Linking mortuary data improves vital statistics on cause of death of children under five years in the Western Cape Province of South Africa.

OBJECTIVES: Reducing child mortality requires good information on its causes. Whilst South African vital registration data have improved, the quality of cause-of-death data remains inadequate. To improve this, data from death certificates were linked with information from forensic mortuaries in Western Cape Province. METHODS: A local mortality surveillance system was established in 2007 by the Western Cape Health Department to improve data quality. Cause-of-death data were captured from copies of death notification forms collected at Department of Home Affairs Offices. Using unique identifiers, additional forensic mortuary data were linked with mortality surveillance system records. Causes of death were coded to the ICD-10 classification. Causes of death in children under five were compared with those from vital registration data for 2011. RESULTS: Cause-of-death data were markedly improved with additional data from forensic mortuaries. The proportion of ill-defined causes was halved (25-12%), and leading cause rankings changed. Lower respiratory tract infections moved above prematurity to rank first, accounting for 20.8% of deaths and peaking in infants aged 1-3 months. Only 11% of deaths from lower respiratory tract infections occurred in hospital, resulting in 86% being certified in forensic mortuaries. Road traffic deaths increased from 1.1-3.1% (27-75) and homicides from 3 to 28. CONCLUSIONS: The quality and usefulness of cause-of-death information for children in the WC was enhanced by linking mortuary and vital registration data. Given the death profile, interventions are required to prevent and manage LRTI, diarrhoea and injuries and to reduce neonatal deaths.

Toward a standardized investigation protocol in sudden unexpected deaths in infancy in South Africa: a multicenter study of medico-legal investigation procedures and outcomes.

INTRODUCTION: South Africa manifests a socio-economic dichotomy that shows features of both a developed and developing country. As a result of this, areas exist where a lack of resources and expertise prevents the implementation of a highly standardized protocol for the investigation of sudden and unexpected deaths in infants (SUDI). Although the medico-legal mortuaries attached to academic centers have the capacity to implement standardized protocols, a previous study conducted at two large medico-legal mortuaries indicated otherwise. This study also revealed that the exact number and incidence of sudden infant death syndrome (SIDS) cases was unknown. These findings prompted a multicenter study of the medico-legal investigation procedures and outcomes in five academic centers in South Africa. METHODS: A retrospective case audit was conducted for a 5-year period (2005-2009) at medico-legal laboratories attached to universities in Bloemfontein, Cape Town-Tygerberg, Durban, Johannesburg, and Pretoria. The total case load as well as the total number of infants younger than 1 year of age admitted to these mortuaries was documented. The case files on all infants younger than 1 year of age who were admitted as sudden and unexpected or unexplained deaths were included in the study population. Data collected on the target population included demographic details, the nature and scope of the post-mortem examinations, as well as the final outcome (cause of death). RESULTS: A total case load of 80,399 cases were admitted to the mortuaries over the 5 year period with a total of 3,295 (6.5 %) infants. In the infant group, 591 (0.7 %) died from non-natural causes and 2,704 (3.3 %) cases of sudden, unexpected and/or unexplained deaths in infants were admitted and included in the detailed case analysis study. One hundred and ninety-nine babies were between 0 and 7 days of age and 210 babies between 8 and 30 days. The remaining 2,295 infants were between 1 month and 12 months of age. Death scene investigation was done in a total of 14 (0.5 %) cases. Discrepancies were present in the extent of the macroscopic post-mortem examinations, as well as the type and extent of the ancillary investigations performed. The investigations were completed in 2,583 of the cases. The majority of these infants died from natural disease processes [1,976 infants (76.5 %)]. Bronchopneumonia was the leading cause of natural deaths at all the mortuaries [674 cases (26.1 %)]. SIDS was diagnosed in only 224 cases (8.7 %) and in 383 (14.8 %) cases, where a full post-mortem examination with ancillary investigations was conducted; the cause of death was recorded as "unascertained." CONCLUSIONS: This study indicated that the admission criteria (to medico-legal mortuaries) and the investigative process/protocols in cases of SUDI differ greatly among 5 of the largest academic medical institutions in South Africa. Establishing and implementing standardized admission criteria (to medico-legal mortuaries) and implementing uniform investigative and autopsy protocols would appear to be an essential prerequisite to gain better understanding of the mystery of SIDS in South Africa.

Obstructive fibrinous tracheal pseudomembrane: Sudden child death following laser removal of papillomata.

Obstructive fibrinous tracheal pseudomembrane (OFTP) is a rare complication usually following endotracheal intubation, occurring when a collection of inflammatory exudate coalesces at the site of damaged epithelium within the trachea and along the tracheal mucosa, creating a luminal narrowing and subsequent airway obstruction.

Tuberculosis in persons with sudden unexpected death, in Cape Town, South Africa.

BACKGROUND: Globally, tuberculosis (TB) remains one of the leading causes of death from a single infectious agent, but there has been little work to estimate mortality before the diagnosis of TB. We investigated the burden of diagnosed and undiagnosed TB in adult and child sudden unexpected deaths (SUDs) evaluated at Tygerberg Forensic Pathology Services, South Africa. METHODS: In a retrospective descriptive study spanning 2016, we identified all SUDs where active TB was detected at post-mortem and matched with routine health service data to differentiate decedents who were diagnosed or undiagnosed with TB before death. A patient pathway analysis of the health service activities preceding SUD in adults with active TB was conducted. RESULTS: Active TB was identified at post-mortem in 6.2% (48/770) of SUDs and was undiagnosed before death in 91.7% (44/48). The prevalence of active TB was 8.1% in adult SUDs (90.1% undiagnosed before SUD) and 1.8% in children (none diagnosed before SUD). Patient pathway analysis was possible for 15 adult SUDs, and this documented primary health care clinic attendances and hospital admissions in the six months preceding death and missed opportunities for TB investigations. CONCLUSION: The prevalence of TB among SUDs in the Eastern Metro of Cape Town is high. Most active TB at post-mortem was undiagnosed before death, and multiple missed opportunities for TB investigation and diagnosis were noted. The systematic evaluation of all SUDs for TB could improve the reporting of undiagnosed TB and support risk mitigation for healthcare workers involved with the post-mortem process.

Nicotinic Receptors in the Brainstem Ascending Arousal System in SIDS With Analysis of Pre-natal Exposures to Maternal Smoking and Alcohol in High-Risk Populations of the Safe Passage Study.

Pre-natal exposures to nicotine and alcohol are known risk factors for sudden infant death syndrome (SIDS), the leading cause of post-neonatal infant mortality. Here, we present data on nicotinic receptor binding, as determined by 125I-epibatidine receptor autoradiography, in the brainstems of infants dying of SIDS and of other known causes of death collected from the Safe Passage Study, a prospective, multicenter study with clinical sites in Cape Town, South Africa and 5 United States sites, including 2 American Indian Reservations. We examined 15 pons and medulla regions related to cardiovascular control and arousal in infants dying of SIDS (n = 12) and infants dying from known causes (n = 20, 10 pre-discharge from time of birth, 10 post-discharge). Overall, there was a developmental decrease in 125I-epibatidine binding with increasing postconceptional age in 5 medullary sites [raphe obscurus, gigantocellularis, paragigantocellularis, centralis, and dorsal accessory olive (p = 0.0002-0.03)], three of which are nuclei containing serotonin cells. Comparing SIDS with post-discharge known cause of death (post-KCOD) controls, we found significant decreased binding in SIDS in the nucleus pontis oralis (p = 0.02), a critical component of the cholinergic ascending arousal system of the rostral pons (post-KCOD, 12.1 ± 0.9 fmol/mg and SIDS, 9.1 ± 0.78 fmol/mg). In addition, we found an effect of maternal smoking in SIDS (n = 11) combined with post-KCOD controls (n = 8) on the raphe obscurus (p = 0.01), gigantocellularis (p = 0.02), and the paragigantocellularis (p = 0.002), three medullary sites found in this study to have decreased binding with age and found in previous studies to have abnormal indices of serotonin neurotransmission in SIDS infants. At these sites, 125I-epibatidine binding increased with increasing cigarettes per week. We found no effect of maternal drinking on 125I-epibatidine binding at any site measured. Taken together, these data support changes in nicotinic receptor binding related to development, cause of death, and exposure to maternal cigarette smoking. These data present new evidence in a prospective study supporting the roles of developmental factors, as well as adverse exposure on nicotinic receptors, in serotonergic nuclei of the rostral medulla-a finding that highlights the interwoven and complex relationship between acetylcholine (via nicotinic receptors) and serotonergic neurotransmission in the medulla.

Concurrent prenatal drinking and smoking increases risk for SIDS: Safe Passage Study report.

BACKGROUND: Sudden infant death syndrome (SIDS) is the leading cause of postneonatal mortality. Although the rate has plateaued, any unexpected death of an infant is a family tragedy thus finding causes and contributors to risk remains a major public health concern. The primary objective of this investigation was to determine patterns of drinking and smoking during pregnancy that increase risk of SIDS. METHODS: The Safe Passage Study was a prospective, multi-center, observational study with 10,088 women, 11,892 pregnancies, and 12,029 fetuses, followed to 1-year post delivery. Subjects were from two sites in Cape Town, South Africa and five United States sites, including two American Indian Reservations. Group-based trajectory modeling was utilized to categorize patterns of drinking and smoking exposure during pregnancy. FINDINGS: One-year outcome was ascertained in 94·2% infants, with 28 SIDS (2·43/1000) and 38 known causes of death (3·30/1000). The increase in relative risk for SIDS, adjusted for key demographic and clinical characteristics, was 11·79 (98·3% CI: 2·59-53·7, p < 0·001) in infants whose mothers reported both prenatal drinking and smoking beyond the first trimester, 3.95 (98·3% CI: 0·44-35·83, p = 0·14), for drinking only beyond the first trimester and 4·86 (95% CI: 0·97-24·27, p = 0·02) for smoking only beyond the first trimester as compared to those unexposed or reported quitting early in pregnancy. INTERPRETATION: Infants prenatally exposed to both alcohol and cigarettes continuing beyond the first trimester have a substantially higher risk for SIDS compared to those unexposed, exposed to alcohol or cigarettes alone, or when mother reported quitting early in pregnancy. Given that prenatal drinking and smoking are modifiable risk factors, these results address a major global public health problem. FUNDING: National Institute on Alcohol Abuse and Alcoholism, Eunice Kennedy Shriver National Institute of Child Health and Human Development, and the National Institute on Deafness and Other Communication Disorders.

A practical classification schema incorporating consideration of possible asphyxia in cases of sudden unexpected infant death.

Although the rate of the sudden infant death syndrome (SIDS) has decreased over the last two decades, medical examiners and coroners are increasingly unwilling to use the SIDS diagnosis, particularly when there is an unsafe sleeping environment that might pose a risk for asphyxia. In order to reliably classify the infant deaths studied in a research setting in the mixed ancestory population in Cape Town, South Africa, we tested a classification system devised by us that incorporates the uncertainty of asphyxial risks at an infant death scene. We classified sudden infant deaths as: A) SIDS (where only a trivial potential for an overt asphyxial event existed); B) Unclassified-Possibly Asphyxial-Related (when any potential for an asphyxial death existed); C) Unclassified-Non-Asphyxial-Related (e.g., hyperthermia); D) Unclassified-No autopsy and/or death scene investigation; and E) Known Cause of Death. Ten infant deaths were classified according to the proposed schema as: SIDS, n = 2; Unclassified-Possibly Asphyxial-Related, n = 4; and Known Cause, n = 4. A conventional schema categorized the deaths as 6 cases, SIDS, and 4 cases, Known Cause, indicating that 4/6 (67%) of deaths previously classified as SIDS are considered related importantly to asphyxia and warrant their own subgroup. This new classification schema applies a simpler, more qualitative approach to asphyxial risk in infant deaths. It also allows us to test hypotheses about the role of asphyxia in sudden infant deaths, such as in brainstem defects in a range of asphyxial challenges.

The Institution of a Standardized Investigation Protocol for Sudden Infant Death in the Eastern Metropole, Cape Town, South Africa,.

The rate for the sudden infant death syndrome (SIDS) in Cape Town, South Africa, is estimated to be among the highest in the world (3.41/1000 live births). In several of these areas, including those of extreme poverty, only sporadic, nonstandardized infant autopsy, and death scene investigation (DSI) occurred. In this report, we detail a feasibility project comprising 18 autopsied infants with sudden and unexpected death whose causes of death were adjudicated according to the 1991 NICHD definitions (SIDS, n = 7; known cause of death, n = 7; and unclassified, n = 4). We instituted a standardized autopsy and infant DSI through a collaborative effort of local forensic pathology officers and clinical providers. The high standard of forensic investigation met international standards, identified preventable disease, and allowed for incorporation of research. We conclude that an effective infant autopsy and DSI protocol can be established in areas with both high sudden unexpected infant death, and elsewhere. (SUID)/SIDS risk and infrastructure challenges.

Serotonin Receptors in the Medulla Oblongata of the Human Fetus and Infant: The Analytic Approach of the International Safe Passage Study.

The Safe Passage Study is an international, prospective study of approximately 12 000 pregnancies to determine the effects of prenatal alcohol exposure (PAE) upon stillbirth and the sudden infant death syndrome (SIDS). A key objective of the study is to elucidate adverse effects of PAE upon binding to serotonin (5-HT) 1A receptors in brainstem homeostatic networks postulated to be abnormal in unexplained stillbirth and/or SIDS. We undertook a feasibility assessment of 5-HT1A receptor binding using autoradiography in the medulla oblongata (6 nuclei in 27 cases). 5-HT1A binding was compared to a reference dataset from the San Diego medical examiner's system. There was no adverse effect of postmortem interval ≤100 h. The distribution and quantitated values of 5-HT1A binding in Safe Passage Study cases were essentially identical to those in the reference dataset, and virtually identical between stillbirths and live born fetal cases in grossly non-macerated tissues. The pattern of binding was present at mid-gestation with dramatic changes in binding levels in the medullary 5-HT nuclei over the second half of gestation; there was a plateau at lower levels in the neonatal period and into infancy. This study demonstrates feasibility of 5-HT1A binding analysis in the medulla in the Safe Passage Study.

Review of immunological and virological aspects as contributory factors in Sudden Unexpected Death in Infancy (SUDI).

Currently in South Africa research into sudden unexpected death in infancy (SUDI) is limited. The causes of sudden infant death syndrome (SIDS) remain obscure despite full medico-legal investigations inclusive of autopsy, scene visit and ancillary studies. Viral infections play an important role as a multitude of respiratory viruses have been detected in autopsy specimens and are implicated in these deaths. The specific contribution of viruses in the events preceding SIDS still warrants deciphering. Infancy is characterised by marked vulnerability to infections due to immaturities of the immune system that may only resolve by the age of 24 months. Routine viral screening of all SUDI cases at Tygerberg Forensic Pathology Service (FPS) Mortuary in Cape Town focuses on only a portion of respiratory viruses from lung and liver tissue. This review highlights important virological and immunological aspects regarding investigations into the infectious nature of SUDI, including the lack of national standardised guidelines for appropriate specimen collection at autopsy and subsequent laboratory analysis.

Profiling the approach to the investigation of viral infections in cases of sudden unexpected death in infancy in the Western Cape Province, South Africa.

BACKGROUND: Sudden unexpected death in infancy is one of the main contributory factors to high infant mortality rates world-wide. Several risk factors, including viral infection, have been implicated in SUDI cases, but no single factor has been confirmed as the main cause of death. At the Tygerberg Medico-legal Laboratory, Cape Town, South Africa, investigation of lung tissue for viral infection forms part of an institutional protocol for the examination of cases of sudden unexpected death in infancy. METHODS: Lung tissue from 82 cases of sudden unexpected death in infancy was collected over a 10 month period. Routine shell vial cultures and histological examination of the tissue were performed according to the standard institutional protocol on fresh and formalin-fixed tissue, respectively. In addition, real-time polymerase chain reactions and immunohistochemical staining for adenovirus, cytomegalovirus and respiratory syncytial virus were done on fresh and formalin-fixed lung tissue, respectively. RESULTS: Huge variation was found in the number of positive cases confirmed by shell vial culture, real-time polymerase chain reaction and immunohistochemistry (0, 2 and 0 for adenovirus; 3, 29 and 2 for cytomegalovirus; and 0, 0 and 4 for respiratory syncytial virus, respectively). CONCLUSIONS: In the absence of a National Protocol for investigation of sudden unexpected death in infancy, we conclude that the selection of viruses and routine diagnostic technique included in the institutional investigation protocol might be suboptimal and should be re-evaluated.

Progressive primary pulmonary tuberculosis presenting as the sudden unexpected death in infancy: a case report.

The classification of an unexpected infant death as the sudden infant death syndrome (SIDS) depends upon a complete autopsy and death scene investigation to exclude known causes of death. Here we report the death of a 4-month-old infant in a tuberculosis endemic area that presented as a sudden unexpected death in infancy (SUDI) with no apparent explanation based on the death scene characteristics. The autopsy, however, revealed progressive primary pulmonary tuberculosis with intrathoracicadenopathy, compression of the tracheobronchial tree and miliary lesions in the liver. This case underscores the clinical difficulties in the diagnosis of infantile tuberculosis, as well as the possibility of sudden death as part of its protean manifestations. The pathology and clinical progression of tuberculosis in infants differ from older children and adults due to the immature immune response in infants. This case dramatically highlights the need for complete autopsies in all sudden and unexpected infant deaths, as well as the public health issues in a sentinel infant tuberculosis diagnosis.

Hepatic hemangioendothelioma presenting as sudden unexpected death in infancy: a case report.

The classification of an unexpected infant death as sudden infant death syndrome (SIDS) depends upon a complete autopsy, death scene investigation, and review of medical history to exclude known causes of death. Death from occult neoplastic disease in infancy is extremely rare but is within the broad differential diagnosis of SIDS. We report the sudden and unexpected death of a 1-month-old infant from a hepatic (infantile) hemangioendothelioma. The physiologic mechanism of death was likely cardiac failure induced by the circulatory demands of this large vascular tumor and respiratory compromise from diaphragmatic thoracic incursion. The clinical progression and pathology of these relatively common tumors of infant livers are extremely variable. This case dramatically illustrates the potential for fatal outcome of this tumor, as well as the need for autopsy to determine the cause of sudden and unexpected death in an infant.

Consent for autopsy research for unexpected death in early life.

Research in sudden death in fetuses (stillbirth) and infants (sudden infant death syndrome [SIDS]) is urgently needed, particularly in high-risk populations involving socioeconomic disadvantaged families. Essential to such research is the analysis of fetal and infant tissues at autopsy. Obtaining consent for donating autopsy tissues for research is especially problematic in socioeconomically disadvantaged populations in which mistrust of the medical establishment often exists. In this article, we present communication strategies for obtaining consent for research in autopsy tissues of stillbirth and SIDS cases in socioeconomically disadvantaged populations. Recommendations are provided about preparation for and the timing, setting, and content of the consent interview. The same lines of open and transparent communication delineated in this article are applicable to obtaining consent for the autopsy and autopsy research. Although the grief responses to the untimely death of the fetus or infant are universal and the recommendations of this essay are widely applicable to the general population, the expression of this grief and feelings toward autopsy-based research in socioeconomically disadvantaged populations may raise special issues that health care workers should be aware of when obtaining consent for research on autopsy-derived tissues.