Validity of verbal autopsy method to determine causes of death among adults in the urban setting of Ethiopia

ABSTRACT: BACKGROUND: Verbal autopsy has been widely used to estimate causes of death in settings with inadequate vital registries, but little is known about its validity. This analysis was part of Addis Ababa Mortality Surveillance Program to examine the validity of verbal autopsy for determining causes of death compared with hospital medical records among adults in the urban setting of Ethiopia. METHODS: This validation study consisted of comparison of verbal autopsy final diagnosis with hospital diagnosis taken as a "gold standard". In public and private hospitals of Addis Ababa, 20,152 adult deaths (15 years and above) were recorded between 2007 and 2010. With the same period, a verbal autopsy was conducted for 4,776 adult deaths of which, 1,356 were deceased in any of Addis Ababa hospitals. Then, verbal autopsy and hospital data sets were merged using the variables; full name of the deceased, sex, address, age, place and date of death. We calculated sensitivity, specificity and positive predictive values with 95% confidence interval. RESULTS: After merging, a total of 335 adult deaths were captured. For communicable diseases, the values of sensitivity, specificity and positive predictive values of verbal autopsy diagnosis were 79%, 78% and 68% respectively. For non-communicable diseases, sensitivity of the verbal autopsy diagnoses was 69%, specificity 78% and positive predictive value 79%. Regarding injury, sensitivity of the verbal autopsy diagnoses was 70%, specificity 98% and positive predictive value 83%. Higher sensitivity was achieved for HIV/AIDS and tuberculosis, but lower specificity with relatively more false positives. CONCLUSION: These findings may indicate the potential of verbal autopsy to provide cost-effective information to guide policy on communicable and non communicable diseases double burden among adults in Ethiopia. Thus, a well structured verbal autopsy method, followed by qualified physician reviews could be capable of providing reasonable cause specific mortality estimates in Ethiopia. However, the limited generalizability of this study due to the fact that matched verbal autopsy deaths were all in-hospital deaths in an urban center, thus results may not be generalizable to rural home deaths. Such application and refinement of existing verbal autopsy methods holds out the possibility of obtaining replicable, sustainable and internationally comparable mortality statistics of known quality. Similar validation studies need to be undertaken considering the limitation of medical records as "gold standard" since records may not be confirmed using laboratory investigations or medical technologies. The validation studies need to address child and maternal causes of death and possibly all underlying causes of death.     

Clinical and pathological disagreement upon the cause of death in a teaching hospital: analysis of 100 autopsy cases in a prospective study

The aim of the present study was to analyze the concordance between clinical and autopsy diagnoses. For this purpose, 100 patients submitted to autopsy from July 2000 to April 2001 were studied prospectively. In all cases, clinicians gave the immediate and the underlying causes of death for patients dying under their care. The diagnoses were compared to the macroscopic autopsy diagnoses. Cohen's kappa coefficient of agreement was estimated. Sixty-four men and 36 women were submitted to autopsy. The most frequent pathological diagnosis of underlying cause of death were diseases of the circulatory system (35%), infections and parasitic diseases (20%) and diseases of the digestive system (11%). The kappa coefficient for immediate cause of death was 0.40 (95% confidence interval (CI): 0.29–0.50); for underlying cause it was 0.38 (95%CI: 0.18–0.44), and for basic cause codified by group according to ICD-10 it was 0.55 (95%CI: 0.44–0.67). Major disagreement occurred in 10 cases involving pathological causes of death as circulatory diseases, in which the clinicians diagnosed a digestive system disease as the cause of death ( n  = 5), or infectious and parasitic diseases ( n  = 5). The present study shows that agreement between clinical and pathological causes of death are moderate, proving that the autopsy is still a very important procedure.     

HIV-1 subtype C in commerical sex workers in Addis Ababa, Ethiopia

In this study, we have investigated the diversity of the current HIV-1 strains circulating in Addis Ababa, Ethiopia; in addition, we have evaluated the applicability of peptide enzyme-linked immunosorbent assay (ELISA) and heteroduplex mobility assay (HMA) for HIV-1 subtyping. Previous studies have indicated that HIV-1 subtype C is the major subtype present in HIV-positive samples collected from various risk groups between 1988 and 1995 in Addis Ababa. To assess the possible influx of new HIV-1 subtypes, 150 commercial sex workers (CSW) reporting in 1997 to two Health Centers in Addis Ababa were enrolled in an unlinked anonymous cross-sectional study. Subtyping was performed according to the World Health Organization algorithm of peptide ELISA, followed by HMA and DNA sequencing. As a result, the HIV-1 prevalence among these CSWs was found to be 45% (67 of 150). Of the 67 samples, 66 contained HIV-1 of subtype C and only one was of subtype D. This confirms the persistent overall presence of HIV-1 subtype C in Addis Ababa and a low influx of other subtypes into this location.     

Reproductive health perceptions,beliefs and sexual risk-taking among youth in Addis Ababa,Ethiopia

Appropriate knowledge and beliefs about sexuality and necessary life skills do not often precede sexual behaviours among young people. This study outlines a profile of sexual risk factors and the underlying sexual and reproductive health perception and beliefs among youth (aged 15-24 years) in Addis Ababa, Ethiopia. Five hundred and sixty-one youth residing in two of the six zones of Addis Ababa filled a self-administered questionnaire. Three outcome variables: history of sexual activity in the past, use of condom during recent sexual intercourse and use of alcohol, were used to construct a pyramid of sexual risk categories. Being a female, age group of 20-24 years and out-of-school significantly increased the likelihood of belonging to the most vulnerable category. Although young people were heterogeneous in their sexual risk-taking, they were equally uninformed on reproductive health matters related to puberty and sexuality. Their respective beliefs also tended to be flexible and unstable to consistently predict their behaviour. Possible reasons for such heterogeneity and its practical implications in sex education strategies are discussed.     

Sudden unexpected death in patients with malignancy: a clinicopathologic study of 28 autopsy cases

Sudden unexpected death (SUD) in patients with malignancy has not been comprehensively studied. We defined SUD as intrinsic natural death within 24h after initial clinical presentation of the disease responsible for the death. Intra- and postoperative death and cases associated with a myelosuppressive state were excluded. Of 2,216 autopsy cases with malignancy registered at Saitama Cancer Center, Japan, 28 SUD cases (1.3%) were studied clinicopathologically. Fifteen cases (53.6%) died of non-neoplastic cardiovascular events (CVEs), with acute myocardial infarction (AMI) being the most common death (n=13). Ten cases (35.7%) died of neoplasm-related complications (NRCs), and a miscellaneous pathophysiology was apparent, including cardiac involvement by tumor cells (n=3), fistula formation between great vessels and the alimentary canal (n=3), hepatic rupture (n=2), cardiac tamponade (n=1), and neoplastic pulmonary emboli (n=1). An anaphylaxis reaction (AR) was the cause of SUD in three cases (10.7%). Our results imply that the main route for prevention of SUD in patients with malignancy is incorporation of measure against ischemic heart disease. In addition, a variety of mechanisms causing SUD as a complication of malignant neoplasms should be recognized, including AR. Accumulation of SUD cases is necessary to better understand the causes of SUD in patients with malignancy.     

Distribution of lymphocyte subsets in healthy human immunodeficiency virus-negative adult Ethiopians from two geographic locales.

Immunological values for 562 factory workers from Wonji, Ethiopia, a sugar estate 114 km southeast of the capital city, Addis Ababa, Ethiopia, were compared to values for 218 subjects from Akaki, Ethiopia, a suburb of Addis Ababa, for whom partial data were previously published. The following markers were measured: lymphocytes, T cells, B cells, NK cells, CD4(+) T cells, and CD8(+) T cells. A more in depth comparison was also made between Akaki and Wonji subjects. For this purpose, various differentiation and activation marker (CD45RA, CD27, HLA-DR, and CD38) expressions on CD4(+) and CD8(+) T cells were studied in 60 male, human immunodeficiency virus-negative subjects (30 from each site). Data were also compared with Dutch blood donor control values. The results confirmed that Ethiopians have significantly decreased CD4(+) T-cell counts and highly activated immune status, independent of the geographic locale studied. They also showed that male subjects from Akaki have significantly higher CD8(+) T-cell counts, resulting in a proportional increase in each of the CD8(+) T-cell compartments studied: na?ve (CD45RA(+)CD27(+)), memory (CD45RA(-)CD27(+)), cytotoxic effector (CD45RA(+)CD27(-)), memory/effector (CD45RA(-)CD27(-)), activated (HLA-DR(+)CD38(+)), and resting (HLA-DR(-)CD38(-)). No expansion of a specific functional subset was observed. Endemic infection or higher immune activation is thus not a likely cause of the higher CD8 counts in the Akaki subjects. The data confirm and extend earlier observations and suggest that, although most lymphocyte subsets are comparable between the two geographical locales, there are also differences. Thus, care should be taken in extrapolating immunological reference values from one population group to another.     

Molecular epidemiology and drug resistance of Mycobacterium tuberculosis isolates from Ethiopian pulmonary tuberculosis patients with and without human immunodeficiency virus infection

We have analyzed the molecular epidemiology and drug resistance of 121 Mycobacterium tuberculosis isolates from consecutive patients with culture-positive pulmonary tuberculosis attending a university hospital outpatient department in Addis Ababa, Ethiopia. Restriction fragment length polymorphism analysis and spoligotyping were used to analyze the DNA fingerprinting patterns. Fifty-one (41.2%) of the isolates were found in 13 clusters with two or more identical DNA patterns. Two such clusters contained 49.0% of all clustered isolates. In a multivariate logistic regression model, human immunodeficiency virus (HIV)-positive serostatus was significantly associated with clustering of isolates for patients of both sexes (odds ratio [OR], 2.55; 95% confidence interval [CI], 1.17 to 5.80). There was a trend toward increased clustering of isolates from tuberculous women residing in Addis Ababa (OR, 2.10; 95% CI, 0.85 to 5.25). In total, 17 of 121 isolates (14.0%) were resistant to one or more of the antituberculosis drugs isoniazid (8.3%), streptomycin (7.4%), rifampin (2.5%), and ethambutol (1.7%). The high rate of drug-resistant isolates (29.6%) coincided with the peak prevalence of HIV infection (77.8%) in patients 35 to 44 years old. The majority (62.5%) of resistant isolates in this group were found within clusters. The simultaneous accumulation of certain bacterial clones in a patient population likely reflects recent transmission. Hence, we conclude that tuberculosis is commonly caused by recent infection with M. tuberculosis in HIV-positive Ethiopian patients. Furthermore, with the rapidly increasing prevalence of HIV infection in Ethiopia, the burden of tuberculosis, including drug-resistant tuberculosis, is likely to increase. Strengthening of classical tuberculosis control measures by promoting active case finding among HIV-positive adults with tuberculosis is warranted to reduce rates of transmission.     

Descriptive epidemiology of the autopsy in Connecticut, 1979-1980

Knowledge of the differences between deaths for which autopsies are performed and all deaths is pertinent to epidemiologic investigation in such areas as disease trends, chronic disease incidence, and occupationally related disease. A population-based study was undertaken to evaluate these differences for deaths in Connecticut in 1979 and 1980. Analyses for 1979 and 1980 were comparable. Of 28,440 deaths in 1980, 14% underwent autopsy. Differences by sex, race, marital status, age, underlying cause of death, and place of occurrence of death were demonstrated when decedents who underwent an autopsy were compared with all decedents. Non-white men who died at 20 to 29 years of age were the most likely group to undergo an autopsy. Proportions of autopsies, by major category of underlying cause, did not parallel the leading causes of death. Deaths due to trauma accounted for a larger proportion of all autopsies (25%) than of all deaths (6%). If a death certificate indicated a circulatory disorder or neoplasm as the cause of death, an autopsy was less likely to be performed. A disproportionately high number of autopsies were performed for deaths occurring in hospitals; the converse was true for deaths occurring in nursing-convalescent homes. We conclude that knowledge of the ways in which autopsies are biased will permit broader use of the sensitive and specific information that can be obtained from them.     

Autopsy-determined causes of death following heart valve replacement

The pathological findings and the principal cause of death were reviewed in 275 patients with 345 heart valve prostheses. Rheumatic fever necessitated valve replacement in 73% of these patients. Tissue valves bore significantly fewer and scantier thrombi than did the mechanical prostheses. Patients with these two groups of valves showed no significant difference with regard to the incidence of infarction of systemic organs. Patients with prostheses showed infarcts of the spleen, brain, and heart more often than did nonoperated controls with valvular disease. Among the mechanical valves, patients with Starr-Edwards valves showed the highest incidence of fatal thromboembolism. Prosthesis-related problems formed the biggest single cause of death in the 275 patients with valve prostheses. The mechanical valve group, which formed 82% of the total, had prosthesis-related problems as the prime cause of death; in the tissue valve group this complication ranked third in importance after unknown causes and diseases unrelated to valve surgery. Analysis of the valve-related causes of death showed that thrombosis and infection of the prosthesis were more important in the mechanical valves, whereas structural failure was more common with the tissue valves. Prosthesis-related fatal complications were present in 13% of the patients who died within 30 days postoperatively and in 61% of those who died later.     

Detection of a human rotavirus strain different from types 1 and 2—A new subgroup? epidemiology of subgroups in a swedish and an ethiopian community

A possible new subgroup of human rotavirus was found by crossed immunoelectrophoresis and enzyme-linked immunosorbent assay. The epidemiology of the established subgroups 1 and 2 and this new variant was studied in two different communities. Of 398 rotavirus isolates from Malm?, Sweden, 26.8% were of type 1, 71.7% of type 2, and 1.5% of the new variant. Corresponding figures for 384 samples from Addis Ababa, Ethiopia, were 33.1% type 1 and 66.9% type 2. A total of 87% of the Swedish and 79% of the Ethiopian rotavirus-positive samples could be classified. The yearly distribution of the subgroups was stable and similar in Sweden and Ethiopia. The new variant could only be found in one outbreak during 1979. Among children with sequential infections eight of ten primary infections were type 1, and no one shed the same type of rotavirus twice.     

54例心源性猝死患者心传导系统病变的分析

目的 探讨心源性猝死的死亡原因。方法 采用本组建立的心脏传导系统检查法,对１２０例心源性猝死者进行常规组织学检查。结果 发现５４例猝死与ＣＣＳ病变有关。猝死者８５．２％为年青人,２０－３０岁为猝死高峰年龄,男性我于女性。病变以ＣＣＳ炎症最多见,其后顺序是脂肪浸润,肥厚性心肌病伴发ＣＣＳ病变,出血,发育异常,心脏神经组织病变,纤维化及肿瘤等。     

A retrospective study of the accuracy between clinical and autopsy cause of death in the University of Malaya Medical Centre

It is well known that diagnostic accuracy of the clinical cause of death has not improved despite advances in diagnostic techniques. We aimed to investigate the accuracy of the clinical cause of death compared with the autopsy cause of death and to see if the Coroner's autopsy can play a role in clinical audit. Our study population consisted of all autopsies where the deceased was hospitalised or resuscitated at the Accident and Emergency Unit of the University of Malaya Medical Centre before death, performed during the period July 1998 to June 2000. The cases were subdivided according to natural and unnatural causes of deaths. Natural deaths were further subdivided in relation to the main organ systems involved while unnatural deaths were subcategorised into trauma, poisoning and burns. The rate of agreement between clinical and autopsy cause of death was further compared with duration of survival in the hospital. Of 132 autopsies included in this study, 115 were Coroner's autopsies. 78% of cases showed agreement between clinical and autopsy cause of death. The agreement rate in Coroner's cases was 80.0%. For natural and unnatural causes, the agreement rate was 56.7% and 84.3% respectively. There were 6 cases (4.5%) where an initial accurate diagnosis might have altered the prognosis of the deceased. In general, the rate of agreement increased with duration of survival of patients. However, this was no longer observed after a survival of more than 28 days. Our findings agree with other similar studies. The diagnostic accuracy of cause of death has not improved despite the modernisation in medical technology. The autopsy still plays an important role in clinical audit and medical education.     

Autopsy findings in the acquired immunodeficiency syndrome (AIDS). A report of 395 cases from the south of France.

Necropsy findings in 395 adult patients with the acquired immunodeficiency syndrome (AIDS) who died in Nice, France, between March 1983 and May 1996 were compared retrospectively with antemortem diagnoses, risk factors and number of positive T CD4 lymphocytes at the time of death. Special emphasis on bacterial infections was made in this study. Lesions observed from 1983 through 1989 and from 1990 through 1996 were compared. We assessed the role of organ lesions in the immediate cause of death. The organ system distribution of major opportunistic infections and neoplasms was similar throughout the years of the study. The most common diagnostic disease entities in all organ sites were cytomegalovirus infection, toxoplasmosis and candidiasis. Toxoplasmosis was more common in the intravenous drug abuser group. Bacterial infections were frequent and contributed to the mortality and morbidity of all risk factor groups. Kaposi' sarcoma continued to occur more frequently in the homosexual population. Cytomegalovirus infection remained one of the most common causes of death from 1983 to 1996. Mortality from fungal and bacterial infections, and mycobacteriosis increased in frequency during the course of this study whereas deaths from pneumocystosis declined. The death rate from malignant lymphoma and carcinoma increased after 1989. The clinical cause of death concurred with the pathological cause in 55% of the cases. Lung was the most frequent organ involved followed by the central nervous system the gastrointestinal tract and the heart.     

Short-term variations in stature growth in Ethiopian and English children

Two groups of young children, one in Addis Ababa and one in Oxford, were measured every calendar month for 6 months. Changes in their stature variability, as evidenced by increasing measurement interval length, are here compared. There is evidence for substantially greater variability in the Addis Ababa children. When the variability is expressed as coefficients of variation both groups show a marked decline with interval length, presumably as constant and additive components of variation become proportionally less important as the mean increases. One constant element is identified in the Addis Ababa children, since a single subtraction from all interval coefficients greater than two months produces the same CV. It is concluded that this probably represents the homeostatic cycle of catch-up growth in this group of children.     

Geriatric autopsy findings in the last 10 years: an Urban Teaching Hospital experience

In this study, we reviewed autopsy records for clinical data and autopsy findings from patients aged 70 or more, over a 10-year period (1993 to 2002) in an urban university hospital. For that period, there were a total of 772 autopsy cases of which 180 (23%) patients were aged 70 years or older. We found that despite a marked decrease in total autopsy rates, there has been a perceptible rise in geriatric cases. Cardiovascular and infectious diseases in this age group are the leading causes of death as reported nationally. We found that women died more of acute myocardial infarctions than men, even though hypertensive and atherosclerotic cardiovascular diseases not otherwise specified were more prevalent in men. It is our conclusion that at our institution: 1) despite a marked decrease in the total autopsy rate, the geriatric autopsy rate is rising; 2) infectious and cardiovascular diseases are the leading causes of death in elderly patients; 3) Myocardial infarcts as a cause of death are more often seen in women for this age group. It is also our impression that better autopsy reporting is needed for maximal utilization of autopsy findings in medical auditing and teaching and for improvements in the quality of patient care in general and the geriatric patient in particular.     

Autopsy findings in cardiac transplant patients. A 10-year experience.

Findings from 44 autopsy examinations of cardiac transplant patients during a 10-year period were reviewed. The autopsy rate was 85%. One half of the autopsy patients underwent original transplantation for ischemic heart disease and 34% for cardiomyopathy. Survival after transplantation ranged from 0 (intraoperative) to 91 months. Rejection (including hyperacute rejection) was responsible for 41% of deaths, followed by infection (25%), and intraoperative deaths at first transplantation (9%). Most of the remaining complications were related to surgery or artificial heart support, accelerated allograft atherosclerosis, and lymphoma. Infections were not only responsible for a substantial percentage of deaths but were also a co-morbid finding in a number of patients who died primarily of other causes. Pulmonary infections represented the most common anatomic site. Twenty-five percent of the autopsy patients had gastrointestinal and/or pancreatic abnormalities, principally mucosal inflammation, erosions or hemorrhage, and pancreatitis. Review of premortem rejection history indicated that 64% of patients who died of or with rejection at autopsy had had an episode of rejection 3 weeks after transplantation and/or at least one episode of severe rejection.     

Autopsy causes of death in HIV-positive individuals in sub-Saharan Africa and correlation with clinical diagnoses

Despite the persistently high HIV-related mortality in sub-Saharan Africa, limited information on the causes of death is available. Pathological autopsies are the gold standard to establish causes of death. In this review we describe the autopsy series performed among HIV-infected individuals in sub-Saharan Africa over the last two decades. We identified nine complete and 11 partial or minimally invasive autopsy series. Complete autopsies were performed in 593 HIV-positive adults and 177 HIV-positive children. Postmortem diagnoses were mainly infectious diseases. Tuberculosis was the most frequent, present in 21-54% of HIV-positive adults and was considered the cause of death in 32-45%. Overall, pulmonary infections accounted for approximately 66% of pathology and central nervous system infections for approximately 20%. A high discordance between clinical and postmortem diagnoses was observed. This review emphasizes the need for reliable information on causes of death in order to improve HIV patient care, guide further research, and inform health policy.     

Introducing medical genetics services in Ethiopia using the MiGene Family History App

PurposeAlmost all low-income countries and many middle-income countries lack the capacity to deliver medical genetics services. We developed the MiGene Family History App (MFHA), which assists doctors with family history collection and population-level epidemiologic analysis. The MFHA was studied at St. Paul’s Hospital in Addis Ababa, Ethiopia.MethodsA needs assessment was used to assess Ethiopian physicians’ experience with genetics services. The MFHA then collected patient data over a 6-month period.ResultsThe majority of doctors provide genetics services, with only 16% reporting their genetics knowledge is sufficient. A total of 1699 patients from the pediatric ward (n = 367), neonatal intensive care unit (NICU) (n = 477), and antenatal clinic (n = 855) were collected using the MFHA with a 4% incidence of a MFHA-screened condition present. The incidence was 11.7% in the pediatric ward, 3% in the NICU, and 0.5% in the antenatal clinic. Heart malformations (5.5% of patients) and trisomy 21 (4.4% of patients) were the most common conditions in the pediatric ward.ConclusionMedical genetics services are needed in Ethiopia. As other countries increase their genetics capacity, the MFHA can provide fundamental genetics services and collect necessary epidemiologic data.     

882例出生缺陷监测尸检病理分析的临床与优生意义

本文对882例出生缺陷病例进行了病理尸检,以正确识别先天畸形。方法采用全国病理统一表格,登记、观察及其他辅助检查。结果:尸检率占出生缺陷死亡儿的26.66％,男:女为1:1.02;死亡原因中先天畸形占首位56.91％,缺氧、颅内出血占第二位25.06％,母儿合并症占第三位11.57％。尸检中,检查出的内脏先天畸形占尸检的23.81％,占各种畸形的41.83％;内脏畸形中心血管畸形占首位33.81％,胃、肠次之。体表畸形合并内脏畸形以NTD合并肾畸形占首位,26.97％,肺、心次之。单纯体表畸形以NTD为首占64.29％。文中还统计了各系统畸形的出现次数,最后讨论了防治方法。