Long-acting reversible contraception use and unmet desire among patients after the Zika Contraception Access Network Program in Puerto Rico.

OBJECTIVES: To describe unmet desire for long-acting reversible contraception (LARC) after the Zika Contraception Access Network (Z-CAN) in Puerto Rico during the 2016-2017 Zika outbreak. STUDY DESIGN: Z-CAN patients completed surveys about contraception experiences over a 3-year period. RESULTS: Of 1809 respondents, 3% never used LARC but reported wanting it since their initial visit. As reasons for not getting LARC, nearly 50% indicated a provider-related reason and 25% reported cost. CONCLUSIONS: Few Z-CAN patients who never used LARC had unmet desire. Provider training in contraception guidelines and strategies to address costs can expand access to the full range of reversible contraception. IMPLICATIONS: Three years after a short-term program provided reversible contraception in Puerto Rico, few respondents had never used but wanted a long-acting reversible contraception method. Nearly half reported provider-related reasons for not receiving long-acting reversible contraception, and 25% reported cost. Provider awareness of contraceptive guidance and method availability can support client-centered care.

Vital Signs: Maternity Care Experiences - United States, April 2023.

Introduction: Maternal deaths increased in the United States during 2018-2021, with documented racial disparities. Respectful maternity care is a component of quality care that includes preventing harm and mistreatment, engaging in effective communication, and providing care equitably. Improving respectful maternity care can be part of multilevel strategies to reduce pregnancy-related deaths. Methods: CDC analyzed data from the PN View Moms survey administered during April 24-30, 2023, to examine the following components of respectful care: 1) experiences of mistreatment (e.g., violations of physical privacy, ignoring requests for help, or verbal abuse), 2) discrimination (e.g., because of race, ethnicity or skin color; age; or weight), and 3) reasons for holding back from communicating questions or concerns during maternity (pregnancy or delivery) care. Results: Among U.S. mothers with children aged <18 years, 20% reported mistreatment while receiving maternity care for their youngest child. Approximately 30% of Black, Hispanic, and multiracial respondents and approximately 30% of respondents with public insurance or no insurance reported mistreatment. Discrimination during the delivery of maternity care was reported by 29% of respondents. Approximately 40% of Black, Hispanic, and multiracial respondents reported discrimination, and approximately 45% percent of all respondents reported holding back from asking questions or discussing concerns with their provider. Conclusions and implications for public health practice: Approximately one in five women reported mistreatment during maternity care. Implementing quality improvement initiatives and provider training to encourage a culture of respectful maternity care, encouraging patients to ask questions and share concerns, and working with communities are strategies to improve respectful maternity care.

Association of Mental Health Conditions, Recent Stressful Life Events, and Adverse Childhood Experiences with Postpartum Substance Use - Seven States, 2019-2020.

Most pregnancy-related deaths due to mental health conditions, which include overdose and poisoning related to substance use disorder, occur during the late (43-365-day) postpartum period (1). Adverse childhood experiences and stressful life events are associated with increased substance use during pregnancy (2,3). Pregnancy Risk Assessment Monitoring System (PRAMS) respondents in seven states with high opioid overdose mortality rates were recontacted 9-10 months after giving birth in 2019 and asked about postpartum prescription opioid misuse,* tobacco use, unhealthy alcohol use,† and use of other substances.§ Substance and polysubstance use prevalence estimates were calculated, stratified by mental health and social adversity indicators. Overall, 25.6% of respondents reported postpartum substance use, and 5.9% reported polysubstance use. The following conditions were associated with higher substance and polysubstance use prevalence in postpartum women: depressive symptoms, depression, anxiety, adverse childhood experiences, and stressful life events. Substance use prevalence was higher among women who experienced six or more stressful life events during the year preceding the birth (67.1%) or four adverse childhood experiences related to household dysfunction (57.9%). One in five respondents who experienced six or more stressful life events in the year before giving birth and 26.3% of women with four adverse childhood experiences reported postpartum polysubstance use. Clinical and community- and systems-level interventions to improve postpartum health can include screening and treatment for depression, anxiety, and substance use disorders during the postpartum period. Evidence-based strategies can prevent adverse childhood experiences and mitigate the immediate and long-term harms.¶.

Patient and Clinician Perspectives of Physical Therapy for Walking Difficulties in Multiple Sclerosis.

Gait speed is frequently the primary efficacy endpoint in clinical trials of interventions targeting mobility in people with multiple sclerosis (MS). However, it is unclear whether increased gait speed is a meaningful outcome for people living with MS. The purpose of this study was to identify the most important aspects of mobility for people with MS and physical therapists and to explore how patients and clinicians perceive whether physical therapy has been effective. Forty-six people with MS and 23 physical therapy clinicians participated in a focus group, one-on-one interview, or electronic survey. The focus group and interview data were transcribed and coded to identify themes. Free-text survey responses were also coded, and multiple-choice options were analyzed for frequency. Among people with MS, falls and difficulties getting out into the community were identified as highly important mobility limitations. Clinicians also identified falls and safety as a priority. Walking speed was infrequently described as a problem, and although gait speed is often measured by clinicians, improving gait speed is rarely a treatment goal. Despite their emphasis on safety, clinicians lacked certainty about how to objectively measure improvements in safety. People with MS evaluated physical therapy effectiveness based on the ease by which they can do things and acknowledged that "not getting worse" is a positive outcome. Clinicians evaluated effectiveness based on the amount of change in objective outcome measures and by patient and caregiver reports of improved function. These findings indicate that gait speed is not of major importance to people with MS or physical therapy clinicians. People with MS want to be able to walk further and without an assistive device, and they want to avoid falls. Clinicians want to maximize safety while improving functional ability. Clinicians and patients may differ in their expected outcomes from physical therapy.

Lessons Learned from Programmatic Gains in HIV Service Delivery During the COVID-19 Pandemic - 41 PEPFAR-Supported Countries, 2020.

The U.S. President's Emergency Plan for AIDS Relief (PEPFAR) supports country programs in identifying persons living with HIV infection (PLHIV), providing life-saving treatment, and reducing the spread of HIV in countries around the world (1,2). CDC used Monitoring, Evaluation, and Reporting (MER) data* to assess the extent to which COVID-19 mitigation strategies affected HIV service delivery across the HIV care continuum† globally during the first year of the COVID-19 pandemic. Indicators included the number of reported HIV-positive test results, the number of PLHIV who were receiving antiretroviral therapy (ART), and the rates of HIV viral load suppression. Percent change in performance was assessed between countries during the first 3 months of 2020, before COVID-19 mitigation efforts began (January-March 2020), and the last 3 months of the calendar year (October-December 2020). Data were reviewed for all 41 countries to assess total and country-level percent change for each indicator. Then, qualitative data were reviewed among countries in the upper quartile to assess specific strategies that contributed to programmatic gains. Overall, positive percent change was observed in PEPFAR-supported countries in HIV treatment (5%) and viral load suppression (2%) during 2020. Countries reporting the highest gains across the HIV care continuum during 2020 attributed successes to reducing or streamlining facility attendance through strategies such as enhancing index testing (offering of testing to the biologic children and partners of PLHIV)§ and community- and home-based testing; treatment delivery approaches; and improvements in data use through monitoring activities, systems, and data quality checks. Countries that reported program improvements during the first year of the COVID-19 pandemic offer important information about how lifesaving HIV treatment might be provided during a global public health crisis.

Perception of moderate-intensity physical activity by onset of obesity: A randomized crossover trial.

Moderate-intensity physical activity is recommended for inactive adults with overweight/obesity (OW/OB). The objective of this study is to determine if differences exist in the selection of moderate intensity between inactive adults with juvenile-onset (JO) and adult-onset (AO) OW/OB. Participants (JO = 18, AO = 20) were stratified by onset and completed two separate 20-minute moderate-intensity exercise sessions on a treadmill and cycle ergometer (randomized order). Multiple linear regression was used to determine whether exercise intensity (average METS, % age-predicted HRmax ), self-reported pleasure or exertion differed by onset, controlling for age and gender. On the treadmill, JO and AO participants selected an average intensity of (mean [SD]) 3.5 (0.9) and 3.7 (0.9) METS, and 64.0 (7.7) and 64.9 (7.5) % of age-predicted HRmax , respectively. On the cycle, JO and AO participants selected an average intensity of 3.3 (0.9) and 3.3 (1.0) METS, and 65.2 (8.8) and 60.7 (7.2) % of age-predicted HRmax . After adjustment, participant intensity selection did not significantly differ by obesity onset when walking or cycling. There were no significant differences in pleasure or perceived exertion by onset, however, perception of exertion was on the high-end of moderate for both the cycle (13.0, 12.5) and treadmill (12.0, 12.1), in JO and AO participants, respectively. Perception of moderate intensity did not differ by obesity onset. Self-selected intensity was at the low end of moderate for walking and cycling.

OpenABM-Covid19-An agent-based model for non-pharmaceutical interventions against COVID-19 including contact tracing.

SARS-CoV-2 has spread across the world, causing high mortality and unprecedented restrictions on social and economic activity. Policymakers are assessing how best to navigate through the ongoing epidemic, with computational models being used to predict the spread of infection and assess the impact of public health measures. Here, we present OpenABM-Covid19: an agent-based simulation of the epidemic including detailed age-stratification and realistic social networks. By default the model is parameterised to UK demographics and calibrated to the UK epidemic, however, it can easily be re-parameterised for other countries. OpenABM-Covid19 can evaluate non-pharmaceutical interventions, including both manual and digital contact tracing, and vaccination programmes. It can simulate a population of 1 million people in seconds per day, allowing parameter sweeps and formal statistical model-based inference. The code is open-source and has been developed by teams both inside and outside academia, with an emphasis on formal testing, documentation, modularity and transparency. A key feature of OpenABM-Covid19 are its Python and R interfaces, which has allowed scientists and policymakers to simulate dynamic packages of interventions and help compare options to suppress the COVID-19 epidemic.

Patterns in COVID-19 Vaccination Coverage, by Social Vulnerability and Urbanicity - United States, December 14, 2020-May 1, 2021.

Disparities in vaccination coverage by social vulnerability, defined as social and structural factors associated with adverse health outcomes, were noted during the first 2.5 months of the U.S. COVID-19 vaccination campaign, which began during mid-December 2020 (1). As vaccine eligibility and availability continue to expand, assuring equitable coverage for disproportionately affected communities remains a priority. CDC examined COVID-19 vaccine administration and 2018 CDC social vulnerability index (SVI) data to ascertain whether inequities in COVID-19 vaccination coverage with respect to county-level SVI have persisted, overall and by urbanicity. Vaccination coverage was defined as the number of persons aged ≥18 years (adults) who had received ≥1 dose of any Food and Drug Administration (FDA)-authorized COVID-19 vaccine divided by the total adult population in a specified SVI category.† SVI was examined overall and by its four themes (socioeconomic status, household composition and disability, racial/ethnic minority status and language, and housing type and transportation). Counties were categorized into SVI quartiles, in which quartile 1 (Q1) represented the lowest level of vulnerability and quartile 4 (Q4), the highest. Trends in vaccination coverage were assessed by SVI quartile and urbanicity, which was categorized as large central metropolitan, large fringe metropolitan (areas surrounding large cities, e.g., suburban), medium and small metropolitan, and nonmetropolitan counties.§ During December 14, 2020-May 1, 2021, disparities in vaccination coverage by SVI increased, especially in large fringe metropolitan (e.g., suburban) and nonmetropolitan counties. By May 1, 2021, vaccination coverage was lower among adults living in counties with the highest overall SVI; differences were most pronounced in large fringe metropolitan (Q4 coverage = 45.0% versus Q1 coverage = 61.7%) and nonmetropolitan (Q4 = 40.6% versus Q1 = 52.9%) counties. Vaccination coverage disparities were largest for two SVI themes: socioeconomic status (Q4 = 44.3% versus Q1 = 61.0%) and household composition and disability (Q4 = 42.0% versus Q1 = 60.1%). Outreach efforts, including expanding public health messaging tailored to local populations and increasing vaccination access, could help increase vaccination coverage in high-SVI counties.

Use of US Public Health Travel Restrictions during COVID-19 Outbreak on Diamond Princess Ship, Japan, February-April 2020.

Public health travel restrictions (PHTR) are crucial measures during communicable disease outbreaks to prevent transmission during commercial airline travel and mitigate cross-border importation and spread. We evaluated PHTR implementation for US citizens on the Diamond Princess during its coronavirus disease (COVID-19) outbreak in Japan in February 2020 to explore how PHTR reduced importation of COVID-19 to the United States during the early phase of disease containment. Using PHTR required substantial collaboration among the US Centers for Disease Control and Prevention, other US government agencies, the cruise line, and public health authorities in Japan. Original US PHTR removal criteria were modified to reflect international testing protocols and enable removal of PHTR for persons who recovered from illness. The impact of PHTR on epidemic trajectory depends on the risk for transmission during travel and geographic spread of disease. Lessons learned from the Diamond Princess outbreak provide critical information for future PHTR use.

Coronavirus Disease 2019 (COVID-19) in Americans Aboard the Diamond Princess Cruise Ship.

BACKGROUND: The Diamond Princess cruise ship was the site of a large outbreak of coronavirus disease 2019 (COVID-19). Of 437 Americans and their travel companions on the ship, 114 (26%) tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). METHODS: We interviewed 229 American passengers and crew after disembarkation following a ship-based quarantine to identify risk factors for infection and characterize transmission onboard the ship. RESULTS: The attack rate for passengers in single-person cabins or without infected cabinmates was 18% (58/329), compared with 63% (27/43) for those sharing a cabin with an asymptomatic infected cabinmate, and 81% (25/31) for those with a symptomatic infected cabinmate. Whole genome sequences from specimens from passengers who shared cabins clustered together. Of 66 SARS-CoV-2-positive American travelers with complete symptom information, 14 (21%) were asymptomatic while on the ship. Among SARS-CoV-2-positive Americans, 10 (9%) required intensive care, of whom 7 were ≥70 years. CONCLUSIONS: Our findings highlight the high risk of SARS-CoV-2 transmission on cruise ships. High rates of SARS-CoV-2 positivity in cabinmates of individuals with asymptomatic infections suggest that triage by symptom status in shared quarters is insufficient to halt transmission. A high rate of intensive care unit admission among older individuals complicates the prospect of future cruise travel during the pandemic, given typical cruise passenger demographics. The magnitude and severe outcomes of this outbreak were major factors contributing to the Centers for Disease Control and Prevention's decision to halt cruise ship travel in US waters in March 2020.

Social Role Stress, Reward, and the American Heart Association Life's Simple 7 in Midlife Women: The Study of Women's Health Across the Nation.

Background Most women occupy multiple social roles during midlife. Perceived stress and rewards from these roles may influence health behaviors and risk factors. This study examined whether social role stress and reward were associated with the American Heart Association Life's Simple 7 in a cohort of midlife women in the United States. Methods and Results Women (n=2764) rated how stressful and rewarding they perceived their social roles during cohort follow-up (age range, 42-61 years). Body mass index, blood pressure, glucose, cholesterol, physical activity, diet, and smoking were assessed multiple times. All components were collected at the fifth study visit for 1694 women (mean age, 51 years). Adjusted linear and logistic regression models were used in analyses of the number of ideal components and the odds of achieving the ideal level of each component, respectively. Longitudinal analyses using all available data from follow-up visits were conducted. At the fifth visit, more stressful and less rewarding social roles were associated with fewer ideal cardiovascular factors. Higher average stress was associated with lower odds of any component of a healthy diet and an ideal blood pressure. Higher rewards were associated with greater odds of ideal physical activity and nonsmoking. Longitudinal analyses produced consistent results; moreover, there was a significant relationship between greater stress and lower odds of ideal glucose and body mass index. Conclusions Perceived stress and rewards from social roles may influence cardiovascular risk factors in midlife women. Considering social role qualities may be important for improving health behaviors and risk factors in midlife women.

speck, First Identified in Drosophila melanogaster in 1910, Is Encoded by the Arylalkalamine N-Acetyltransferase (AANAT1) Gene.

The pigmentation mutation speck is a commonly used recombination marker characterized by a darkly pigmented region at the wing hinge. Identified in 1910 by Thomas Hunt Morgan, speck was characterized by Sturtevant as the most "workable" mutant in the rightmost region of the second chromosome and eventually localized to 2-107.0 and 60C1-2. Though the first speck mutation was isolated over 110 years ago, speck is still not associated with any gene. Here, as part of an undergraduate-led research effort, we show that speck is encoded by the Arylalkylamine N-acetyltransferase 1 (AANAT1) gene. Both alleles from the Morgan lab contain a retrotransposon in exon 1 of the RB transcript of the AANAT1 gene. We have also identified a new insertion allele and generated multiple deletion alleles in AANAT1 that all give a strong speck phenotype. In addition, expression of AANAT1 RNAi constructs either ubiquitously or in the dorsal portion of the developing wing generates a similar speck phenotype. We find that speck alleles have additional phenotypes, including ectopic pigmentation in the posterior pupal case, leg joints, cuticular sutures and overall body color. We propose that the acetylated dopamine generated by AANAT1 decreases the dopamine pool available for melanin production. When AANAT1 function is decreased, the excess dopamine enters the melanin pathway to generate the speck phenotype.

Public Health Responses to COVID-19 Outbreaks on Cruise Ships - Worldwide, February-March 2020.

An estimated 30 million passengers are transported on 272 cruise ships worldwide each year* (1). Cruise ships bring diverse populations into proximity for many days, facilitating transmission of respiratory illness (2). SARS-CoV-2, the virus that causes coronavirus disease (COVID-19) was first identified in Wuhan, China, in December 2019 and has since spread worldwide to at least 187 countries and territories. Widespread COVID-19 transmission on cruise ships has been reported as well (3). Passengers on certain cruise ship voyages might be aged ≥65 years, which places them at greater risk for severe consequences of SARS-CoV-2 infection (4). During February-March 2020, COVID-19 outbreaks associated with three cruise ship voyages have caused more than 800 laboratory-confirmed cases among passengers and crew, including 10 deaths. Transmission occurred across multiple voyages of several ships. This report describes public health responses to COVID-19 outbreaks on these ships. COVID-19 on cruise ships poses a risk for rapid spread of disease, causing outbreaks in a vulnerable population, and aggressive efforts are required to contain spread. All persons should defer all cruise travel worldwide during the COVID-19 pandemic.

Changes Over Time in Disparities in Health Behaviors and Outcomes by Race in Allegheny County: 2009 to 2015.

Racial/ethnic disparities in health behaviors and disease outcomes on the national level have persisted over time despite overall improvements in public health. To better understand the changes over time in racial/ethnic health disparities at the county level, we examined the Allegheny County Health Survey (ACHS) for Pittsburgh, PA and the surrounding area, which was conducted in 2009/2010 and 2015/2016 using random digit dialing of residents aged 18 and older. The prevalence rates and rate ratios at each time period were calculated using survey weights and general linear models. The change in prevalence over time was calculated using race-time interaction terms. The results showed a significant improvement in asthma, stroke, cholesterol, and fair or poor health disparities as well as persistent disparities in diabetes and hypertension after adjustment for socioeconomic factors. The change over time in the prevalence of fair or poor health in black compared to white respondents was significant, with absolute improvement of approximately 5% versus < 1%, respectively (p = 0.01). These findings demonstrate that some disparities improved while others persist, noting the importance of monitoring the changes over time at the local health department level.

Understanding Racial/Ethnic Disparities in Physical Performance in Midlife Women: Findings From SWAN (Study of Women's Health Across the Nation).

OBJECTIVES: Evaluate degree to which racial/ethnic differences in physical performance are mediated by sociodemographic, health, behavioral, and psychosocial factors. METHODS: Physical performance was evaluated using a decile score derived from grip strength, timed 4 m walk, and timed repeat chair stand in 1,855 African American, Caucasian, Chinese, Hispanic, and Japanese women, mean age = 61.8 (SD = 2.7) in the Study of Women's Health Across the Nation. Mediators included education, financial strain, comorbidities, pain, body mass index (BMI), physical activity, and perceived stress. Structural equation models provided estimates of the total difference in physical performance between Caucasians and each race/ethnic groups and differences due to direct effects of race/ethnicity and indirect effects through mediators. RESULTS: The mean decile score for Caucasian women was 16.9 (SD = 5.6), 1.8, 2.6, and 2.1 points higher than the model-estimated scores in African Americans, Hispanics and Chinese, respectively, and 1.3 points lower than the Japanese. Differences between Caucasians and the Chinese and Japanese were direct effects of race/ethnicity whereas in African Americans and Hispanics 75% or more of that disparity was through mediators, particularly education, financial strain, BMI, physical activity, and pain. DISCUSSION: Addressing issues of poverty, racial inequality, pain, and obesity could reduce some racial/ethnic disparity in functional limitations as women age.

Social Role-Related Stress and Social Role-Related Reward as Related to Subsequent Subclinical Cardiovascular Disease in a Longitudinal Study of Midlife Women: The Study of Women's Health Across the Nation.

OBJECTIVE: The purpose of this study was to determine if midlife social role quality, defined by the stress and rewards associated with four social roles, is related to later-life subclinical cardiovascular disease (SCVD) in a cohort of women transitioning through menopause. METHODS: The Study of Women's Health Across the Nation (SWAN) is a longitudinal cohort study of midlife women. Stress and reward from four social roles (spouse, parent, employee, caregiver) were assessed at seven early visits. Later-life SCVD was assessed via carotid ultrasound and brachial-ankle pulse wave velocity at two later visits. We tested whether ever reporting an "extremely" or "quite a bit" stressful role was related to SCVD. We also tested whether cumulative stress and reward, as well as baseline and change in stress and reward were related to SCVD, adjusting for demographics and cardiovascular risk factors. RESULTS: Among 1602 women, reporting a stressful role during midlife (between ages 47 and 52 years) was associated with later-life (age 61 years) carotid intima-media thickness, which was 21 µm thicker than never reporting a stressful role. No significant relationships between stressful roles and other SCVD measures were identified. Cumulative and baseline change models of stress and reward were not related to SCVD. CONCLUSION: A stressful social role in midlife was associated with greater atherosclerotic burden in later-life in a cohort of women transitioning through menopause. Social role rewards were unrelated to better later-life SCVD. These findings extend the knowledge of stress and cardiovascular disease in women by using measures of stress and reward for multiple social roles over the years of midlife.

Analysis of causes of death using verbal autopsies and vital registration in Hidalgo, Mexico.

INTRODUCTION: Verbal autopsy (VA) is a useful tool for evaluating causes of death, especially in places with limited or no vital registration systems. The Population Health Metrics Research Consortium (PHMRC) developed a validated questionnaire and a set of automated methods to determine the cause of death from a VA. However, the application of these methods needs to be tested in a community environment. OBJECTIVE: To estimate cause-specific mortality fractions (CSMFs) using VAs and compare them against those obtained in the vital statistics of the state of Hidalgo, Mexico. METHODS: A random sample of deaths occurred in 2009 was selected from vital statistics in the state of Hidalgo. The full PHMRC validated VA instrument was applied to the relatives of the deceased, and the cause of death was determined using Tariff's automated method. The causes of death were grouped into 34 causes for adults, 21 for children and 6 for newborns. Results were compared with cause of death on death certificates for all deaths. RESULTS: A total of 1,198 VAs were analyzed. The Tariff method was not able to assign a cause of death in only 9% of adults, 2% of children and 7% of neonatal deaths. The CSMFs obtained from the Tariff method were similar in some cases to those of vital statistics (e.g. cirrhosis), but different in others (e.g. sepsis). CONCLUSION: The application of VAs in a community sample, analyzed with the Tariff method, allowed assigning a cause of death to most of the cases, with results similar to those of vital statistics for most conditions. This tool can be useful to strengthen the quality of vital statistics.

The epidemiological transition in Papua New Guinea: new evidence from verbal autopsy studies.

BACKGROUND: Recent economic growth in Papua New Guinea (PNG) would suggest that the country may be experiencing an epidemiological transition, characterized by a reduction in infectious diseases and a growing burden from non-communicable diseases (NCDs). However, data on cause-specific mortality in PNG are very sparse, and the extent of the transition within the country is poorly understood. METHODS: Mortality surveillance was established in four small populations across PNG: West Hiri in Central Province, Asaro Valley in Eastern Highlands Province, Hides in Hela Province and Karkar Island in Madang Province. Verbal autopsies (VAs) were conducted on all deaths identified, and causes of death were assigned by SmartVA and classified into five broad disease categories: endemic NCDs; emerging NCDs; endemic infections; emerging infections; and injuries. Results from previous PNG VA studies, using different VA methods and spanning the years 1970 to 2001, are also presented here. RESULTS: A total of 868 deaths among adolescents and adults were identified and assigned a cause of death. NCDs made up the majority of all deaths (40.4%), with the endemic NCD of chronic respiratory disease responsible for the largest proportion of deaths (10.5%), followed by the emerging NCD of diabetes (6.2%). Emerging infectious diseases outnumbered endemic infectious diseases (11.9% versus 9.5%). The distribution of causes of death differed across the four sites, with emerging NCDs and emerging infections highest at the site that is most socioeconomically developed, West Hiri. Comparing the 1970-2001 VA series with the present study suggests a large decrease in endemic infections. CONCLUSIONS: Our results indicate immediate priorities for health service planning and for strengthening of vital registration systems, to more usefully serve the needs of health priority setting.

Collecting verbal autopsies: improving and streamlining data collection processes using electronic tablets.

BACKGROUND: There is increasing interest in using verbal autopsy to produce nationally representative population-level estimates of causes of death. However, the burden of processing a large quantity of surveys collected with paper and pencil has been a barrier to scaling up verbal autopsy surveillance. Direct electronic data capture has been used in other large-scale surveys and can be used in verbal autopsy as well, to reduce time and cost of going from collected data to actionable information. METHODS: We collected verbal autopsy interviews using paper and pencil and using electronic tablets at two sites, and measured the cost and time required to process the surveys for analysis. From these cost and time data, we extrapolated costs associated with conducting large-scale surveillance with verbal autopsy. RESULTS: We found that the median time between data collection and data entry for surveys collected on paper and pencil was approximately 3 months. For surveys collected on electronic tablets, this was less than 2 days. For small-scale surveys, we found that the upfront costs of purchasing electronic tablets was the primary cost and resulted in a higher total cost. For large-scale surveys, the costs associated with data entry exceeded the cost of the tablets, so electronic data capture provides both a quicker and cheaper method of data collection. CONCLUSIONS: As countries increase verbal autopsy surveillance, it is important to consider the best way to design sustainable systems for data collection. Electronic data capture has the potential to greatly reduce the time and costs associated with data collection. For long-term, large-scale surveillance required by national vital statistical systems, electronic data capture reduces costs and allows data to be available sooner.