Trend and causes of adult mortality in Kersa health and demographic surveillance system (Kersa HDSS), eastern Ethiopia: verbal autopsy method

Background

The health problems of adults have been neglected in many developing countries, yet many studies in these countries show high rates of premature mortality in adults. Measuring adult mortality and its cause through verbal autopsy (VA) methods is becoming an important process for mortality estimates and is a good indicator of the overall mortality rates in resource-limited settings. The objective of this analysis is to describe the levels, distribution, and trends of adult mortality over time (2008-2013) and causes of adult deaths using VA in Kersa Health and Demographic Surveillance System (Kersa HDSS).

Methods

Kersa HDSS is a demographic and health surveillance and research center established in 2007 in the eastern part of Ethiopia. This is a community-based longitudinal study where VA methods were used to assign probable cause of death. Two or three physicians independently assigned cause of death based on the completed VA forms in accordance with the World Health Organization’s International Classification of Diseases. In this analysis, the VA data considered were of all deaths of adults age 15 years and above, over a period of six years (2008–2013). The mortality fractions were determined and the causes of death analyzed. Analysis was done using STATA and graphs were designed using Microsoft Excel.

Results

A total of 1535 adult deaths occurred in the surveillance site during the study period and VA was completed for all these deaths. In general, the adult mortality rate over the six-year period was 8.5 per 1000 adult population, higher for males (9.6) and rural residents (8.6) than females (7.5) and urban residents (8.2). There is a general decrease in the mortality rates over the study period from 9.4 in 2008–2009 to 8.1 in 2012–2013. Out of the total deaths, about one-third (32.4%) occurred due to infectious and parasitic causes, and the second leading cause of death was diseases of circulatory system (11.4%), followed by gastrointestinal disorders (9.2%). Tuberculosis (TB) showed an increasing trend over the years and has been the leading cause of death in 2012 and 2013 for all adult age categories (15–49, 50–64, and 65 years and over). Chronic liver disease (CLD) was indicated as leading cause of death among adults in the age group 15–49 years.

Conclusion

The increasing TB-related mortality in the study years as well as the relative high mortality due to CLD among adults of age 15–49 years should be further investigated and triangulated with health service data to understand the root cause of death.

     

Estimated causes of death in Thailand, 2005: implications for health policy

Background  

Almost 400,000 deaths are registered each year in Thailand. Their value for public health policy and planning is greatly diminished by incomplete registration of deaths and by concerns about the quality of cause-of-death information. This arises from misclassification of specified causes of death, particularly in hospitals, as well as from extensive use of ill-defined and vague codes to attribute the underlying cause of death. Detailed investigations of a sample of deaths in and out of hospital were carried out to identify misclassification of causes and thus derive a best estimate of national mortality patterns by age, sex, and cause of death.     

Mortality and causes of death in Jordan 1995-96: assessment by verbal autopsy.

Mortality indicators and causes of death in Jordan were assessed by verbal autopsy. A random sample of 100 clusters of ca. 300 households each were monitored for one year by notification assistants selected from the study area itself. Registered deaths were reported to research assistants who visited the family to complete the verbal autopsy form, which was structured and contained about 100 questions. Causes of death were determined by two physicians according to preset algorithms. A total of 965 deaths were reported among 198,989 persons, giving a crude death rate of 5 per 1000 population per year. The three leading causes of death were diseases of the circulatory system, malignancies and accidents. In the absence of a health information system, verbal autopsy as implemented in Jordan can serve as a reliable substitute.     

Childhood mortality and probable causes of death using verbal autopsy in Niakhar, Senegal, 1989-2000

BACKGROUND: In African rural settings, medically certified information on causes of death is largely lacking. The authors applied the verbal autopsy to identify causes of death before 15 years old in a rural area of Senegal where a demographic surveillance system is operating. METHODS: Between 1989 and 2000, a postmortem interview was conducted using a standardized questionnaire which was independently reviewed by two physicians who assigned the probable underlying cause of death. Discordant diagnoses were discussed by a panel of physicians. Causes of death were grouped into a few categories; cause-specific mortality rates and fractions were generated. RESULTS: Between 1989 and 1997, all-cause mortality fluctuated. Diarrhoeal diseases, malaria and acute respiratory infections explained between 30% and 70% of the mortality before 10 years of age. In children 1-9 years old, malaria death rate increased between 1989 and 1994 and thereafter did not change. The 1998-2000 years were marked by a peak in mortality, attributed to a meningitis outbreak in children more than one year old paralleled by an increase in death rate from fever of unknown origin, diarrhoeal diseases, and acute respiratory infections in children under 5 years. CONCLUSIONS: Verbal autopsy provided useful information on the mortality structure responsible for the 1998-2000 peak in mortality. It underlined that, outside outbreak situations, malaria was a leading cause of death for 1-9 year old children and that diarrhoea, acute respiratory infections, or fever from unknown origin accounted for up to 50% of the deaths among the children under 5 years.     

Effect of misclassification of causes of death in verbal autopsy: can it be adjusted?

BACKGROUND: Verbal autopsy (VA) is an indirect method of ascertaining cause of death from information about symptoms and signs obtained from bereaved relatives. This method has been used in several settings to assess cause-specific mortality. However, cause-specific mortality estimates obtained by VA are susceptible to bias due to misclassification of causes of death. One way of overcoming this limitation of VA is to adjust the crude VA estimate of cause-specific mortality fractions (CSMF) using the sensitivity and specificity of the VA tool. This paper explores the application of sensitivity and specificity of VA data obtained from a hospital-based validation study for adjusting the effect of misclassification error in VA data obtained from a demographic surveillance system. METHOD: Data from a multi-centre validation study of 796 adult VA, conducted in Tanzania, Ethiopia and Ghana, were used to explore the effect of distribution of causes of death in the validation study population and the pattern of misclassification on the sensitivity and specificity of VA. VA estimates of CSMF for six causes (acute febrile illness, diarrhoeal diseases, TB/AIDS, cardiovascular disorders, direct maternal causes and injures) were obtained from a demographic surveillance system in Morogoro Rural District in Tanzania. These were adjusted for misclassification error by using sensitivity and specificity values of VA obtained from the validation study in a model proposed for correcting the effect of misclassification error in morbidity prevalence surveys. RESULTS: Sensitivity and specificity of VA differed between the three validation study sites depending on the distribution of causes of death. These differences were explained by variations in the level and pattern of misclassification between sites. When these estimates of sensitivity and specificity were applied to data from the demographic surveillance system with a comparable structure of causes of death the difference between crude and adjusted VA estimates of CSMF ranged from 3 to 83%. CONCLUSION: Estimates of sensitivity and specificity obtained from hospital-based validation studies must be used cautiously as a de facto 'gold standard' for adjusting the misclassification error in CSMF derived from VA. It is not possible to use sensitivity and specificity estimates derived from a location-specific validation study to adjust for misclassification in VA data from populations with substantially different patterns of cause-specific mortality.     

Magnitude,trends and causes of maternal mortality among reproductive aged women in Kersa health and demographic surveillance system,eastern Ethiopia

Background

Despite efforts at curbing maternal morbidity and mortality, developing countries are still burdened with high rates of maternal morbidity and mortality. Ethiopia is not an exception and has one of the world’s highest rates of maternal deaths. Reducing the huge burden of maternal mortality remains the single most serious challenge in Ethiopia. There is a paucity of information with regards to the local level magnitude and causes of maternal mortality. We assessed the magnitude, trends and causes of maternal mortality using surveillance data from the Kersa Health and Demographic Surveillance System (HDSS), in Eastern Ethiopia.

Method

The analysis used surveillance data extracted from the Kersa HDSS database for the duration of 2008 to 2014. Data on maternal deaths and live births during the seven year period were used to determine the maternal mortality ratio in the study. The data were mainly extracted from a verbal autopsy database. The sample was comprised of all reproductive aged women who died during pregnancy, childbirth or 42?days after delivery. Chi-squared test for linear trend was used to examine the significance of change in rates over time.

Results

Out of the total 311 deaths of reproductive aged women during the study period, 72 (23.2%) died during pregnancy or within 42?days of delivery. The overall estimated maternal mortality ratio was 324 per 100,000 live births (95% CI: 256, 384). The observed maternal mortality ratio has shown a declining trend over the seven years period though there is no statistical significance for the reduction (χ²?=?0.56, P?=?0.57). The estimated pregnancy related mortality ratio was 543 per 100,000 live births (95% CI: 437, 663). Out of those who died due to pregnancy and related causes, only 26% attended at least one antenatal care service. The most common cause of maternal death was postpartum haemorrhage (46.5%) followed by hypertensive disorders of pregnancy (16.3%).

Conclusion

The magnitude of maternal mortality is considerably high but has shown a decreasing trend. Community-based initiatives that aim to improve maternal health should be strengthened further to reduce the prevailing maternal mortality. Targeted information education and communication should be provided.

     

Causes of childhood deaths in Bangladesh: results of a nationwide verbal autopsy study.

While knowledge of causes of deaths is important for health sector planning, little is known from conventional sources about the causes of deaths in Bangladesh. This is partly due to deficiencies in the registration system and partly because few deaths are attended by qualified physicians. The present study was undertaken to update the information available on causes of deaths among under-5-year-olds, taking advantage of advances in verbal autopsy methodology and of the national Bangladesh Demographic and Health Survey conducted in 1993-94. About 25% of the deaths were associated with acute lower respiratory infections (ALRI) and about 20% with diarrhoea. Neonatal tetanus and measles remained important causes of death, and drowning was a major cause for 1-4-year-olds. Research and programmes to enable mothers to identify ALRI cases, particularly pneumonia, and to encourage timely and appropriate care-seeking and strengthening of ALRI case management at the primary care facilities are important priorities. While promotion of oral rehydration for watery diarrhoea and antibiotic treatment for dysentery should continue, broader preventive interventions including provision of safe water and sanitation, and improvements in personal hygiene require more attention. Further intensification of immunization programmes and innovative experimental interventions to reduce childhood from drowning should be designed and tested.     

The use of simplified verbal autopsy in identifying causes of adult death in a predominantly rural population in Ethiopia

Background  

Information on adult mortality is essentially non-existent in Ethiopia particularly from rural areas where access to health services is limited and most deaths occur at home. This study was conducted with the aim of identifying causes of adult death in a rural population of Ethiopia using a simplified verbal autopsy instrument.     

Safe-delivery practices in rural Bangladesh and its associated factors: evidence from Bangladesh demographic and health survey-2004

OBJECTIVES: This study examined the safe-delivery practices and its associated factors among rural Bangladeshi women. DESIGN: Cross-sectional survey data from Bangladesh Demographic and Health Survey (BDHS) 2004 were used. SETTING: Rural Bangladesh. PARTICIPANTS: A total of 3874 ever-married rural women age 10-49 years. Measurements: Age, education, working, religion, clinic visit, association with media, place and types of attendants at delivery. RESULTS: About 94% deliveries took place at homes and 67% were assisted by the untrained traditional birth attendants called Dai. The qualified doctors and nurses (professionals) assisted only 9% of the deliveries while about 13% are by the trained traditional birth attendants. Age group has a significant effect on safe-delivery practices. Education of the respondents as well as their partner's has direct effect on delivery practices. The uneducated women were less likely to have their delivery assisted by the medically trained persons (MTPs) while women with 10 or more years of schooling had 29 times higher probability than the uneducated women. Currently working and religion had also statistically significant. Mass media influences directly delivery practices in rural areas. The women who listen to radio and watch television had more than 2 times higher probability of having delivery assisted by MTPs than that of non-user counterparts. There is more than 4 times higher chance of delivery assisted by the MTPs than that of women with no reading of news papers or magazines. CONCLUSIONS: Delivery practices in rural Bangladesh are unsafe, took place at homes, conducted by untrained traditional birth attendants and associated positively with demographic, socio-economic, cultural and programmatic factors.     

Knowledge on AIDS among female adolescents in Bangladesh: evidence from the Bangladesh demographic and health survey data

To assess the knowledge on acquired immunodeficiency syndrome (AIDS) among female adolescents in Bangladesh, this study used data extracted from the Bangladesh Demographic and Health Survey (BDHS) 1996-1997. Of 1,446 ever-married women included in the study, most were currently married (96%), Muslims (92%) and from rural areas (91%). Only one in six adolescents had ever heard of AIDS. Of them, 57% reported AIDS as a fatal disease almost always, while only 22% believed that AIDS could be avoided. Multivariate analysis revealed that knowledge on AIDS was strongly and positively associated with education of female adolescents and their husbands and varied significantly across different parts of the country. Knowledge on AIDS was higher among relatively older and urban residents who had access to television or radio and whose husbands were using condom. Strong efforts are needed to improve awareness and to clarify misconceptions about AIDS. Improved access to education, mass-media, and promotion of condom use could prevent AIDS among female adolescents in Bangladesh.     

Rising mortality from injury in urban China: demographic burden, underlying causes and policy implications

In urban China, mortality from injuries has increased over the past five decades. By contrast, life expectancy has continued to increase and has come to nearly equal life expectancy in developed countries. Currently, most of the life expectancy lost due to injury (65%) in urban China would be recovered if injury rates were the same as in countries with low injury-related mortality. Fundamentally, the rising trend in urban injury mortality in China reflects a continued focus on injury treatment rather than prevention in the face of fast socioeconomic development and increasing exposure to risk factors for injury. Despite improved injury prevention legislation and a "Safe Community" campaign, urban China needs to modify its approach to urban injury management and focus on prevention. The gap between urban China and countries with low injury mortality can be closed by means of legislation, strengthened law enforcement and the establishment of safer communities. Risks affecting children and migrants deserve greater attention, and the government needs to allocate more resources to injury prevention, especially to urban areas in the central-west region of China. Based on the population size of urban China, measures for the prevention of injury mortality would save an annual 436.4 million years of life.     

Deaths attributable to childbearing in Matlab, Bangladesh: indirect causes of maternal mortality questioned

Little is known about the nature of diseases aggravated by pregnancy or the magnitude of mortality from causes indirectly related to pregnancy. This study aims at clarifying the contribution of indirect causes to maternal mortality by analyzing the problem from an epidemiologic perspective, using population-based data from Matlab, Bangladesh, for the period 1976-1993. The time spent during pregnancy and the puerperium was considered a transitory exposure period in women's lives, and death rates were calculated for women aged 15-44 years, while exposed and while not exposed. During or shortly after pregnancy, death rates from all causes are more than twice as high as outside this period. Once direct obstetric causes and injuries are excluded, the death rates among women while exposed are substantially lower than the death rates among women while not exposed. Several interpretations of this finding are discussed, particularly the role of selective factors ("healthy pregnant woman effect"?). This study highlights the complexity of the concept of indirect causes of maternal mortality and clearly illustrates the inherent difficulties in estimating the excess risk of death attached to pregnancy and the puerperium.     

Hypertension care in demographic surveillance sites: a cross-sectional study in Bangladesh,India, Indonesia,Malaysia, Viet Nam

ObjectiveTo determine the proportion of adults with hypertension who reported: (i) having been previously diagnosed with hypertension; (ii) taking blood pressure-lowering medication; and (iii) having achieved hypertension control, in five health and demographic surveillance system sites across five countries in Asia.MethodsData were collected during household surveys conducted between 2016 and 2020 in the five surveillance sites in Bangladesh, India, Indonesia, Malaysia and Viet Nam. We defined hypertension as systolic blood pressure ≥ 140 mmHg, diastolic blood pressure ≥ 90 mmHg or taking blood pressure-lowering medication. We defined hypertension control as systolic blood pressure < 140 mmHg and diastolic blood pressure < 90 mmHg. We disaggregated hypertension awareness, treatment and control by surveillance site, and within each site by sex, age group, education, body mass index and smoking status.FindingsOf 22 142 participants, 11 137 had hypertension (Bangladesh: 211; India: 487; Indonesia: 1641; Malaysia: 8164; and Viet Nam: 634). The mean age of participants with hypertension was 60 years (range: 19–101 years). Only in the Malaysian site were more than half of individuals with hypertension aware of their condition. Hypertension treatment ranged from 20.8% (341/1641; 95% CI: 18.8–22.8%) in the Indonesian site to 44.7% (3649/8164; 95% CI: 43.6–45.8%) in the Malaysian site. Less than one in four participants with hypertension had achieved hypertension control in any site. Hypertension awareness, treatment and control were generally higher among women and older adults.ConclusionWhile hypertension awareness and treatment varied widely across surveillance sites, hypertension control was low in all sites.     

Women and AIDS in Africa: demographic implications for health promotion

The population pyramid in most African countries is symmetricalwith a broad base. However, in urban areas, one finds a prominentone-sided bulge caused by the migration of young males (aged18–35) into the cities for employment. The prevalenceof HIV infection in urban populations in Africa is highest inthe 25–35 year old age-group in males and in the 15–25year old age-group in females. This difference is due to thefact that on average, sexual partnerships are formed betweenolder men and younger women. The distortion of the urban populationprofile caused by male migration results in an overall 1:1 female:maleprevalence ratio of infection. However, as the epidemic spreadsinto the larger rural population, the absolute size of the mostseverely affected younger female population is larger than thesize of the older male population, which eventually resultsin a higher number of infections in women. This excess of female morbidity from HIV infection has importantimplications for the social and the economic role of women insociety. It also adds fuel to an emerging epidemic of paediatricAIDS. Health promotion strategies to address this issue shouldinclude: (1) public policies designed to narrow the male:femaleage-gap of sexual partnership formation; (2) policies addressingthe economic migration patterns of the male work force and;(3) policies to narrow the base of the general population pyramid.     

Addressing the demographic imperative through health, empowerment, and rights: ICPD implementation in Bangladesh

It has been debated since the 1994 International Conference on Population and Development (ICPD) whether the ICPD program of action constitutes population policy. Opponents of the ICPD reproductive health approach argue that vertical family planning programs will be more cost-effective, while proponents counter that the reproductive health approach will be more cost-effective in meeting demographic goals. The program of action calls for social investments to be made by development agencies and budgets, not from family planning budgets. The roles of population professionals and agencies in the program are to conduct relevant research and advocate for broader policy change. The case of Bangladesh is examined. The following issues need to be researched in both Bangladesh and worldwide in order to support the implementation of the ICPD program of action: the situation of young people, the significance of sex and gender in reproductive and health-seeking behavior, the decision-making environment, and applied demographic research into the costs and benefits of reproductive health services. Professionals working in the field of population need to get involved in assessing and promoting changes in broader national development policies.     

Sinonasal cancer in the Italian national surveillance system: Epidemiology,occupation, and public health implications

Background

Sinonasal cancer (SNC) is a rare tumor with predominant occupational etiology associated with exposures to specific carcinogens. The aim of this study is to describe SNC cases recorded in Italy in the period 2000‐2016.

Methods

Clinical information, occupational history, and lifestyle habits of SNC cases collected in the Italian Sinonasal Cancer Register were examined. Age‐standardized rates were estimated.

Results

Overall, 1529 cases were recorded. The age‐standardized incidence rates per 100 000 person‐years were 0.65 in men and 0.26 in women. Occupational exposures were predominant among the attributed exposure settings, primarily to wood and leather dusts. Other putative causal agents included chrome, solvents, tannins, formaldehyde, textile dusts, and pesticides. Many cases had unknown exposure.

Conclusions

Epidemiological surveillance of SNC cases and their occupational history is fundamental for monitoring the occurrence of the disease in exposed workers in industrial sectors generally not considered at risk of SNC as well as in non‐occupational settings.