated 7% of overall deaths in U5 children. Key policies that governments in Africa are able to implement would reduce mortality in SCD, focusing on newborn screening and comprehensive SCD care programmes. Such programmes would ensure that interventions such as prevention of infections using penicillin plus prompt diagnosis and treatment of complications are provided to all individuals with SCD.     

Rates and causes of death in Chiradzulu District, Malawi, 2008: a key informant study

In September 2008, we measured all-cause mortality in Chiradzulu District, Malawi (population 291, 000) over a 60-day retrospective period, using capture-recapture analysis of three lists of deaths provided by (i) key community informants, (ii) graveyard officials and (iii) health system sources. Estimated crude and under-5-year mortality rates were 18.6 (95% CI 13.9-24.5) and 30.6 (95% CI 17.5-59.9) deaths per 1000 person-years. We also classified causes of death through verbal autopsy interviews on 50 deaths over the previous 40 days. Half of deaths were attributable to infection, and half of deaths among children aged under 5 were attributable to neonatal causes. HIV/AIDS was the leading cause of death (16.6%), with a cause-attributable mortality rate of 1.8 (0.4-3.6) deaths per 1000 person-years.     

Research needs for an improved primary care response to chronic non‐communicable diseases in Africa

With non‐communicable diseases (NCDs) projected to become leading causes of morbidity and mortality in developing countries, research is needed to improve the primary care response, especially in sub‐Saharan Africa. This region has a particularly high double burden of communicable diseases and NCDs and the least resources for an effective response. There is a lack of good quality epidemiological data from diverse settings on chronic NCD burden in sub‐Saharan Africa, and the approach to primary care of people with chronic NCDs is currently often unstructured. The main primary care research needs are therefore firstly, epidemiological research to document the burden of chronic NCDs, and secondly, health system research to deliver the structured, programmatic, public health approach that has been proposed for the primary care of people with chronic NCDs. Documentation of the burden and trends of chronic NCDs and associated risk factors in different settings and different population groups is needed to enable health system planning for an improved primary care response. Key research issues in implementing the programmatic framework for an improved primary care response are how to (i) integrate screening and prevention within health delivery; (ii) validate the use of standard diagnostic protocols for NCD case‐finding among patients presenting to the local health facilities; (iii) improve the procurement and provision of standardised treatment and (iv) develop and implement a data collection system for standardised monitoring and evaluation of patient outcomes. Important research considerations include the following: selection of research sites and the particular NCDs targeted; research methodology; local research capacity; research collaborations; ethical issues; translating research findings into policy and practice and funding. Meeting the research needs for an improved health system response is crucial to deliver effective, affordable and equitable care for the millions of people with chronic NCDs in developing countries in Africa.     

Adult mortality and probable cause of death in rural northern Malawi in the era of HIV treatment

Objectives Developing countries are undergoing demographic transition with a shift from high mortality caused by communicable diseases (CD) to lower mortality rates caused by non‐communicable diseases (NCD). HIV/AIDS has disrupted this trend in sub‐Saharan Africa. However, in recent years, HIV‐associated mortality has been reduced with the introduction of widely available antiretroviral therapy (ART). Side effects of ART may lead to increased risk of cardiovascular diseases, raising the prospects of an accelerated transition towards NCD as the primary cause of death. We report population‐based data to investigate changes in cause of death owing to NCD during the first 4 years after introduction of HIV treatment. Methods We analysed data from a demographic surveillance system in Karonga district, Malawi, from September 2004 to August 2009. ART was introduced in mid‐2005. Clinician review of verbal autopsies conducted 2–6 weeks after a death was used to establish a single principal cause of death. Results Over the entire period, there were 905 deaths, AIDS death rate fell from 505 to 160/100 000 person‐years, and there was no evidence of an increase in NCD rates. The proportion of total deaths attributable to AIDS fell from 42% to 17% and from NCD increased from 37% to 49%. Discussion Our findings show that 4 years after the introduction of ART into HIV care in Karonga district, all‐cause mortality has fallen dramatically, with no evidence of an increase in deaths owing to NCD.     

Verbal autopsies for adult deaths: their development and validation in a multicentre study

Summary background Verbal autopsy (VA) has been widely used to ascertain causes of child deaths, but little is known about the usefulness of VA for adult deaths. This paper describes the process used to develop a VA tool for adult deaths and the results of a multicentre validation of this tool. methods A mortality classification was developed by including causes of death that might be arrived at by VAs and causes that are responsive to public health interventions. An algorithm was designed for each cause in the classification, based on classifying symptoms into essential, supportive and differential. A structured questionnaire designed to elicit information on these symptoms was developed in English translated into the local languages. The tool was validated on deaths occurring at hospitals in Tanzania (315 deaths), Ethiopia (249) and Ghana (232). Hospital records of all adult deaths occurring at the study hospitals from June 1993 to April 1995 were collected prospectively. Non-medical interviewers with at least 12 years of formal education conducted VA interviews. Causes of death were diagnosed by a panel of physicians and by a computerized algorithm. The validity of the VA was assessed by comparing the VA diagnoses with hospital diagnoses. results Specificity of VAs by physicians fell below 95% only for acute febrile illness (AFI) and TB/AIDS. Sensitivity and positive predictive value (PPV), however, varied widely both across the sites and between causes. Sensitivity was > 75% for tetanus, rabies, direct maternal causes, injuries and TB/AIDS and ranged between 60% and 74% for diarrhoea, acute abdominal conditions and AFI. The PPV was > 75% for tetanus, rabies, hepatitis and injuries and ranged between 60 and 74% for meningitis, AFI, TB/AIDS and direct maternal causes. When the communicable diseases were combined in a single group, the sensitivity was 82%, specificity 78% and PPV 85%. For the group of noncommunicable diseases the corresponding sensitivity, specificity and PPV were 71%, 87% and 67%, respectively. Use of an algorithm resulted in lower sensitivity, specificity and PPV than the VAs by physician. conclusion VAs by a panel of physicians performed better than an opinion-based algorithm. The validity of VA diagnosis was highest for AFI, direct maternal causes, TB/AIDS, tetanus, rabies and injuries.     

Substandard emergency obstetric care – a confidential enquiry into maternal deaths at a regional hospital in Tanzania

Objective (i) To identify clinical causes of maternal deaths at a regional hospital in Tanzania and through confidential enquiry (CE) assess major substandard care and make a comparison to the findings of the internal maternal deaths audits (MDAs); (ii) to describe hospital staff reflections on causes of substandard care. Methods A CE into maternal deaths was conducted based on information available from written sources supplemented with participatory observations and interviews with staff. The compiled information was summarized and presented anonymously for external expert review to assess for major substandard care. Hospital based maternal deaths between 2006 and 2008 (35 months) were included. Of 68 registered maternal deaths sufficient information for reviewing was retrieved for 62 cases (91%). As a supplement, in‐depth interviews with staff about the underlying causes of substandard care were performed. Results The causes of death were infection (40%), abortion (25%), eclampsia (13%), post‐partum haemorrhage (12%), obstructed labour (6%) and others (4%). The median time available for hospital staff to manage the fatal complication was 47 h. The CE identified major substandard care in 46 (74%) of the 62 cases reviewed. During the same time period MDA identified substandard care in 18 cases. Staff perceived poor organization of work and lack of training as important causes for substandard care. Local MDA was considered useful although time‐consuming and sometimes threatening, and staff dedication to the process was questioned. Conclusion Quality assurance of emergency obstetric care might be strengthened by supplementing internal MDA with external CE.     

Incidence,risk factors and causes of death in an HIV care programme with a large proportion of injecting drug users

Objectives To identify factors influencing mortality in an HIV programme providing care to large numbers of injecting drug users (IDUs) and patients co‐infected with hepatitis C (HCV). Methods A longitudinal analysis of monitoring data from HIV‐infected adults who started antiretroviral therapy (ART) between 2003 and 2009 was performed. Mortality and programme attrition rates within 2 years of ART initiation were estimated. Associations with individual‐level factors were assessed with multivariable Cox and piece‐wise Cox regression. Results A total of 1671 person‐years of follow‐up from 1014 individuals was analysed. Thirty‐four percent of patients were women and 33% were current or ex‐IDUs. 36.2% of patients (90.8% of IDUs) were co‐infected with HCV. Two‐year all‐cause mortality rate was 5.4 per 100 person‐years (95% CI, 4.4–6.7). Most HIV‐related deaths occurred within 6 months of ART start (36, 67.9%), but only 5 (25.0%) non‐HIV‐related deaths were recorded during this period. Mortality was higher in older patients (HR = 2.50; 95% CI, 1.42–4.40 for ≥40 compared to 15–29 years), and in those with initial BMI < 18.5 kg/m² (HR = 3.38; 95% CI, 1.82–5.32), poor adherence to treatment (HR = 5.13; 95% CI, 2.47–10.65 during the second year of therapy), or low initial CD4 cell count (HR = 4.55; 95% CI, 1.54–13.41 for <100 compared to ≥100 cells/μl). Risk of death was not associated with IDU status (P = 0.38). Conclusion Increased mortality was associated with late presentation of patients. In this programme, death rates were similar regardless of injection drug exposure, supporting the notion that satisfactory treatment outcomes can be achieved when comprehensive care is provided to these patients.     

Seasonal patterns of cardiovascular disease mortality of adults in Burkina Faso,West Africa

Objective To evaluate seasonal patterns of cardiovascular death in adults, which are possibly influenced by hot and dry climate, in a rural setting of Burkina Faso. Methods Cause of death was ascertained by verbal autopsy. Age‐specific death rates (cardiovascular death and all‐cause) by month of death were calculated. Seasonal trends and temperature effects were modelled with Poisson regression. Results In 11 174 adults (40+), 1238 deaths were recorded for the period 1999–2003. All‐cause mortality in adults (40–64 years) and the elderly (65+ years) was 1269 per 100 000 (95% CI 1156–1382) and 7074 (95% CI 6569–7579), respectively. Cardiovascular death was the fourth most frequent cause of death in adults (40+), with a mortality of 109.9 (95% CI 76.6–143.1) for ages 40–64 and 544.9 (95% CI 404.6–685.1) for ages 65+. For all‐causes, the mortality was highest in March and for cardiovascular death highest in April, the hot dry season (March–May). Mean monthly temperature was significantly related to mortality in old ages. Conclusions Cardiovascular mortality varies by season, with higher mortality rates in the hot dry season. The pattern seems to be consistent with other studies suggesting association between hot weather and cardiovascular disease. A ‘heat‐wave’ effect appears to be observable also in areas with hot average temperatures.     

Susceptibility status of malaria vectors to insecticides commonly used for malaria control in Tanzania

Objective The aim of the study was to monitor the insecticide susceptibility status of malaria vectors in 12 sentinel districts of Tanzania. Methods WHO standard methods were used to detect knock‐down and mortality in the wild female Anopheles mosquitoes collected in sentinel districts. The WHO diagnostic doses of 0.05% deltamethrin, 0.05% lambdacyhalothrin, 0.75% permethrin and 4% DDT were used. Results The major malaria vectors in Tanzania, Anopheles gambiae s.l., were susceptible (mortality rate of 98–100%) to permethrin, deltamethrin, lambdacyhalothrin and DDT in most of the surveyed sites. However, some sites recorded marginal susceptibility (mortality rate of 80–97%); Ilala showed resistance to DDT (mortality rate of 65% [95% CI, 54–74]), and Moshi showed resistance to lambdacyhalothrin (mortality rate of 73% [95% CI, 69–76]) and permethrin (mortality rate of 77% [95% CI, 73–80]). Conclusions The sustained susceptibility of malaria vectors to pyrethroid in Tanzania is encouraging for successful malaria control with Insecticide‐treated nets and IRS. However, the emergency of focal points with insecticide resistance is alarming. Continued monitoring is essential to ensure early containment of resistance, particularly in areas that recorded resistance or marginal susceptibility and those with heavy agricultural and public health use of insecticides.     

The impact of antiretroviral treatment on mortality trends of HIV‐positive adults in rural Uganda: a longitudinal population‐based study, 1999–2009

Objective To investigate trends in all‐cause adult mortality after the roll‐out of an antiretroviral therapy (ART) programme in rural Uganda. Methods Longitudinal population‐based cohort study of approximately 20 000 residents in rural Uganda. Mortality in adults aged 15–59 years was determined for the 5‐year period (1999–2003) before introduction of ART in January 2004 and for the 5‐year period afterwards. Poisson regression was used to estimate mortality rate ratios (RRs) for the period before ART, 1 year after ART introduction (from January 2004 to January 2005) and more than 1 year after ART introduction. Trends in mortality were analysed by HIV status, age and sex. Results Before ART became available, the mortality rate (deaths per 1000 person‐years) was 4.0 (95% CI = 3.3–4.8) among HIV‐negative individuals and 116.4 (95% CI = 101.9–133.0) among HIV‐positive individuals. During the period January 2004–end November 2009, 279 individuals accessed ART. In the year after ART was introduced, the mortality rate (deaths per 1000 person‐years) among HIV‐negative individuals did not change significantly (adjusted RR = 0.95, 95% CI = 0.61–1.47), but among HIV‐positive individuals dropped by 25% to 87.4 (adjusted RR = 0.75, 95% CI = 0.53–1.06). In the period 2005–2009, the mortality rate (deaths per 1000 person‐years) among HIV‐positive individuals fell further to 39.9 (adjusted RR = 0.33, 95% CI = 0.26–0.43). The effect was greatest among individuals aged 30–44 years, and trends were similar in men and women. Conclusion The substantially reduced mortality rate among HIV‐positive individuals after ART roll‐out lends further support to the intensification of efforts to ensure universal access to ART.     

Mortality measurement in transition: proof of principle for standardised multi‐country comparisons

Objective To demonstrate the viability and value of comparing cause‐specific mortality across four socioeconomically and culturally diverse settings using a completely standardised approach to VA interpretation. Methods Deaths occurring between 1999 and 2004 in Butajira (Ethiopia), Agincourt (South Africa), FilaBavi (Vietnam) and Purworejo (Indonesia) health and socio‐demographic surveillance sites were identified. VA interviews were successfully conducted with the caregivers of the deceased to elicit information on signs and symptoms preceding death. The information gathered was interpreted using the InterVA method to derive population cause‐specific mortality fractions for each of the four settings. Results The mortality profiles derived from 4784 deaths using InterVA illustrate the potential of the method to characterise sub‐national profiles well. The derived mortality patterns illustrate four populations with plausible, markedly different disease profiles, apparently at different stages of health transition. Conclusions Given the standardised method of VA interpretation, the observed differences in mortality cannot be because of local differences in assigning cause of death. Standardised, fit‐for‐purpose methods are needed to measure population health and changes in mortality patterns so that appropriate health policy and programmes can be designed, implemented and evaluated over time and place. The InterVA approach overcomes several longstanding limitations of existing methods and represents a valuable tool for health planners and researchers in resource‐poor settings.     

The increasing mortality burden of liver disease among opioid-dependent people: cohort study

Aims Hepatitis C (HCV) infection is highly prevalent among injection drug users (IDUs) and likely to cause significant mortality over time, but little research attention has focused upon the magnitude of this risk, particularly among ageing users. This study examined trends over time in mortality attributed to liver disease, and in particular contrasting this with other more commonly studied causes of death [acquired immune deficiency syndrome (AIDS), suicide and overdose] among an ageing cohort of heroin‐dependent people in Australia. Design Data linkage study of methadone treatment entrants with the National Deaths Index. Setting A cohort entering methadone treatment for heroin dependence in New South Wales, Australia, 1980–85. Participants A total of 2489 people entering methadone treatment for heroin dependence and 54 847 person‐years (PY) of follow‐up. Measurements Linkage of data on all methadone entrants between 1980 and 1985 with data from the Australian National Deaths Index, linked using probabilistic record linkage software. Findings There were 8.2 deaths per 1000 PY [95% confidence interval (CI) 7.5–9.0], with standardized mortality ratios (SMRs) of 4.6 (95% CI 4.2–5.0). Almost one in five (17%) of deaths were from underlying liver‐related causes, most commonly viral hepatitis. The overall mortality rate for any liver cause was 1.4 deaths per 1000 PY (95% CI 1.1–1.7), 17 times higher than to the general population (95% CI 13.4–21.3), with relative elevations more marked for females (SMR 27.9; 95% CI 17.7–41.9) than males (SMR 14.5; 95% CI 10.8–19.0). Liver mortality increased over time, becoming the most common cause of death by the end of follow‐up. Conclusions Liver disease has become the most common cause of mortality among ageing opioid‐dependent people in an ageing Australian cohort. There is an imperative to reduce the long‐term risks of HCV and other risks to the liver, including alcohol consumption, which are typically not the major clinical focus for this group.     

Causes of deaths using verbal autopsy among adolescents and adults in rural western Kenya

Objective To establish causes and patterns of deaths among adolescents and adults (age >11 years) using verbal autopsy (VA) in a rural area of western Kenya where malaria and HIV are common. Methods Village reporters reported all deaths in Asembo and Gem (population 135 000), an area under routine demographic surveillance. After an interval of ≥1 month, a trained interviewer used a structured questionnaire to ask the caretaker about signs and symptoms that preceded death. Three clinical officers independently reviewed the interviews and assigned two unranked causes of death; a common cause was designated as the cause of death. Results In 2003, 1816 deaths were reported from residents; 48% were male and 72% were between 20 and 64 years of age. Most residents (97%) were ill before death, with 60% of illnesses lasting more than 2 months; 87% died at home. Care was sought by 96%; a health facility was the most common source, visited by 73%. For 1759 persons (97%), a common cause of death was designated. Overall, 74% of deaths were attributed to infectious causes. HIV (32%) and tuberculosis (TB) (16%) were the most frequent, followed by malaria, respiratory infections, anaemia and diarrhoeal disease (approximately 6% each). Death in a health facility was associated with young age, higher education, higher SES, a non‐infectious disease cause and a shorter duration of illness. Conclusion In this area, the majority of adult and adolescent deaths were attributed to potentially preventable infectious diseases. Deaths in health facilities were not representative of deaths in the community. Programmes to prevent HIV and TB infection and to decrease mortality have started. Their impact can be evaluated against this baseline information.     

Can the rural poor in India afford to treat non‐communicable diseases

Objective Non‐communicable diseases (NCD) are on the increase in low‐income countries, where healthcare costs are paid mostly out‐of‐pocket. We investigate the financial burden of NCD vs. communicable diseases (CD) among rural poor in India and assess whether they can afford to treat NCD. Methods We used data from two household surveys undertaken in 2009–2010 among 7389 rural poor households (39 205 individuals) in Odisha and Bihar. All persons from the sampled households, irrespective of age and gender, were included in the analysis. We classify self‐reported illnesses as NCD, CD or ‘other morbidities’ following the WHO classification. Results Non‐communicable diseases accounted for around 20% of the diseases in the month preceding the survey in Odisha and 30% in Bihar. The most prevalent NCD, representing the highest share in outpatient costs, were musculoskeletal, digestive and cardiovascular diseases. Cardiovascular and digestive problems also generated the highest inpatient costs. Women, older persons and less‐poor households reported higher prevalence of NCD. Outpatient costs (consultations, medicines, laboratory tests and imaging) represented a bigger share of income for NCD than for CD. Patients with NCD were more likely to report a hospitalisation. Conclusion Patients with NCD in rural poor settings in India pay considerably more than patients with CD. For NCD cases that are chronic, with recurring costs, this would be aggravated. The cost of NCD care consumes a big part of the per person share of household income, obliging patients with NCD to rely on informal intra‐family cross‐subsidisation. An alternative solution to finance NCD care for rural poor patients is needed.     

The shifting pattern of cause-specific mortality in a cohort of human immunodeficiency virus-infected and non-infected injecting drug users

AIMS: To monitor changes in cause-specific mortality before and after 1997 according to human immunodeficiency virus (HIV) serological status in a cohort of injecting drug users (IDUs) observed for a 17-year period (1987--2004). DESIGN: Community-based prospective cohort study of IDUs recruited in three acquired immunodeficiency virus (AIDS) prevention centres (1987--96) and followed-up until to 2004. METHODS: We obtained annual overall mortality rates and mortality rates by specific causes according to HIV status. Poisson regression models were adjusted to compare mortality rates between calendar periods. Significant changes in slope trends were evaluated by join-point regression. Disease-specific mortality rates were estimated using competing risk models. FINDINGS: From 7186 IDUs recruited (80677.218 person-years), 1589 deaths were observed with an overall mortality rate of 19.7 per 1000 person-years (95% CI, 18.8-20.7). This rate decreased from 22.9 per 1000 (95% CI, 21.4-24.7) before 1997 to 17.4 per 1000 (95% CI, 16.3-18.6) after 1997 [relative risk (RR) 0.83; 95% confidence interval (CI), 0.75-0.92]. Risk of death for HIV-positive was four times higher than for HIV-negative (RR 4.08; 95% CI, 3.63-4.58). Among HIV-positive individuals a significantly decreased change point in trend was found in 1997 for both total and AIDS mortality. HIV-negative individuals showed a similar pattern for drug overdose, suicide and accident mortality. Both groups showed an increase in proportional mortality by liver-related causes, cardiovascular diseases and cancer. Furthermore, a progressively increasing trend was observed for the three causes. However, there were no significant differences according to serological groups. CONCLUSIONS: Cardiovascular and cancer mortality are increasing among IDUs, but the increases are not related to HIV infection. We have not found a link between highly active antiretroviral therapy (HAART) introduction and increases in mortality for specific causes.     

High mortality among young crack cocaine users in Brazil: a 5-year follow-up study

Aims Follow‐up studies show that smokers, alcoholics and heroin addicts have high mortality rates, but there is little information on crack users. We have investigated the mortality rate among this population, including its risk factors and causes of death. Design A 5‐year follow‐up study. Participants and setting A cohort of 131 crack‐dependent patients, admitted to a public detoxification unit in São Paulo between 1992 and 1994. Measurements Data collected from a structured personal interview and from a review of patients’ hospital records, confirming the deaths from records held at the Municipal Offices. Findings Of the 124 (94.6%) patients located, 23 (18.5%) had died (a mortality ratio of 7.6). Homicide was the most common cause of death (n = 13). Observed mortality rate, adjusted for age and sex, was 24.92 per 1000, while the expected all‐cause mortality rate in São Paulo, also adjusted for age and sex, was 3.28 per 1000, giving an excess mortality rate of 21.64 per 1000. Survival analysis showed that the probability of being alive 5 years post‐treatment was 0.80 (95% CI = 0.77–0.84). Cox's proportional hazards regression showed three factors predicted mortality: history of intravenous drug use (hazard ratio 3.28, 95% CI 1.42–7.59), unemployment at index admission (hazard ratio 3.48, 95% CI 1.03–11.80) and premature discharge from index admission (hazard ratio 2.21, CI 0.94–5.18). Conclusions Community‐based and tailored interventions should be considered to improve those patients’ social support and permanence in treatment.     

Effectiveness of an intervention on uptake of maternal care in four counties in Ningxia,China

Objectives To understand the utilisation of prenatal care and hospitalised delivery among pregnant Muslim women in Ningxia, China, and to explore the effectiveness of the integrated interventions to reduce maternal mortality. Methods Cross‐sectional surveys before and after the intervention were carried out. Using multistage sampling, 1215 mothers of children <5 years old were recruited: 583 in the pre‐intervention survey and 632 in the post‐intervention study. Data on prenatal care and delivery were collected from face‐to‐face interviews. Maternal mortality ratio (MMR) data were obtained from the local Maternal and Child Mortality Report System. Results After the intervention, the MMR significantly decreased (45.5 deaths per 100 000 live births to 32.7 deaths). Fewer children were born at home after the intervention than before the intervention (OR, 0.11; 95% CI, 0.08–0.15). The proportion of women who attended prenatal care at least once increased from 78.2% to 98.9% (OR, 24.55; 95% CI, 11.37–53.12). The proportion of women who had prenatal visit(s) in the first trimester of pregnancy increased from 35.1% to 82.6% (OR, 8.77; 95% CI, 6.58–11.69). The quality of prenatal care was greatly improved. Effects of the intervention on the utilisation of maternal care remained significant after adjusting for education level and household possessions. Conclusions The findings suggest that integrated strategies can effectively reduce maternal mortality.     

Burial surveillance detected significant reduction in HIV--related deaths in Addis Ababa, Ethiopia

Objective To determine the level of HIV‐related mortality reduction after the introduction of large‐scale antiretroviral therapy (ART) using a burial surveillance system coupled with verbal autopsy (VA) in Addis Ababa, Ethiopia. Methods Prospective burial surveillance was established in 2001 at cemeteries in Addis Ababa. VA interviews were periodically conducted on a random sample of adult burials registered between 2001 and 2009. Independent physicians reviewed the completed VA questionnaires and assigned underlying causes of death. The period before 2005 was defined as pre‐ART and that since 2005 as the ART era. HIV‐specific mortality fractions were calculated by age, sex and year of burial to examine the mortality trends before and during the ART era. Results Of the 4239 VA physician diagnoses, 1087 (25.6%) were ascribed to HIV‐related deaths. HIV‐related deaths in 2009 were 33% fewer than in 2001. The proportion of HIV‐related deaths was reduced from 44.0% in the pre‐ART period to 20.0% in the ART era. Mortality in women (36.7%) declined more than in men (30%). A marked reduction in HIV‐specific mortality was observed in the age group 30–39 years (from 69.1% pre‐ART to 46.8% during ART era) compared to 20–29 (from 60.5% pre‐ART to 41.0% during ART) and 40–49 year olds (49.7%) pre‐ART to 34.4% during ART provision). Conclusion Burial surveillance combined with VA demonstrated a significant reduction in HIV‐related deaths during the provision of free ART. Replication of burial surveillance is recommended in similar settings, where a vital registration system is non‐existent, to track large‐scale population‐level interventions.     

Reaching millennium development goal 4 - the Gambia

Objective To describe how, through a DSS in a rural area of The Gambia, it has been possible to measure substantial reductions in child mortality rates and how we investigated whether the decline paralleled the registered fall in malaria incidence in the country. Methods Demographic surveillance data spanning 19.5 years (1 April 1989–30 September 2008) from 42 villages around the town of Farafenni, The Gambia, were used to estimate childhood mortality rates for neonatal, infant, child (1–4 years) and under‐5 age groups. Data were presented in five a priori defined time periods, and annual rates per 1000 live births were derived from Kaplan–Meier survival probabilities. Results From 1989–1992 to 2004–2008, under‐5 mortality declined by 56% (95% CI: 48–63%), from 165 (95% CI: 151–181) per 1000 live births to 74 (95% CI: 65–84) per 1000 live births. In 1‐ to 4‐year‐olds, mortality during the period 2004–2008 was 69% (95% CI: 60–76%) less than in 1989–1992. The corresponding mortality decline in infants was 39% (95% CI: 23–52%); in neonates, it was 38% (95% CI: 13–66%). The derived annual under‐5 mortality rates declined from 159 per 1000 live births in 1990 to 45 per 1000 live births in 2008, thus implying an attainment of MDG4 seven years in advance of the target year of 2015. Conclusion Achieving MDG4 is possible in poor, rural areas of Africa through widespread deployment of relatively simple measures that improve child survival, such as immunisation and effective malaria control.     

Estimates of US influenza‐associated deaths made using four different methods

Background A wide range of methods have been used for estimating influenza‐associated deaths in temperate countries. Direct comparisons of estimates produced by using different models with US mortality data have not been published. Objective Compare estimates of US influenza‐associated deaths made by using four models and summarize strengths and weaknesses of each model. Methods US mortality data from the 1972–1973 through 2002–2003 respiratory seasons and World Health Organization influenza surveillance data were used to estimate influenza‐associated respiratory and circulatory deaths. Four models were used: (i) rate‐difference (using peri‐season or summer‐season baselines), (ii) Serfling least squares cyclical regression, (iii) Serfling–Poisson regression, (iv) and autoregressive integrated moving average models. Results Annual estimates of influenza‐associated deaths made using each model were similar and positively correlated, except for estimates from the summer‐season rate‐difference model, which were consistently higher. From the 1976/1977 through the 2002/2003 seasons the, the Poisson regression models estimated that an annual average of 25 470 [95% confidence interval (CI) 19 781–31 159] influenza‐associated respiratory and circulatory deaths [9·9 deaths per 100 000 (95% CI 7·9–11·9)], while peri‐season rate‐difference models using a 15% threshold estimated an annual average of 22 454 (95% CI 16 189–28 719) deaths [8·6 deaths per 100 000 (95% CI 6·4–10·9)]. Conclusions Estimates of influenza‐associated mortality were of similar magnitude. Poisson regression models permit the estimation of deaths associated with influenza A and B, but require robust viral surveillance data. By contrast, simple peri‐season rate‐difference models may prove useful for estimating mortality in countries with sparse viral surveillance data or complex influenza seasonality.