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We evaluated the impact of the COVID-19 pandemic on excess mortality by race/skin colour in Brazil, between epidemiological weeks 12 and 50 of 2020. We compared the 2020 point estimate and the expected point estimate applying 2019 mortality rates to the 2020 population. There was an excess of 187 002 deaths (+20.2%) compared to the expected. Excess mortality was 26.3% (23.3-29.3%) among blacks/browns compared to 15.1% (14.1-16.1%) among whites (58.9% of excess among black/browns). Age-standardized rates increased from 377 to 419/100 000 among blacks/browns compared to 328 to 398/100 000 in whites, resulting in 9% relative risk. Excess mortality in Brazil depicts a considerable gap, with increased mortality in all age groups in the black/brown population.
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COVID-19 , Brasil/epidemiologia , Humanos , Mortalidade , Pandemias , SARS-CoV-2 , População BrancaRESUMO
The complex and evolving picture of COVID-19-related mortality highlights the need for data to guide the response. Yet many countries are struggling to maintain their data systems, including the civil registration system, which is the foundation for detailed and continuously available mortality statistics. We conducted a search of country and development agency Web sites and partner and media reports describing disruptions to the civil registration of births and deaths associated with COVID-19 related restrictions.We found considerable intercountry variation and grouped countries according to the level of disruption to birth and particularly death registration. Only a minority of the 66 countries were able to maintain service continuity during the COVID-19 restrictions. In the majority, a combination of legal and operational challenges resulted in declines in birth and death registration. Few countries established business continuity plans or developed strategies to deal with the backlog when restrictions are lifted.Civil registration systems and the vital statistics they generate must be strengthened as essential services during health emergencies and as core components of the response to COVID-19.
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Declaração de Nascimento , COVID-19 , Atestado de Óbito , Notificação de Abuso , Sistema de Registros/estatística & dados numéricos , Estatísticas Vitais , Bases de Dados Factuais , Humanos , Internacionalidade , QuarentenaRESUMO
BACKGROUND: Monitoring medically certified causes of death is essential to shape national health policies, track progress to Sustainable Development Goals, and gauge responses to epidemic and pandemic disease. The combination of electronic health information systems with new methods for data quality monitoring can facilitate quality assessments and help target quality improvement. Since 2015, Tanzania has been upgrading its Civil Registration and Vital Statistics system including efforts to improve the availability and quality of mortality data. METHODS: We used a computer application (ANACONDA v4.01) to assess the quality of medical certification of cause of death (MCCD) and ICD-10 coding for the underlying cause of death for 155,461 deaths from health facilities from 2014 to 2018. From 2018 to 2019, we continued quality analysis for 2690 deaths in one large administrative region 9 months before, and 9 months following MCCD quality improvement interventions. Interventions addressed governance, training, process, and practice. We assessed changes in the levels, distributions, and nature of unusable and insufficiently specified codes, and how these influenced estimates of the leading causes of death. RESULTS: 9.7% of expected annual deaths in Tanzania obtained a medically certified cause of death. Of these, 52% of MCCD ICD-10 codes were usable for health policy and planning, with no significant improvement over 5 years. Of certified deaths, 25% had unusable codes, 17% had insufficiently specified codes, and 6% were undetermined causes. Comparing the before and after intervention periods in one Region, codes usable for public health policy purposes improved from 48 to 65% within 1 year and the resulting distortions in the top twenty cause-specific mortality fractions due to unusable causes reduced from 27.4 to 13.5%. CONCLUSION: Data from less than 5% of annual deaths in Tanzania are usable for informing policy. For deaths with medical certification, errors were prevalent in almost half. This constrains capacity to monitor the 15 SDG indicators that require cause-specific mortality. Sustainable quality assurance mechanisms and interventions can result in rapid improvements in the quality of medically certified causes of death. ANACONDA provides an effective means for evaluation of such changes and helps target interventions to remaining weaknesses.
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Confiabilidade dos Dados , Instalações de Saúde , Causas de Morte , Certificação , Humanos , Tanzânia/epidemiologiaRESUMO
BACKGROUND: Verbal autopsy (VA) is a practical method for determining probable causes of death at the population level in places where systems for medical certification of cause of death are weak. VA methods suitable for use in routine settings, such as civil registration and vital statistics (CRVS) systems, have developed rapidly in the last decade. These developments have been part of a growing global momentum to strengthen CRVS systems in low-income countries. With this momentum have come pressure for continued research and development of VA methods and the need for a single standard VA instrument on which multiple automated diagnostic methods can be developed. METHODS AND FINDINGS: In 2016, partners harmonized a WHO VA standard instrument that fully incorporates the indicators necessary to run currently available automated diagnostic algorithms. The WHO 2016 VA instrument, together with validated approaches to analyzing VA data, offers countries solutions to improving information about patterns of cause-specific mortality. This VA instrument offers the opportunity to harmonize the automated diagnostic algorithms in the future. CONCLUSIONS: Despite all improvements in design and technology, VA is only recommended where medical certification of cause of death is not possible. The method can nevertheless provide sufficient information to guide public health priorities in communities in which physician certification of deaths is largely unavailable. The WHO 2016 VA instrument, together with validated approaches to analyzing VA data, offers countries solutions to improving information about patterns of cause-specific mortality.
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Autopsia/métodos , Autopsia/normas , Estatísticas Vitais , Organização Mundial da Saúde , Causas de Morte , HumanosRESUMO
The health and development challenges of the coming decades cannot be tackled effectively without reliable data for births, deaths, and causes of death, which only a comprehensive civil registration and vital statistics (CRVS) system can deliver. Alternative methods such as surveys, censuses, or surveillance are not adequate substitutes from a statistical perspective, and do not provide individuals with the legal documentation they need to benefit from services and participate fully in a modern society. Research is needed to generate and disseminate evidence about which CRVS strategies work best in which contexts and to ensure that the potential benefits of innovation are successfully scaled up, and that possible pitfalls are avoided. Research findings need to be compiled and made readily accessible to users for policy making, programming, and practice. Modernisation of CRVS systems necessitates new, broad-based national and international coalitions. The global architecture for CRVS, so far dominated by UN agencies, should extend to include bilateral donors, funds, foundations, non-governmental organisations, the private sector, academic institutions, and civil society. This change is essential to ensure that further development of CRVS systems is inclusive, participatory, multisectoral, and has a strong evidence base.
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Saúde Global , Sistema de Registros , Estatísticas Vitais , HumanosRESUMO
Increasing demand for better quality data and more investment to strengthen civil registration and vital statistics (CRVS) systems will require increased emphasis on objective, comparable, cost-effective monitoring and assessment methods to measure progress. We apply a composite index (the vital statistics performance index [VSPI]) to assess the performance of CRVS systems in 148 countries or territories during 1980-2012 and classify them into five distinct performance categories, ranging from rudimentary (with scores close to zero) to satisfactory (with scores close to one), with a mean VSPI score since 2005 of 0·61 (SD 0·31). As expected, the best performing systems were mostly in the European region, the Americas, and Australasia, with only two countries from east Asia and Latin America. Most low-scoring countries were in the African or Asian regions. Globally, only modest progress has been made since 2000, with the percentage of deaths registered increasing from 36% to 38%, and the percentage of children aged under 5 years whose birth has been registered increasing from 58% to 65%. However, several individual countries have made substantial improvements to their CRVS systems in the past 30 years by capturing more deaths and improving accuracy of cause-of-death information. Future monitoring of the effects of CRVS strengthening will greatly benefit from application of a metric like the VSPI, which is objective, costless to compute, and able to identify components of the system that make the largest contributions to good or poor performance.
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Saúde Global , Sistemas de Informação/organização & administração , Sistema de Registros , Estatísticas Vitais , Humanos , Controle de QualidadeRESUMO
New momentum for civil registration and vital statistics (CRVS) is building, driven by the confluence of growing demands for accountability and results in health, improved equity, and rights-based approaches to development challenges, and by the immense potential of innovation and new technologies to accelerate CRVS improvement. Examples of country successes in strengthening of hitherto weak systems are emerging. The key to success has been to build collaborative partnerships involving local ownership by several sectors that span registration, justice, health, statistics, and civil society. Regional partners can be important to raise awareness, set regional goals and targets, foster country-to-country exchange and mutual learning, and build high-level political commitment. These regional partners continue to provide a platform through which country stakeholders, development partners, and technical experts can share experiences, develop and document good practices, and propose innovative approaches to tackle CRVS challenges. This country and regional momentum would benefit from global leadership, commitment, and support.
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Saúde Global , Sistemas de Informação/organização & administração , Relações Interinstitucionais , Cooperação Internacional , Sistema de Registros , Estatísticas Vitais , HumanosRESUMO
In this Series paper, we examine whether well functioning civil registration and vital statistics (CRVS) systems are associated with improved population health outcomes. We present a conceptual model connecting CRVS to wellbeing, and describe an ecological association between CRVS and health outcomes. The conceptual model posits that the legal identity that civil registration provides to individuals is key to access entitlements and services. Vital statistics produced by CRVS systems provide essential information for public health policy and prevention. These outcomes benefit individuals and societies, including improved health. We use marginal linear models and lag-lead analysis to measure ecological associations between a composite metric of CRVS performance and three health outcomes. Results are consistent with the conceptual model: improved CRVS performance coincides with improved health outcomes worldwide in a temporally consistent manner. Investment to strengthen CRVS systems is not only an important goal for individuals and societies, but also a development imperative that is good for health.
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Saúde Global , Avaliação de Resultados em Cuidados de Saúde , Melhoria de Qualidade , Sistema de Registros , Estatísticas Vitais , HumanosRESUMO
The impetus and opportunities for improving birth, death, and cause of death data have never been more propitious. Renewed country commitment to strengthen vital registration systems is clearly evident, supported by nascent regional coalitions of technical and development organisations. The announcement of a major new investment by Bloomberg Philanthropies to strengthen data systems and capacity in selected countries has the potential to catalyse and realise significant improvements in the availability and quality of data for health. This will require technical leadership, strategic intervention choices, strong country partnerships, and efficient delivery and management of multiple technical interventions across participating countries.
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Sistemas de Informação , Informática em Saúde Pública , Sistema de Registros , Estatísticas Vitais , Humanos , Sistemas de Informação/organização & administração , Sistemas de Informação/normas , Sistemas de Informação/tendências , Informática em Saúde Pública/organização & administração , Informática em Saúde Pública/normas , Informática em Saúde Pública/tendênciasRESUMO
Background: Three-quarters of births in Indonesia occur in a health facility, yet the neonatal mortality rate remains high at 15 per 1000 live births. The Pathway to Survival (P-to-S) framework of steps needed to return sick neonates and young children to health focuses on caregiver recognition of and care-seeking for severe illness. In view of increased institutional delivery in Indonesia and other low- and middle-income countries, a modified P-to-S is needed to assess the role of maternal complications in neonatal survival. Methods: We conducted a retrospective cross-sectional verbal and social autopsy study of all neonatal deaths from June through December 2018, identified by a proven listing method in two districts of Java, Indonesia. We examined care-seeking for maternal complications, delivery place, and place and timing of neonatal illness onset and death. Results: The fatal illnesses of 189/259 (73%) neonates began in their delivery facility (DF), 114/189 (60%) of whom died before discharge. Mothers whose neonate's illness started at their delivery hospital and lower-level DF were more than six times (odds ratio (OR) = 6.5; 95% confidence interval (CI) = 3.4-12.5) and twice (OR = 2.0; 95% CI = 1.01-4.02) as likely to experience a maternal complication as those whose neonates fell fatally ill in the community, and illness started earlier (mean = 0.3 vs 3.6 days; P < 0.001) and death came sooner (3.5 vs 5.3 days; P = 0.06) to neonates whose illness started at any DF. Despite going to the same number of providers/facilities, women with a labour and delivery (L/D) complication who sought care from at least one other provider or facility on route to their DF took longer than those without a complication to reach their DF (median = 3.3 vs 1.3 hours; P = 0.01). Conclusions: Neonates' fatal illness onset in their DF was strongly associated with maternal complications. Mothers with a L/D complication experienced delays in reaching their DF, and nearly half the neonatal deaths occurred in association with a complication, suggesting that mothers with complications first seeking care at a hospital providing emergency maternal and neonatal care might have prevented some deaths. A modified P-to-S highlights the importance of rapid access to quality institutional delivery care in settings where many births occur in facilities and/or there is good care-seeking for L/D complications.
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Morte Perinatal , Recém-Nascido , Criança , Humanos , Feminino , Pré-Escolar , Indonésia/epidemiologia , Estudos Retrospectivos , Estudos Transversais , Mortalidade Infantil , Mães , Instalações de SaúdeRESUMO
The purpose of this article is to quantify the amount of misclassification of the Coronavirus Disease-2019 (COVID-19) mortality occurring in hospitals and other health facilities in selected cities in Brazil, discuss potential factors contributing to this misclassification, and consider the implications for vital statistics. Hospital deaths assigned to causes classified as garbage code (GC) COVID-related cases (severe acute respiratory syndrome, pneumonia unspecified, sepsis, respiratory failure and ill-defined causes) were selected in three Brazilian state capitals. Data from medical charts and forensic reports were extracted from standard forms and analyzed by study physicians who re-assigned the underlying cause based on standardized criteria. Descriptive statistical analysis was performed and the potential impact in vital statistics in the country was also evaluated. Among 1,365 investigated deaths due to GC-COVID-related causes, COVID-19 was detected in 17.3% in the age group 0-59 years and 25.5% deaths in 60 years and over. These GCs rose substantially in 2020 in the country and were responsible for 211,611 registered deaths. Applying observed proportions by age, location and specific GC-COVID-related cause to national data, there would be an increase of 37,163 cases in the total of COVID-19 deaths, higher in the elderly. In conclusion, important undercount of deaths from COVID-19 among GC-COVID-related causes was detected in three selected capitals of Brazil. After extrapolating the study results for national GC-COVID-related deaths we infer that the burden of COVID-19 disease in Brazil in official vital statistics was probably under estimated by at least 18% in the country in 2020.
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BACKGROUND: Despite the increased access to facility-based delivery in Indonesia, the country's maternal mortality remains unacceptably high. Reducing maternal mortality requires a good understanding of the care-seeking pathways for maternal complications, especially with the government moving toward universal health coverage. This study examined care-seeking practices and health insurance in instances of pregnancy-related deaths in Jember District, East Java, Indonesia. METHODS: This was a community-based cross-sectional study to identify all pregnancy-related deaths in the district from January 2017 to December 2018. Follow-up verbal and social autopsy interviews were conducted to collect information on care-seeking behavior, health insurance, causes of death, and other factors. FINDINGS: Among 103 pregnancy-related deaths, 40% occurred after 24 hours postpartum, 36% during delivery or within the first 24 hours postpartum, and 24% occurred while pregnant. The leading causes of deaths were hemorrhage (38.8%), pregnancy-induced hypertension (20.4%), and sepsis (16.5%). Most deaths occurred in health facilities (81.6%), primarily hospitals (74.8%). Nearly all the deceased sought care from a formal health provider during their fatal illness (93.2%). Seeking any care from an informal provider during the fatal illness was more likely among women who died after 24 hours postpartum (41.0%, OR 7.4, 95% CI 1.9, 28.5, p = 0.049) or during pregnancy (29.2%, OR 4.4, 95% CI 1.0, 19.2, p = 0.003) than among those who died during delivery or within 24 hours postpartum (8.6%). There was no difference in care-seeking patterns between insured and uninsured groups. CONCLUSIONS: The fact that women sought care and reached health facilities regardless of their insurance status provides opportunities to prevent deaths by ensuring that every woman receives timely and quality care. Accordingly, the increasing demand should be met with balanced readiness of both primary care and hospitals to provide quality care, supported by an effective referral system.
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Mortalidade Materna , Aceitação pelo Paciente de Cuidados de Saúde , Estudos Transversais , Feminino , Humanos , Indonésia/epidemiologia , Seguro Saúde , GravidezRESUMO
OBJECTIVES: To assess the quality of cause of death reporting in Shanghai for both hospital and home deaths. DESIGN AND SETTING: Medical records review (MRR) to independently establish a reference data set against which to compare original and adjusted diagnoses from a sample of three tertiary hospitals, one secondary level hospital and nine community health centres in Shanghai. PARTICIPANTS: 1757 medical records (61% males, 39% females) of deaths that occurred in these sample sites in 2017 were reviewed using established diagnostic standards. INTERVENTIONS: None. PRIMARY OUTCOME: Original underlying cause of death (UCOD) from medical facilities. SECONDARY OUTCOME: Routine UCOD assigned from the Shanghai Civil Registration and Vital Statistics (CRVS) system and MRR UCODs from MRR. RESULTS: The original UCODs as assigned by doctors in the study facilities were of relatively low quality, reduced to 31% of deaths assigned to garbage codes, reduced to 2.3% following data quality and follow back procedures routinely applied by the Shanghai CRVS system. The original UCOD had lower chance-corrected concordance and cause-specific mortality fraction accuracy of 0.57 (0.44, 0.70) and 0.66, respectively, compared with 0.75 (0.66, 0.85) and 0.96, respectively, after routine data checking procedures had been applied. CONCLUSIONS: Training in correct death certification for clinical doctors, especially tertiary hospital doctors, is essential to improve UCOD quality in Shanghai. A routine quality control system should be established to actively track diagnostic performance and provide feedback to individual doctors or facilities as needed.
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Estatísticas Vitais , Causas de Morte , China/epidemiologia , Atestado de Óbito , Feminino , Humanos , Masculino , Prontuários Médicos , Estudos RetrospectivosRESUMO
BACKGROUND: The Government of Indonesia is determined to follow global commitments to reduce the neonatal mortality rate. Yet, there is a paucity of information on contributing factors and causes of neonatal deaths, particularly at the sub-national level. This study describes care-seeking during neonates' fatal illnesses and their causes of death. METHODS: We conducted a cross-sectional community-based study to identify all neonatal deaths in Serang and Jember Districts, Indonesia. Follow-up interviews were conducted with the families of deceased neonates using an adapted verbal and social autopsy instrument. Cause of death was determined using the InSilicoVA algorithm. RESULTS: The main causes of death of 259 neonates were prematurity (44%) and intrapartum-related events (IPRE)-mainly birth asphyxia (39%). About 83% and 74% of the 259 neonates were born and died at a health facility, respectively; 79% died within the first week after birth. Of 70 neonates whose fatal illness began at home, 59 (84%) sought care during the fatal illness. Forty-eight of those 59 neonates went to a formal care provider; 36 of those 48 neonates (75%) were moderately or severely ill when the family decided to seek care. One hundred fifteen of 189 neonates (61%) whose fatal illnesses began at health facilities were born at a hospital. Among those 115, only 24 (21%) left the hospital alive-of whom 16 (67%) were referred by the hospital. CONCLUSIONS: The high proportion of deaths due to prematurity and IPRE suggests the need for improved management of small and asphyxiated newborns. The moderate to severe condition of neonates at the time when care was sought from home highlights the importance of early illness recognition and appropriate management for sick neonates. Among deceased neonates whose fatal illness began at their delivery hospital, the high proportion of referrals may indicate issues with hospital capability, capacity, and/or cost.
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Asfixia Neonatal , Morte Perinatal , Autopsia , Causas de Morte , Estudos Transversais , Feminino , Humanos , Indonésia/epidemiologia , Lactente , Mortalidade Infantil , Recém-NascidoRESUMO
Over the past 70 years, significant advances have been made in determining the causes of death in populations not served by official medical certification of cause at the time of death using a technique known as Verbal Autopsy (VA). VA involves an interview of the family or caregivers of the deceased after a suitable bereavement interval about the circumstances, signs and symptoms of the deceased in the period leading to death. The VA interview data are then interpreted by physicians or, more recently, computer algorithms, to assign a probable cause of death. VA was originally developed and applied in field research settings. This paper traces the evolution of VA methods with special emphasis on the World Health Organization's (WHO)'s efforts to standardize VA instruments and methods for expanded use in routine health information and vital statistics systems in low- and middle-income countries (LMICs). These advances in VA methods are culminating this year with the release of the 2022 WHO Standard Verbal Autopsy (VA) Toolkit. This paper highlights the many contributions the late Professor Peter Byass made to the current VA standards and methods, most notably, the development of InterVA, the most commonly used automated computer algorithm for interpreting data collected in the WHO standard instruments, and the capacity building in low- and middle-income countries (LMICs) that he promoted. This paper also provides an overview of the methods used to improve the current WHO VA standards, a catalogue of the changes and improvements in the instruments, and a mapping of current applications of the WHO VA standard approach in LMICs. It also provides access to tools and guidance needed for VA implementation in Civil Registration and Vital Statistics Systems at scale.
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Estatísticas Vitais , Autopsia/métodos , Causas de Morte , Certificação , Humanos , Masculino , PobrezaRESUMO
Although HIV positive patients' adherence to antiretroviral therapy (ART) is relatively high in African nations, as compared with industrialized nations, few studies have explored why. In the research presented here we aimed to understand the dynamics of good adherence to ART among patients receiving free ART and HIV-related services from a clinic in Arusha, Tanzania. We conducted individual semi-structured interviews with 6 health care providers and 36 patients at a health care center in Arusha in 2006. Interviews were conducted in Swahili using interview guides informed by social cognitive theory. All interviews were audio-recorded, transcribed in Kiswahili, translated into English and coded for themes and patterns with ATLAS.ti. Of the 36 patients interviewed (mean time on ART 9.8 months; range 1-23 months), 32 reported perfect adherence in the previous month. Self-reported adherence was high despite economic hardship, depression, low rates of HIV disclosure and high perceived HIV-associated stigma. Five factors emerged to explain excellent adherence in the face of such barriers. First, all respondents experienced substantial improvements in their health after starting ART; this supported their confidence in the medication and motivated them to adhere. Second, their perceived need to be able to meet their family responsibilities motivated respondents to stay healthy. Third, respondents developed specific strategies to remember to take pills, particularly routinizing pill-taking by linking it with daily activities or events. Fourth, material and emotional support received from others facilitated adherence. Finally, respondents trusted the advice and instructions of their health care providers, who regularly emphasized adherence. The facilitating factors identified were consistent with the constructs of social cognitive theory and highlighted the importance of interventions that address multiple levels of influence on adherence.
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Antirretrovirais/uso terapêutico , Terapia Antirretroviral de Alta Atividade/psicologia , Infecções por HIV/tratamento farmacológico , Infecções por HIV/psicologia , Adesão à Medicação/psicologia , Adulto , Terapia Antirretroviral de Alta Atividade/economia , Atitude do Pessoal de Saúde , Atitude Frente a Saúde , Feminino , Financiamento Governamental , Política de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Relações Profissional-Paciente , Apoio Social , Fatores Socioeconômicos , Tanzânia , Adulto JovemRESUMO
BACKGROUND TO THE DEBATE: Demographic surveillance--the process of monitoring births, deaths, causes of deaths, and migration in a population over time--is one of the cornerstones of public health research, particularly in investigating and tackling health disparities. An international network of demographic surveillance systems (DSS) now operates, mostly in sub-Saharan Africa and Asia. Thirty-eight DSS sites are coordinated by the International Network for the Continuous Demographic Evaluation of Populations and Their Health (INDEPTH). In this debate, Daniel Chandramohan and colleagues argue that DSS data in the INDEPTH database should be made available to all researchers worldwide, not just to those within the INDEPTH Network. Basia Zaba and colleagues argue that the major obstacles to DSS sites sharing data are technical, managerial, and financial rather than proprietorial concerns about analysis and publication. This debate is further discussed in this month's Editorial.
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Comportamento Cooperativo , Vigilância da População/métodos , Pesquisadores , Demografia , Humanos , InternacionalidadeRESUMO
Good public-health decisionmaking is dependent on reliable and timely statistics on births and deaths (including the medical causes of death). All high-income countries, without exception, have national civil registration systems that record these events and generate regular, frequent, and timely vital statistics. By contrast, these statistics are not available in many low-income and lower-middle-income countries, even though it is in such settings that premature mortality is most severe and the need for robust evidence to back decisionmaking most critical. Civil registration also has a range of benefits for individuals in terms of legal status, and the protection of economic, social, and human rights. However, over the past 30 years, the global health and development community has failed to provide the needed technical and financial support to countries to develop civil registration systems. There is no single blueprint for establishing and maintaining such systems and ensuring the availability of sound vital statistics. Each country faces a different set of challenges, and strategies must be tailored accordingly. There are steps that can be taken, however, and we propose an approach that couples the application of methods to generate better vital statistics in the short term with capacity-building for comprehensive civil registration systems in the long run.