Are cause of death data for Shanghai fit for purpose? A retrospective study of medical records.

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.

How advanced is the epidemiological transition in Papua New Guinea? New evidence from verbal autopsy.

BACKGROUND: Reliable cause of death (COD) data are not available for the majority of deaths in Papua New Guinea (PNG), despite their critical policy value. Automated verbal autopsy (VA) methods, involving an interview and automated analysis to diagnose causes of community deaths, have recently been trialled in PNG. Here, we report VA results from three sites and highlight the utility of these methods to generate information about the leading CODs in the country. METHODS: VA methods were introduced in one district in each of three provinces: Alotau in Milne Bay; Tambul-Nebilyer in Western Highlands; and Talasea in West New Britain. VA interviews were conducted using the Population Health Metrics Research Consortium (PHMRC) shortened questionnaire and analysed using the SmartVA automated diagnostic algorithm. RESULTS: A total of 1655 VAs were collected between June 2018 and November 2019, 87.0% of which related to deaths at age 12 years and over. Our findings suggest a continuing high proportion of deaths due to infectious diseases (27.0%) and a lower proportion of deaths due to non-communicable diseases (NCDs) (50.8%) than estimated by the Global Burden of Disease Study (GBD) 2017: 16.5% infectious diseases and 70.5% NCDs. The proportion of injury deaths was also high compared with GBD: 22.5% versus 13.0%. CONCLUSIONS: Health policy in PNG needs to address a 'triple burden' of high infectious mortality, rising NCDs and a high fraction of deaths due to injuries. This study demonstrates the potential of automated VA methods to generate timely, reliable and policy-relevant data on COD patterns in hard-to-reach populations in PNG.

Equity in disease prevention: Vaccines for the older adults - a national workshop, Australia 2014.

On the 20th June, 2014 the National Health and Medical Research Council's Centre for Research Excellence in Population Health "Immunisation in under Studied and Special Risk Populations", in collaboration with the Public Health Association of Australia, hosted a workshop "Equity in disease prevention: vaccines for the older adults". The workshop featured international and national speakers on ageing and vaccinology. The workshop was attended by health service providers, stakeholders in immunisation, ageing, primary care, researchers, government and non-government organisations, community representatives, and advocacy groups. The aims of the workshop were to: provide an update on the latest evidence around immunisation for the older adults; address barriers for prevention of infection in the older adults; and identify immunisation needs of these groups and provide recommendations to inform policy. There is a gap in immunisation coverage of funded vaccines between adults and infants. The workshop reviewed provider misconceptions, lack of Randomised Control Trials (RCT) and cost-effectiveness data in the frail elderly, loss of autonomy, value judgements and ageism in health care and the need for an adult vaccination register. Workshop recommendations included recognising the right of elderly people to prevention, the need for promotion in the community and amongst healthcare workers of the high burden of vaccine preventable diseases and the need to achieve high levels of vaccination coverage, in older adults and in health workers involved in their care. Research into new vaccine strategies for older adults which address poor coverage, provider attitudes and immunosenescence is a priority. A well designed national register for tracking vaccinations in older adults is a vital and basic requirement for a successful adult immunisation program. Eliminating financial barriers, by addressing inequities in the mechanisms for funding and subsidising vaccines for the older adults compared to those for children, is important to improve equity of access and vaccination coverage. Vaccination coverage rates should be included in quality indicators of care in residential aged care for older adults. Vaccination is key to healthy ageing, and there is a need to focus on reducing the immunisation gap between adults and children.

Measuring subnational under-5 mortality: lessons from a survey in the eastern Indonesian district of Ende.

There is an urgent need for measurements of the magnitude and determinants of under-5 mortality at the district level in Indonesia. This article describes a sample household survey conducted in Ende District, East Nusa Tenggara province. Complete birth histories were recorded from all women residing in a sample of 32 villages (7454 households) of Ende. The survey was conducted in early 2010, deriving measures for the period 2000-2009. The survey instrument also included key variables required to measure determinants of under-5 mortality. The results showed that there are significant differentials in under-5 mortality risk within Ende, ranging from 27 to 85 per 1000. This information will assist the district health office to implement maternal and child health programs to meet national targets for United Nations Millennium Development Goal 4. The findings provide robust mortality measures at the district level and demonstrate the feasibility of conducting such a study using local resources, in a short time, and with low costs.

Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010.

BACKGROUND: Reliable and timely information on the leading causes of death in populations, and how these are changing, is a crucial input into health policy debates. In the Global Burden of Diseases, Injuries, and Risk Factors Study 2010 (GBD 2010), we aimed to estimate annual deaths for the world and 21 regions between 1980 and 2010 for 235 causes, with uncertainty intervals (UIs), separately by age and sex. METHODS: We attempted to identify all available data on causes of death for 187 countries from 1980 to 2010 from vital registration, verbal autopsy, mortality surveillance, censuses, surveys, hospitals, police records, and mortuaries. We assessed data quality for completeness, diagnostic accuracy, missing data, stochastic variations, and probable causes of death. We applied six different modelling strategies to estimate cause-specific mortality trends depending on the strength of the data. For 133 causes and three special aggregates we used the Cause of Death Ensemble model (CODEm) approach, which uses four families of statistical models testing a large set of different models using different permutations of covariates. Model ensembles were developed from these component models. We assessed model performance with rigorous out-of-sample testing of prediction error and the validity of 95% UIs. For 13 causes with low observed numbers of deaths, we developed negative binomial models with plausible covariates. For 27 causes for which death is rare, we modelled the higher level cause in the cause hierarchy of the GBD 2010 and then allocated deaths across component causes proportionately, estimated from all available data in the database. For selected causes (African trypanosomiasis, congenital syphilis, whooping cough, measles, typhoid and parathyroid, leishmaniasis, acute hepatitis E, and HIV/AIDS), we used natural history models based on information on incidence, prevalence, and case-fatality. We separately estimated cause fractions by aetiology for diarrhoea, lower respiratory infections, and meningitis, as well as disaggregations by subcause for chronic kidney disease, maternal disorders, cirrhosis, and liver cancer. For deaths due to collective violence and natural disasters, we used mortality shock regressions. For every cause, we estimated 95% UIs that captured both parameter estimation uncertainty and uncertainty due to model specification where CODEm was used. We constrained cause-specific fractions within every age-sex group to sum to total mortality based on draws from the uncertainty distributions. FINDINGS: In 2010, there were 52·8 million deaths globally. At the most aggregate level, communicable, maternal, neonatal, and nutritional causes were 24·9% of deaths worldwide in 2010, down from 15·9 million (34·1%) of 46·5 million in 1990. This decrease was largely due to decreases in mortality from diarrhoeal disease (from 2·5 to 1·4 million), lower respiratory infections (from 3·4 to 2·8 million), neonatal disorders (from 3·1 to 2·2 million), measles (from 0·63 to 0·13 million), and tetanus (from 0·27 to 0·06 million). Deaths from HIV/AIDS increased from 0·30 million in 1990 to 1·5 million in 2010, reaching a peak of 1·7 million in 2006. Malaria mortality also rose by an estimated 19·9% since 1990 to 1·17 million deaths in 2010. Tuberculosis killed 1·2 million people in 2010. Deaths from non-communicable diseases rose by just under 8 million between 1990 and 2010, accounting for two of every three deaths (34·5 million) worldwide by 2010. 8 million people died from cancer in 2010, 38% more than two decades ago; of these, 1·5 million (19%) were from trachea, bronchus, and lung cancer. Ischaemic heart disease and stroke collectively killed 12·9 million people in 2010, or one in four deaths worldwide, compared with one in five in 1990; 1·3 million deaths were due to diabetes, twice as many as in 1990. The fraction of global deaths due to injuries (5·1 million deaths) was marginally higher in 2010 (9·6%) compared with two decades earlier (8·8%). This was driven by a 46% rise in deaths worldwide due to road traffic accidents (1·3 million in 2010) and a rise in deaths from falls. Ischaemic heart disease, stroke, chronic obstructive pulmonary disease (COPD), lower respiratory infections, lung cancer, and HIV/AIDS were the leading causes of death in 2010. Ischaemic heart disease, lower respiratory infections, stroke, diarrhoeal disease, malaria, and HIV/AIDS were the leading causes of years of life lost due to premature mortality (YLLs) in 2010, similar to what was estimated for 1990, except for HIV/AIDS and preterm birth complications. YLLs from lower respiratory infections and diarrhoea decreased by 45-54% since 1990; ischaemic heart disease and stroke YLLs increased by 17-28%. Regional variations in leading causes of death were substantial. Communicable, maternal, neonatal, and nutritional causes still accounted for 76% of premature mortality in sub-Saharan Africa in 2010. Age standardised death rates from some key disorders rose (HIV/AIDS, Alzheimer's disease, diabetes mellitus, and chronic kidney disease in particular), but for most diseases, death rates fell in the past two decades; including major vascular diseases, COPD, most forms of cancer, liver cirrhosis, and maternal disorders. For other conditions, notably malaria, prostate cancer, and injuries, little change was noted. INTERPRETATION: Population growth, increased average age of the world's population, and largely decreasing age-specific, sex-specific, and cause-specific death rates combine to drive a broad shift from communicable, maternal, neonatal, and nutritional causes towards non-communicable diseases. Nevertheless, communicable, maternal, neonatal, and nutritional causes remain the dominant causes of YLLs in sub-Saharan Africa. Overlaid on this general pattern of the epidemiological transition, marked regional variation exists in many causes, such as interpersonal violence, suicide, liver cancer, diabetes, cirrhosis, Chagas disease, African trypanosomiasis, melanoma, and others. Regional heterogeneity highlights the importance of sound epidemiological assessments of the causes of death on a regular basis. FUNDING: Bill & Melinda Gates Foundation.

Mortality from diabetic renal disease: a hidden epidemic.

BACKGROUND: Population-level mortality indicators can be useful outcome measures of diabetes care. Death registration systems serve as the main source of data for such measures. However, standard mortality indicators based on underlying causes do not adequately reflect the burden from diabetic renal disease. METHODS: This article presents findings from analysis of multiple causes of death available from death registration data for Australia and USA. Both countries use an automated system that applies prescribed rules to select and code the underlying cause for each registered death. Deaths with diabetes as underlying cause were grouped according to their diabetic complications as defined by the International Classification of Diseases. Age-standardized mortality rates were calculated for the underlying cause rubric 'diabetes with renal complications'. These were contrasted with rates calculated using additional deaths where diabetes was the underlying cause and renal failure was listed as a consequence. RESULTS: These analyses identified that current automated programmes code three-fourths of all diabetes deaths to 'diabetes without complications', despite additional factors being listed. Estimated multiple cause death rates from diabetic renal disease are four to nine times higher than underlying cause rates for 'diabetes with renal complications' in both countries; and show a rising trend in contrast to the latter. CONCLUSION: These findings indicate that routine underlying cause statistics for USA and Australia grossly under estimate mortality from diabetic renal disease. Clear guidelines on the certification, coding and statistical presentation of diabetes mortality are needed for epidemiology and health policy.

The impact of the stopping rule on sex ratio of last births in Vietnam.

This study examines the hypothesis that the stopping rule - a traditional postnatal sex selection method where couples decide to cease childbearing once they bear a son - plays a role in high sex ratio of last births (SRLB). The study develops a theoretical framework to demonstrate the operation of the stopping rule in a context of son preference. This framework was used to demonstrate the impact of the stopping rule on the SRLB in Vietnam, using data from the Population Change Survey 2006. The SRLB of Vietnam was high at the level of 130 in the period 1970-2006, and particularly in the period 1986-1995, when sex-selective abortion was not available. Women were 21% more likely to stop childbearing after a male birth compared with a female birth. The SRLB was highest at parity 2 (138.7), particularly in rural areas (153.5), and extremely high (181.9) when the previous birth was female. Given the declining fertility, the stopping rule has a potential synergistic effect with sex-selective abortion to accentuate a trend of one-son families in the population.

Utility of local health registers in measuring perinatal mortality: a case study in rural Indonesia.

BACKGROUND: Perinatal mortality is an important indicator of obstetric and newborn care services. Although the vast majority of global perinatal mortality is estimated to occur in developing countries, there is a critical paucity of reliable data at the local level to inform health policy, plan health care services, and monitor their impact. This paper explores the utility of information from village health registers to measure perinatal mortality at the sub district level in a rural area of Indonesia. METHODS: A retrospective pregnancy cohort for 2007 was constructed by triangulating data from antenatal care, birth, and newborn care registers in a sample of villages in three rural sub districts in Central Java, Indonesia. For each pregnancy, birth outcome and first week survival were traced and recorded from the different registers, as available. Additional local death records were consulted to verify perinatal mortality, or identify deaths not recorded in the health registers. Analyses were performed to assess data quality from registers, and measure perinatal mortality rates. Qualitative research was conducted to explore knowledge and practices of village midwives in register maintenance and reporting of perinatal mortality. RESULTS: Field activities were conducted in 23 villages, covering a total of 1759 deliveries that occurred in 2007. Perinatal mortality outcomes were 23 stillbirths and 15 early neonatal deaths, resulting in a perinatal mortality rate of 21.6 per 1000 live births in 2007. Stillbirth rates for the study population were about four times the rates reported in the routine Maternal and Child Health program information system. Inadequate awareness and supervision, and alternate workload were cited by local midwives as factors resulting in inconsistent data reporting. CONCLUSIONS: Local maternal and child health registers are a useful source of information on perinatal mortality in rural Indonesia. Suitable training, supervision, and quality control, in conjunction with computerisation to strengthen register maintenance can provide routine local area measures of perinatal mortality for health policy, and monitoring of newborn care interventions. Similar efforts are required to strengthen routine health data in all developing countries, to guide planned progress towards reduction in the local, national and international burden from perinatal mortality.

Using historical vital statistics to predict the distribution of under-five mortality by cause.

BACKGROUND: Cause-specific mortality data is essential for planning intervention programs to reduce mortality in the under age five years population (under-five). However, there is a critical paucity of such information for most of the developing world, particularly where progress towards the United Nations Millennium Development Goal 4 (MDG 4) has been slow. This paper presents a predictive cause of death model for under-five mortality based on historical vital statistics and discusses the utility of the model in generating information that could accelerate progress towards MDG 4. METHODS: Over 1400 country years of vital statistics from 34 countries collected over a period of nearly a century were analyzed to develop relationships between levels of under-five mortality, related mortality ratios, and proportionate mortality from four cause groups: perinatal conditions; diarrhea and lower respiratory infections; congenital anomalies; and all other causes of death. A system of multiple equations with cross-equation parameter restrictions and correlated error terms was developed to predict proportionate mortality by cause based on given measures of under-five mortality. The strength of the predictive model was tested through internal and external cross-validation techniques. Modeled cause-specific mortality estimates for major regions in Africa, Asia, Central America, and South America are presented to illustrate its application across a range of under-five mortality rates. RESULTS: Consistent and plausible trends and relationships are observed from historical data. High mortality rates are associated with increased proportions of deaths from diarrhea and lower respiratory infections. Perinatal conditions assume importance as a proportionate cause at under-five mortality rates below 60 per 1000 live births. Internal and external validation confirms strength and consistency of the predictive model. Model application at regional level demonstrates heterogeneity and non-linearity in cause-composition arising from the range of under-five mortality rates and related mortality ratios. CONCLUSIONS: Historical analyses suggest that under-five mortality transitions are associated with significant changes in cause of death composition. Sub-national differentials in under-five mortality rates could require intervention programs targeted to address specific cause distributions. The predictive model could, therefore, help set broad priorities for interventions at the local level based on periodic under-five mortality measurement. Given current resource constraints, such priority setting mechanisms are essential to accelerate reductions in under-five mortality.

Mortality in Central Java: results from the indonesian mortality registration system strengthening project.

BACKGROUND: Mortality statistics from death registration systems are essential for health policy and development. Indonesia has recently mandated compulsory death registration across the entire country in December 2006. This article describes the methods and results from activities to ascertain causes of registered deaths in two pilot registration areas in Central Java during 2006-2007. The methods involved several steps, starting with adaptation of international standards for reporting causes of registered deaths for implementation in two sites, Surakarta (urban) and Pekalongan (rural). Causes for hospital deaths were certified by attending physicians. Verbal autopsies were used for home deaths. Underlying causes were coded using ICD-10. Completeness of registration was assessed in a sample of villages and urban wards by triangulating data from the health sector, the civil registration system, and an independent household survey. Finally, summary mortality indicators and cause of death rankings were developed for each site. FINDINGS: A total of 10,038 deaths were registered in the two sites during 2006-2007; yielding annual crude death rates of 5.9 to 6.8 per 1000. Data completeness was higher in rural areas (72.5%) as compared to urban areas (52%). Adjusted life expectancies at birth were higher for both males and females in the urban population as compared to the rural population. Stroke, ischaemic heart disease and chronic respiratory disease are prominent causes in both populations. Other important causes are diabetes and cancer in urban areas; and tuberculosis and diarrhoeal diseases in rural areas. CONCLUSIONS: Non-communicable diseases cause a significant proportion of premature mortality in Central Java. Implementing cause of death reporting in conjunction with death registration appears feasible in Indonesia. Better collaboration between health and registration sectors is required to improve data quality. These are the first local mortality measures for health policy and monitoring in Indonesia. Strong demand for data from different stakeholders can stimulate further strengthening of mortality registration systems.

Maternal socioeconomic and demographic factors associated with the sex ratio at birth in Vietnam.

In recent years Vietnam has experienced a high sex ratio at birth (SRB) amidst rapid socioeconomic and demographic changes. However, little is known about the differentials in SRB between maternal socioeconomic and demographic groups. The paper uses data from the annual Population Change Survey (PCS) in 2006 to examine the relationship of the sex ratio of the most recent birth with maternal socioeconomic and demographic characteristics and the number of previous female births. The SRB of Vietnam was significantly high at 111.4 (95% CI 109.7-113.1) for the period 1st April 2000 to 31st March 2006. Multivariate analysis reveals that sex of the most recent birth is strongly related with the number of previous female births. This association is consistent across different socioeconomic and demographic groups of women. Given the high SRB in Vietnam, further research into the reasons for high SRB in these groups is required, as are intervention programmes such as those raising the public awareness of its negative consequences.

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. METHODS: A nationally representative sample of 11,984 deaths in 2005 was selected, and verbal autopsy interviews were conducted for almost 10,000 deaths. Verbal autopsy procedures were validated against 2,558 cases for which medical record review was possible. Misclassification matrices for leading causes of death, including ill-defined causes, were developed separately for deaths inside and outside of hospitals and proportionate mortality distributions constructed. Estimates of mortality undercount were derived from "capture-recapture" methods applied to the 2005-06 Survey of Population Change. Proportionate mortality distributions were applied to this mortality "envelope" and ill-defined causes redistributed according to Global Burden of Disease methods to yield final estimates of mortality levels and patterns in 2005. RESULTS: Estimated life expectancy in Thailand in 2005 was 68.5 years for males and 75.6 years for females, two years lower than vital registration data suggest. Upon correction, stroke is the leading cause of death in Thailand (10.7%), followed by ischemic heart disease (7.8%) and HIV/AIDS (7.4%). Other leading causes are road traffic accidents (males) and diabetes mellitus (females). In many cases, estimated mortality is at least twice what is estimated in vital registration. Leading causes of death have remained stable since 1999, with the exception of a large decline in HIV/AIDS mortality. CONCLUSIONS: Field research into the accuracy of cause-of-death data can result in substantially different patterns of mortality than suggested by routine death registration. Misclassification errors are likely to have very significant implications for health policy debates. Routine incorporation of validated verbal autopsy methods could significantly improve cause-of-death data quality in Thailand.

Cause-of-death ascertainment for deaths that occur outside hospitals in Thailand: application of verbal autopsy methods.

BACKGROUND: Ascertainment of cause for deaths that occur in the absence of medical attention is a significant problem in many countries, including Thailand, where more than 50% of such deaths are registered with ill-defined causes. Routine implementation of standardized, rigorous verbal autopsy methods is a potential solution. This paper reports findings from field research conducted to develop, test, and validate the use of verbal autopsy (VA) methods in Thailand. METHODS: International verbal autopsy methods were first adapted to the Thai context and then implemented to ascertain causes of death for a nationally representative sample of 11,984 deaths that occurred in Thailand in 2005. Causes of death were derived from completed VA questionnaires by physicians trained in ICD-based cause-of-death certification. VA diagnoses were validated in the sample of hospital deaths for which reference diagnoses were available from medical record review. Validated study findings were used to adjust VA-based causes of death derived for deaths in the study sample that had occurred outside hospitals. Results were used to estimate cause-specific mortality patterns for deaths outside hospitals in Thailand in 2005. RESULTS: VA-based causes of death were derived for 6,328 out of 7,340 deaths in the study sample that had occurred outside hospitals, constituting the verification arm of the study. The use of VA resulted in large-scale reassignment of deaths from ill-defined categories to specific causes of death. The validation study identified that VA tends to overdiagnose important causes such as diabetes, liver cancer, and tuberculosis, while undercounting deaths from HIV/AIDS, liver diseases, genitourinary (essential renal), and digestive system disorders. CONCLUSIONS: The use of standard VA methods adapted to Thailand enabled a plausible assessment of cause-specific mortality patterns and a substantial reduction of ill-defined diagnoses. Validation studies enhance the utility of findings from the application of verbal autopsy. Regular implementation of VA in Thailand could accelerate development of the quality and utility of vital registration data for deaths outside hospitals.

Mortality patterns in Vietnam, 2006: Findings from a national verbal autopsy survey.

BACKGROUND: Accurate nationally representative statistics on total and cause-specific mortality in Vietnam are lacking due to incomplete capture in government reporting systems. This paper presents total and cause-specific mortality results from a national verbal autopsy survey conducted first time in Vietnam in conjunction with the annual population change survey and discusses methodological and logistical challenges associated with the implementation of a nation-wide assessment of mortality based on surveys.Verbal autopsy interviews, using the WHO standard questionnaire, were conducted with close relatives of the 6798 deaths identified in the 2007 population change survey in Vietnam. Data collectors were health staff recruited from the commune health station who undertook 3-day intensive training on VA interview. The Preston-Coale method assessed the level of completeness of mortality reporting from the population change survey. The number of deaths in each age-sex grouping is inflated according to the estimate of completeness to produce an adjusted number of deaths. Underlying causes of death were aggregated to the International Classification of Diseases Mortality Tabulation List 1. Leading causes of death were tabulated by sex for three broad age groups: 0-14 years; 15-59 years; and 60 years and above. FINDINGS: Completeness of mortality reporting was 69% for males and 54% for females with substantial regional variation. The use of VA has resulted in 10% of deaths being classified to ill-defined among males, and 15% among females. More ill-defined deaths were reported among the 60 year or above age group. Incomplete death reporting, wide geographical dispersal of deaths, extensive travel between households, and substantial variation in local responses to VA interviews challenged the implementation of a national mortality and cause of death assessment based on surveys. CONCLUSIONS: Verbal autopsy can be a viable tool to identify cause of death in Vietnam. However logistical challenges limit its use in conjunction with the national sample survey. Sentinel population clusters for mortality surveillance should be tested to develop an effective and sustainable option for routine mortality and cause of death data collection in Vietnam.

Changes in certification of diabetes with cardiovascular diseases increased reported diabetes mortality in Australia and the United States.

OBJECTIVE: This paper seeks to better understand diabetes-related mortality in Australia and the United States through analysis of the impact of certification practices of diabetes as a multiple cause of death, specifically with cardiovascular diseases (CVDs). STUDY DESIGN AND SETTING: Vital registration multiple cause of death data in Australia and the United States since 1999 are used to examine trends in the ratio of diabetes reported in Part I (underlying cause) and Part II (associated cause) of the death certificate, when CVDs are also reported. RESULTS: Underlying cause of death (UCOD) statistics mask the magnitude of diabetes-related mortality. In both countries, since 1999 there has been an increase in the ratio of diabetes deaths in Part I vs. Part II where CVD deaths, including ischemic heart disease and cerebrovascular diseases, are also reported. In Australia, diabetes reported as an UCOD would be 12% lower in 2006 if the ratio from 1999 was applied. CONCLUSION: The increasing likelihood of physicians to report diabetes in Part I reflects the subjectivity of diabetes death certification. There is a need for specific guidelines on death certification of diabetes with cardiovascular conditions, relating to its reporting as an underlying or associated cause.

Unmet need for contraception among HIV-positive women in Lesotho and implications for mother-to-child transmission.

In Lesotho, the risk of mother-to-child-transmission (MTCT) of HIV is substantial; women of childbearing age have a high HIV prevalence rate (26.4%), low knowledge of HIV status and a total fertility rate of 3.5 births per woman. An effective means of preventing MTCT is to reduce unwanted fertility. This paper examines the unmet need for contraception to limit and space births among HIV-positive women in Lesotho aged 15-49 years, using the 2004 Lesotho Demographic and Health Survey. HIV-positive women have their need for contraception unmet in almost one-third of cases, and multivariate analysis reveals this unmet need is most likely amongst the poor and amongst those not approving of family planning. Urgent action is needed to lower the level of unmet need and reduce MTCT. A constructive strategy is to improve access to family planning for all women in Lesotho, irrespective of HIV status, and, more specifically, integrate family planning with MTCT prevention and voluntary counselling and testing services.

HIV status and age at first marriage among women in Cameroon.

Recent research has highlighted the risk of HIV infection for married teenage women compared with their unmarried counterparts (Clark, 2004). This study assesses whether a relationship exists, for women who have completed their adolescence (age 20-29 years), between HIV status with age at first marriage and the length of time between first sex and first marriage. Multivariate analysis utilizing the nationally representative 2004 Cameroon Demographic and Health Survey shows that late-marrying women and those with a longer period of pre-marital sex have the highest risk of HIV. Although women in urban areas overall marry later than their rural counterparts, the positive relationship between age at marriage and HIV risk is stronger in rural areas. The higher wealth status and greater number of lifetime sexual partners of late-marrying women contribute to their higher HIV risk. Given that the age at first marriage and the gap between first marriage and first sex have increased in recent years, focusing preventive efforts on late-marrying women will be of much importance in reducing HIV prevalence among females.