Comparing tariff and medical assistant assigned causes of death from verbal autopsy interviews in Matlab, Bangladesh: implications for a health and demographic surveillance system.

BACKGROUND: Deaths in developing countries often occur outside health facilities, making it extremely difficult to gather reliable cause of death (COD) information. Automated COD assignment using a verbal autopsy instrument (VAI) has been proposed as a reliable and cost-effective alternative to traditional physician-certified verbal autopsy, but its performance is still being evaluated. The purpose of this study was to compare the similarity of diagnosis by Medical Assistants (MA) in the Matlab Health and Demographic Surveillance System (HDSS) with the SmartVA Analyze 1.2 (Tariff 2.0) diagnosis. METHODS: This study took place between January 2011 and April 2014 in Matlab, Bangladesh. MA with 3 years of medical training assigned COD to Matlab residents by reviewing the information collected using the Population Health Metrics Research Consortium (PHMRC) long-form VAI. Smart VA Analyze 1.2 automatically assigned COD using the same questionnaire. COD agreement and cause-specific mortality fractions (CSMFs) were compared for MA and Tariff. RESULTS: Of the 4969 verbal autopsy cases reviewed, 4328 were adults, 296 were children, and 345 were neonates. Cohen's kappa was 0.38 (0.36, 0.40) for adults, 0.43 (0.38, 0.49) for children, and 0.27 (0.22, 0.33) for neonates. For adults, the top two COD for MA were stroke (29.6%) and ischemic heart diseases (IHD) (14.2%) and for Tariff these were stroke (32.0%) and IHD (14.0%). For children, the top two COD for MA were drowning (33.5%) and pneumonia (13.2%) and for Tariff these were also drowning (36.8%) and pneumonia (12.4%). For neonates, the top two COD for MA were birth asphyxia (41.2%) and meningitis/sepsis (22.3%) and for Tariff these were birth asphyxia (37.0%) and preterm delivery (30.9%). CONCLUSION: The CSMFs for Tariff and MA showed very close agreement across all age categories but some differences were observed for neonate preterm delivery and meningitis/sepsis. Given the known advantages of automated methods over physician certified verbal autopsy, the SmartVA software, incorporating the shortened VAI questionnaire and Tariff 2.0, could serve as a cost-effective alternative to Matlab MA to routinely collect and analyze verbal autopsy data in a HDSS to generate essential population level COD data for planning.

The quality of medical death certification of cause of death in hospitals in rural Bangladesh: impact of introducing the International Form of Medical Certificate of Cause of Death.

BACKGROUND: Accurate and timely data on cause of death are critically important for guiding health programs and policies. Deaths certified by doctors are implicitly considered to be reliable and accurate, yet the quality of information provided in the international Medical Certificate of Cause of Death (MCCD) usually varies according to the personnel involved in certification, the diagnostic capacity of the hospital, and the category of hospitals. There are no published studies that have analysed how certifying doctors in Bangladesh adhere to international rules when completing the MCCD or have assessed the quality of clinical record keeping. METHODS: The study took place between January 2011 and April 2014 in the Chandpur and Comilla districts of Bangladesh. We introduced the international MCCD to all study hospitals. Trained project physicians assigned an underlying cause of death, assessed the quality of the death certificate, and reported the degree of certainty of the medical records provided for a given cause. We examined the frequency of common errors in completing the MCCD, the leading causes of in-hospital deaths, and the degree of certainty in the cause of death data. RESULTS: The study included 4914 death certificates. 72.9% of medical records were of too poor quality to assign a cause of death, with little difference by age, hospital, and cause of death. 95.6% of death certificates did not indicate the time interval between onset and death, 31.6% required a change in sequence, 13.9% required to include a new diagnosis, 50.7% used abbreviations, 41.5% used multiple causes per line, and 33.2% used an ill-defined condition as the underlying cause of death. 99.1% of death certificates had at least one error. The leading cause of death among adults was stroke (15.8%), among children was pneumonia (31.7%), and among neonates was birth asphyxia (52.8%). CONCLUSION: Physicians in Bangladeshi hospitals had difficulties in completing the MCCD correctly. Physicians routinely made errors in death certification practices and medical record quality was poor. There is an urgent need to improve death certification practices and the quality of hospital data in Bangladesh if these data are to be useful for policy.

Implementing the PHMRC shortened questionnaire: Survey duration of open and closed questions in three sites.

BACKGROUND: More countries are using verbal autopsy as a part of routine mortality surveillance. The length of time required to complete a verbal autopsy interview is a key logistical consideration for planning large-scale surveillance. METHODS: We use the PHMRC shortened questionnaire to conduct verbal autopsy interviews at three sites and collect data on the length of time required to complete the interview. This instrument uses a novel checklist of keywords to capture relevant information from the open response. The open response section is timed separately from the section consisting of closed questions. RESULTS: We found the median time to complete the entire interview was approximately 25 minutes and did not vary substantially by age-specific module. The median time for the open response section was approximately 4 minutes and 60% of interviewees mentioned at least one keyword within the open response section. CONCLUSIONS: The length of time required to complete the interview was short enough for large-scale routine use. The open-response section did not add a substantial amount of time and provided useful information which can be used to increase the accuracy of the predictions of the cause of death. The novel checklist approach further reduces the burden of transcribing and translating a large amount of free text. This makes the PHMRC instrument ideal for national mortality surveillance.

Bacterial contaminants in carbonated soft drinks sold in Bangladesh markets.

A total of 225 carbonated soft drink (CSD) samples from nine brands, from various locations in five metropolitan cities of Bangladesh were examined to determine their bacteriological quality. Most samples were not in compliance with microbiological standards set by organizations like the World Health Organization (WHO). Pseudomonas aeruginosa was the predominant species with an incidence of 95%. Streptococcus spp. and Bacillus stearothermophilus were the next most prevalent with numbers ranging from 6 to 122 and 9 to 105 cfu/100 ml, respectively. Fifty four percent of the samples yielded Salmonella spp. at numbers ranging from 2 to 90 cfu/100 ml. Total coliform (TC) and faecal coliform (FC) counts were found in 68-100% and 76-100% of samples of individual brands, at numbers ranging from 5 to 213 and 3 to 276 cfu/100 ml, respectively. According to WHO standards 60-88% of samples from six brands and 32% and 40% of samples from two other brands belonged to the intermediate risk group with FC counts of 100-1000 cfu/100 ml. Heterotrophic plate counts, however, were under the permissible limit in all 225 samples. These findings suggest that carbonated soft drinks commercially available in Bangladesh pose substantial risks to public health.