Further evidence of misclassification of the injury deaths in South Africa: When will the barriers to accurate injury death statistics be removed?

BACKGROUND: Contrary to the World Health Organization's internationally recommended medical certificate of cause of death, the South African (SA) death notification form (DNF) does not allow for the reporting of the manner of death to permit accurate coding of external causes of injury deaths. OBJECTIVES: To describe the injury cause-of-death profile from forensic pathology records collected for the National Cause-of-Death Validation (NCoDV) Project and compare it with profiles from other sources of injury mortality data. In particular, the recording of firearm use in homicides is compared between sources. METHODS: The NCoDV Project was a cross-sectional study of deaths that occurred during a fixed period in 2017 and 2018, from a nationally representative sample of 27 health subdistricts in SA. Trained fieldworkers scanned forensic records for all deaths investigated at the forensic mortuaries serving the sampled subdistricts during the study period. Forensic practitioners reviewed the records and completed a medical certificate of cause of death for each decedent. Causes of death were coded to the International Statistical Classification of Diseases, 10th revision (ICD-10), using Iris automated coding software. Cause-specific mortality fractions for injury deaths were compared with Injury Mortality Survey 2017 (IMS 2017) and Statistics South Africa 2017 (Stats SA 2017) datasets. The cause profile for all firearm-related deaths was compared between the three datasets. RESULTS: A total of 5 315 records were available for analysis. Males accounted for 77.6% of cases, and most decedents were aged between 25 and 44 years. Homicide was the leading cause of death (34.7%), followed by transport injuries (32.6%) and suicide (14.7%). This injury cause profile was similar to IMS 2017 but differed markedly from the official statistics, which showed markedly lower proportions of these three causes (15.0%, 11.6% and 0.7%, respectively), and a much higher proportion of other unintentional causes. Investigation of firearm-related deaths revealed that most were homicides in NCoDV 2017/18 (88.5%) and IMS 2017 (93.1%), while in the Stats SA 2017 data, 98.7% of firearm deaths were classified as accidental. Approximately 7% of firearm-related deaths were suicides in NCoDV 2017/18 and IMS 2017, with only 0.3% in Stats SA 2017. CONCLUSION: The official cause-of-death data for injuries in SA in 2017 differed substantially from findings from the NCoDV 2017/18 study and IMS 2017. Accurate data sources would ensure that public health interventions are designed to reduce the high injury burden. Inclusion of the manner of death on the DNF, as is recommended internationally, is critically important to enable more accurate, reliable and valid reporting of the injury profile.

Estimating the changing disease burden attributable to smoking in South Africa for 2000, 2006 and 2012.

BACKGROUND: Ongoing quantification of the disease burden attributable to smoking is important to monitor and strengthen tobacco control policies. OBJECTIVES: To estimate the attributable burden due to smoking in South Africa for 2000, 2006 and 2012. METHODS: We estimated attributable burden due to smoking for selected causes of death in South African (SA) adults aged ≥35 years for 2000, 2006 and 2012. We combined smoking prevalence results from 15 national surveys (1998 - 2017) and smoking impact ratios using national mortality rates. Relative risks between smoking and select causes of death were derived from local and international data. RESULTS: Smoking prevalence declined from 25.0% in 1998 (40.5% in males, 10.9% in females) to 19.4% in 2012 (31.9% in males, 7.9% in females), but plateaued after 2010. In 2012 tobacco smoking caused an estimated 31 078 deaths (23 444 in males and 7 634 in females), accounting for 6.9% of total deaths of all ages (17.3% of deaths in adults aged ≥35 years), a 10.5% decline overall since 2000 (7% in males; 18% in females). Age-standardised mortality rates (and disability-adjusted life years (DALYs)) similarly declined in all population groups but remained high in the coloured population. Chronic obstructive pulmonary disease accounted for most tobacco-attributed deaths (6 373), followed by lung cancer (4 923), ischaemic heart disease (4 216), tuberculosis (2 326) and lower respiratory infections (1 950). The distribution of major causes of smoking-attributable deaths shows a middle- to high-income pattern in whites and Asians, and a middle- to low-income pattern in coloureds and black Africans. The role of infectious lung disease (TB and LRIs) has been underappreciated. These diseases comprised 21.0% of deaths among black Africans compared with only 4.3% among whites. It is concerning that smoking rates have plateaued since 2010. CONCLUSION: The gains achieved in reducing smoking prevalence in SA have been eroded since 2010. An increase in excise taxes is the most effective measure for reducing smoking prevalence. The advent of serious respiratory pandemics such as COVID-19 has increased the urgency of considering the role that smoking cessation/abstinence can play in the prevention of, and post-hospital recovery from, any condition.

Overview.

BACKGROUND: South Africa (SA) faces multiple health challenges. Quantifying the contribution of modifiable risk factors can be used to identify and prioritise areas of concern for population health and opportunities for health promotion and disease prevention interventions. OBJECTIVE: To estimate the attributable burden of 18 modifiable risk factors for 2000, 2006 and 2012. METHODS: Comparative risk assessment (CRA), a standardised and systematic approach, was used to estimate the attributable burden of 18 risk factors. Risk exposure estimates were sourced from local data, and meta-regressions were used to model the parameters, depending on the availability of data. Risk-outcome pairs meeting the criteria for convincing or probable evidence were assessed using relative risks against a theoretical minimum risk exposure level to calculate either a potential impact fraction or population attributable fraction (PAF). Relative risks were sourced from the Global Burden of Disease, Injuries, and Risk Factors (GBD) study as well as published cohort and intervention studies. Attributable burden was calculated for each risk factor for 2000, 2006 and 2012 by applying the PAF to estimates of deaths and years of life lost from the Second South African National Burden of Disease Study (SANBD2). Uncertainty analyses were performed using Monte Carlo simulation, and age-standardised rates were calculated using the World Health Organization standard population. RESULTS: Unsafe sex was the leading risk factor across all years, accounting for one in four DALYs (26.6%) of the estimated 20.6 million DALYs in 2012. The top five leading risk factors for males and females remained the same between 2000 and 2012. For males, the leading risks were (in order of descending rank): unsafe sex; alcohol consumption; interpersonal violence; tobacco smoking; and high systolic blood pressure; while for females the leading risks were unsafe sex; interpersonal violence; high systolic blood pressure; high body mass index; and high fasting plasma glucose. Since 2000, the attributable age-standardised death rates decreased for most risk factors. The largest decrease was for household air pollution (-41.8%). However, there was a notable increase in the age-standardised death rate for high fasting plasma glucose (44.1%), followed by ambient air pollution (7%). CONCLUSION: This study reflects the continued dominance of unsafe sex and interpersonal violence during the study period, as well as the combined effects of poverty and underdevelopment with the emergence of cardiometabolic-related risk factors and ambient air pollution as key modifiable risk factors in SA. Despite reductions in the attributable burden of many risk factors, the study reveals significant scope for health promotion and disease prevention initiatives and provides an important tool for policy makers to influence policy and programme interventions in the country.

Unnatural deaths, alcohol bans and curfews: Evidence from a quasi-natural experiment during COVID-19.

BACKGROUND: Coronavirus disease-19 (COVID-19) restrictions, particularly relating to the sale of alcohol and hours of curfew, have had a marked effect on the temporal pattern of unnatural deaths in South Africa. Methods. Death data were collected over 68 weeks from January 2020 to April 2021, together with information on the nature of restrictions (if any) on the sale of alcohol, and hours of curfew. Data were analysed using a simple ordinary least square (OLS) regression model to estimate the relative contribution of restrictions on the sale of alcohol and hours of curfew to the pattern of excess unnatural deaths. Results. The complete restriction on the sale of alcohol resulted in a statistically significant reduction in unnatural deaths regardless of the length of curfew. To the contrary, periods where no or limited restrictions on alcohol were in force had no significant effect, or resulted in significantly increased unnatural deaths. Conclusions. The present study highlights an association between alcohol availability and the number of unnatural deaths and demonstrates the extent to which those deaths might be averted by disrupting the alcohol supply. While this is not a long-term solution to addressing alcohol-related harm, it further raises the importance of implementing evidence-based alcohol control measures.

Tracking mortality in near to real time provides essential information about the impact of the COVID-19 pandemic in South Africa in 2020.

BACKGROUND: Producing timely and accurate estimates of the impact of COVID-19 on mortality is challenging for most countries, but impossible for South Africa (SA) from cause-of-death statistics. Objectives. To quantify the excess deaths and likely magnitude of COVID-19 in SA in 2020 and draw conclusions on monitoring the epidemic in 2021. Methods. Basic details of deaths registered on the National Population Register by the Department of Home Affairs (DoHA) are provided to the South African Medical Research Council weekly. Adjustments are made to the numbers of weekly deaths to account for non-registration on the population register, as well as late registration of death with the DoHA. The weekly number of deaths is compared with the number predicted based on the Holt-Winters time-series analysis of past deaths for provinces and metropolitan areas. Excess deaths were calculated for all-causes deaths and natural deaths, using the predicted deaths as a baseline. In addition, an adjustment was made to the baseline for natural deaths to account for the drop in natural deaths due to lockdown. Results. We estimated that just over 550 000 deaths occurred among persons aged ≥1 year during 2020, 13% higher than the 485 000 predicted before the pandemic. A pronounced increase in weekly deaths from natural causes peaked in the middle of July across all ages except <20 years, and across all provinces with slightly different timing. During December, it became clear that SA was experiencing a second wave of COVID-19 that would exceed the death toll of the first wave. In 2020, there were 70 000 - 76 000 excess deaths from natural causes, depending on the base. Using the adjusted base, the excess death rate from natural causes was 122 per 100 000 population, with a male-to-female ratio of 0.78. Deaths from unnatural causes halved for both males and females during the stringent lockdown level 5. The numbers reverted towards the predicted number with some fluctuations as lockdown restrictions varied. Just under 5 000 unnatural deaths were averted. Conclusions. Tracking the weekly numbers of deaths in near to real time has provided important information about the spatiotemporal impact of the pandemic and highlights that the ~28 000 reported COVID-19 deaths during 2020 substantially understate the death toll from COVID-19. There is an urgent need to re-engineer the system of collecting and processing cause-of-death information so that it can be accessed in a timely way to inform public health actions.

COVID deaths in South Africa: 99 days since South Africa's first death.

BACKGROUND: Understanding the pattern of deaths from COVID-19 in South Africa (SA) is critical to identifying individuals at high risk of dying from the disease. The Minister of Health set up a daily reporting mechanism to obtain timeous details of COVID-19 deaths from the provinces to track mortality patterns. OBJECTIVES: To provide an epidemiological analysis of the first COVID-19 deaths in SA. METHODS: Provincial deaths data from 28 March to 3 July 2020 were cleaned, information on comorbidities was standardised, and data were aggregated into a single data set. Analysis was performed by age, sex, province, date of death and comorbidities. RESULTS: SA reported 3 088 deaths from COVID-19, i.e. an age-standardised death rate of 64.5 (95% confidence interval (CI) 62.3 - 66.8) deaths per million population. Most deaths occurred in Western Cape (65.5%) followed by Eastern Cape (16.8%) and Gauteng (11.3%). The median age of death was 61 years (interquartile range 52 - 71). Males had a 1.5 times higher death rate compared with females. Individuals with two or more comorbidities accounted for 58.6% (95% CI 56.6 - 60.5) of deaths. Hypertension and diabetes were the most common comorbidities reported, and HIV and tuberculosis were more common in individuals aged <50 years. CONCLUSIONS: Data collection for COVID-19 deaths in provinces must be standardised. Even though the data had limitations, these findings can be used by the SA government to manage the pandemic and identify individuals who are at high risk of dying from COVID-19.

COVID deaths in South Africa: 99 days since South Africa's first death

Background. Understanding the pattern of deaths from COVID-19 in South Africa (SA) is critical to identifying individuals at high risk of dying from the disease. The Minister of Health set up a daily reporting mechanism to obtain timeous details of COVID-19 deaths from the provinces to track mortality patterns.Objectives. To provide an epidemiological analysis of the first COVID-19 deaths in SA.Methods. Provincial deaths data from 28 March to 3 July 2020 were cleaned, information on comorbidities was standardised, and data were aggregated into a single data set. Analysis was performed by age, sex, province, date of death and comorbidities.Results. SA reported 3 088 deaths from COVID-19, i.e. an age-standardised death rate of 64.5 (95% confidence interval (CI) 62.3 - 66.8) deaths per million population. Most deaths occurred in Western Cape (65.5%) followed by Eastern Cape (16.8%) and Gauteng (11.3%). The median age of death was 61 years (interquartile range 52 - 71). Males had a 1.5 times higher death rate compared with females. Individuals with two or more comorbidities accounted for 58.6% (95% CI 56.6 - 60.5) of deaths. Hypertension and diabetes were the most common comorbidities reported, and HIV and tuberculosis were more common in individuals aged <50 years.Conclusions. Data collection for COVID-19 deaths in provinces must be standardised. Even though the data had limitations, these findings can be used by the SA government to manage the pandemic and identify individuals who are at high risk of dying from COVID-19

Trends and inequities in amenable mortality between 1997 and 2012 in South Africa.

BACKGROUND: Amenable mortality comprises causes of death that should not occur with timely and effective healthcare. It is commonly used to assess healthcare performance. It could also be used to assess the effectiveness of the pending National Health Insurance (NHI) in South Africa (SA), but to do this, the level and distribution of amenable mortality are required using a local list of amenable causes. OBJECTIVES: To establish an amenable cause-of-death list appropriate for SA and to determine the levels, trends, geographical distribution, population group differences and international comparisons of mortality amenable to healthcare. METHODS: A local list of amenable causes of death was developed with input from public health and disease-specific medical experts. The Second SA National Burden of Disease estimates were reclassified into amenable mortality. Analyses of age-standardised death rates (ASDRs) and amenable mortality proportions were conducted by province and population group between 1997 and 2012. Excess mortality in relation to the best- performing province and population group was also analysed. ASDRs for SA were compared with those of European Union (EU) and Organisation for Economic Co-operation and Development (OECD) countries. RESULTS: The local list of amenable conditions contained 45 causes of death. There were large disparities in amenable mortality between provinces and population groups, which did not attenuate over time. There was an average annual percentage increase in amenable ASDRs, but when HIV/AIDS was excluded from the analysis there was an average annual decrease of 1.12%. In the post-peak HIV/AIDS period between 2008 and 2012, an annual average of 207 810 amenable deaths could have been saved if all provinces had the same ASDR as the Western Cape. SA's ASDR was 2.6 and 2.2 times higher than that of the worst-performing EU and OECD country, respectively. CONCLUSIONS: This is the first study known to the authors that has established a local amenable mortality list and described the epidemiology of amenable mortality in SA. Amenable mortality could be used as an indicator of the performance of the pending NHI over time and, in combination with other indicators, could identify areas of the health system that require improvement. Benchmarking could also quantify gaps in health system performance between geographical regions and indicate whether these are reduced with time.

Child mortality trends and causes of death in South Africa, 1997 - 2012, and the importance of a national burden of disease study.

BACKGROUND: The Rapid Mortality Surveillance System has reported reductions in child mortality rates in recent years in South Africa (SA). In this article, we present information about levels of mortality and causes of death from the second SA National Burden of Disease Study (SA NBD) to inform the response required to reduce child mortality further. OBJECTIVES: To estimate trends in and causes of childhood mortality at national and provincial levels for the period 1997 - 2012, to highlight the importance of the SA NBD. METHODS: Numbers of registered child deaths were adjusted for under-reporting. Adjustments were made for the misclassification of AIDS deaths and the proportion of ill-defined natural causes. Non-natural causes were estimated using results from the National Injury Mortality Surveillance System for 2000 and the National Injury Mortality Survey for 2009. Six neonatal conditions and 11 other causes were consolidated from the SA NBD and the Child Health Epidemiological Reference Group lists of causes of death for the analysis. The NBD cause-fractions were compared with those from Statistics South Africa, the United Nations Children's Fund (UNICEF) and the Institute for Health Metrics and Evaluation (IHME). RESULTS: Under-5 mortality per 1 000 live births increased from 65 in 1997 to 79 in 2004 as a result of HIV/AIDS, before dropping to 40 by 2012. The neonatal mortality rate declined from 1997 to 2001, followed by small variations. The death rate from diarrhoeal diseases began to decrease in 2008 and the death rate from pneumonia from 2010. By 2012, neonatal deaths accounted for 27% of child deaths, with conditions associated with prematurity, birth asphyxia and severe infections being the main contributors. In 1997, KwaZulu-Natal, Free State, Mpumalanga and Eastern Cape provinces had the highest under-5 mortality, close to 80 per 1 000 live births. Mortality rates in North West were in the mid-range and then increased, placing this province in the highest group in the later years. The Western Cape had the lowest mortality rate, declining throughout the period apart from a slight increase in the early 2000s. CONCLUSIONS: The SA NBD identified the causes driving the trends, making it clear that prevention of mother-to-child transmission of HIV, the Expanded Programme on Immunisation and programmes aimed at preventing neonatal deaths need to be equitably implemented throughout the country to address persistent provincial inequalities in child deaths. The rapid reduction of childhood mortality since 2005 suggests that the 2030 Sustainable Development Goal target of 25 per 1 000 for under-5 mortality is achievable for SA. Comparison with alternative estimates highlights the need for cause-of-death data from civil registration to be adjusted using a burden-of-disease approach.

Burden of disease in South Africa: Protracted transitions driven by social pathologies.

For several decades, researchers from the South African Medical Research Council have made invaluable contributions towards improving the health of the population through the analysis and interpretation of cause of death data. This article reflects the mortality trends in pre-and post-apartheid South Africa (SA), and describes efforts to improve vital statistics, innovations to fill data gaps, and studies to estimate the burden of disease after adjusting for data deficiencies. The profound impact of HIV/AIDS, particularly among black African children and young adults, is striking, within a protracted epidemiological transition and the current reversals of multiple epidemics. Over the next 20 years, it will be important to sustain and enhance the country's capacity to collect, analyse and utilise cause of death data. SA needs to support development in the region, harnessing new data platforms and approaches such as including verbal autopsy tools in the official system and improving data linkage.

Trends and inequities in amenable mortality between 1997 and 2012 in South Africa

Background. Amenable mortality comprises causes of death that should not occur with timely and effective healthcare. It is commonly used to assess healthcare performance. It could also be used to assess the effectiveness of the pending National Health Insurance (NHI) in South Africa (SA), but to do this, the level and distribution of amenable mortality are required using a local list of amenable causes. Objectives. To establish an amenable cause-of-death list appropriate for SA and to determine the levels, trends, geographical distribution, population group differences and international comparisons of mortality amenable to healthcare. Methods. A local list of amenable causes of death was developed with input from public health and disease-specific medical experts. The Second SA National Burden of Disease estimates were reclassified into amenable mortality. Analyses of age-standardised death rates (ASDRs) and amenable mortality proportions were conducted by province and population group between 1997 and 2012. Excess mortality in relation to the best- performing province and population group was also analysed. ASDRs for SA were compared with those of European Union (EU) and Organisation for Economic Co-operation and Development (OECD) countries. Results. The local list of amenable conditions contained 45 causes of death. There were large disparities in amenable mortality between provinces and population groups, which did not attenuate over time. There was an average annual percentage increase in amenable ASDRs, but when HIV/AIDS was excluded from the analysis there was an average annual decrease of 1.12%. In the post-peak HIV/AIDS period between 2008 and 2012, an annual average of 207 810 amenable deaths could have been saved if all provinces had the same ASDR as the Western Cape. SA's ASDR was 2.6 and 2.2 times higher than that of the worst-performing EU and OECD country, respectively. Conclusions. This is the first study known to the authors that has established a local amenable mortality list and described the epidemiology of amenable mortality in SA. Amenable mortality could be used as an indicator of the performance of the pending NHI over time and, in combination with other indicators, could identify areas of the health system that require improvement. Benchmarking could also quantify gaps in health system performance between geographical regions and indicate whether these are reduced with time

A retrospective time trend study of firearm and non-firearm homicide in Cape Town from 1994 to 2013.

BACKGROUND: Gunshot injuries from interpersonal violence are a major cause of mortality. In South Africa (SA), the Firearms Control Act of 2000 sought to address firearm violence by removing illegally owned firearms from circulation, stricter regulation of legally owned firearms, and stricter licensing requirements. Over the last few years, varied implementation of the Act and police corruption have increased firearm availability. OBJECTIVES: To investigate whether changes in firearm availability in SA were associated with changes in firearm homicide rates. METHODS: This was a retrospective time trend study (1994 - 2013) using postmortem data. Time trends of firearm and non-firearm homicide rates were analysed with generalised linear models. Distinct time periods for temporal trends were assigned based on a priori assumptions regarding changes in the availability of firearms. RESULTS: Firearm and non-firearm homicide rates adjusted for age, sex and race exhibited different temporal trends. Non-firearm homicide rates either decreased or remained stable over the entire period. Firearm homicide increased at 13% annually from 1994 through 2000, and decreased by 15% from 2003 through 2006, corresponding with changes in firearm availability in 2001, 2003, 2007 and 2011. A 21% annual increase in firearm homicide after 2010 coincided with police fast-tracking new firearm licence applications. Cape Town's coloured population experienced a significantly greater increase than other population groups following additional exposure to illegal firearms from 2007. CONCLUSIONS: The strong association between firearm availability and homicide, and the reversal of a decreasing firearm homicide trend during a period of lax enforcement, provide further support for the association between reduced firearm homicide and stricter regulation.

Mortality trends in the City of Cape Town between 2001 and 2013: Reducing inequities in health.

BACKGROUND: The City of Cape Town (CoCT), South Africa, has collected cause-of-death data from death certificates for many years to monitor population health. In 2000, the CoCT and collaborators set up a local mortality surveillance system to provide timeous mortality data at subdistrict level. Initial analyses revealed large disparities in health across subdistricts and directed the implementation of public health interventions aimed at reducing these disparatities. OBJECTIVES: To describe the changes in mortality between 2001 and 2013 in health subdistricts in the CoCT. METHODS: Pooled mortality data for the periods 2001 - 2004 and 2010 - 2013, from a local mortality surveillance system in the CoCT, were analysed by age, gender, cause of death and health subdistrict. Age-specific mortality rates for each period were calculated and age-standardised using the world standard population, and then compared across subdistricts. RESULTS: All-cause mortality in the CoCT declined by 8% from 938 to 863 per 100 000 between 2001 - 2004 and 2010 - 2013. Mortality in males declined more than in females owing to a large reduction in male injury mortality, particularly firearm-related homicide. HIV/AIDS and tuberculosis (TB) mortality dropped by ~10% in both males and females, but there was a marked shift to older ages. Mortality in children aged <5 years dropped markedly, mostly owing to reductions in HIV/AIDS and TB mortality. Health inequities between subdistricts were reduced, with the highest-burden subdistricts achieving the largest reductions in mortality. CONCLUSIONS: Local mortality surveillance provides important data for planning, implementing and evaluating targeted health interventions at small-area level. Trends in mortality over the past decade indicate some gains in health and equity, but highlight the need for multisectoral interventions to focus on HIV and TB and homicide and the emerging epidemic of non-communicable diseases.

Where do Children Die and what are the Causes? Under-5 Deaths in the Metro West Geographical Service Area of the Western Cape; South Africa; 2011

BACKGROUND:Accurate child mortality data are essential to plan health interventions to reduce child deaths.OBJECTIVES:To review the deaths of children aged etlt;5 years during 2011 in the Metro West geographical service area (GSA) of the Western Cape Province (WC); South Africa; from routine data sources.METHODSA retrospective study of under-5 deaths in the Metro West GSA was done using the WC Local Mortality Surveillance System (LMSS); the Child Healthcare Problem Identification Programme (Child PIP) and the Perinatal Problem Identification Programme (PPIP); and linking where possible.RESULTS:The LMSS reported 700 under-5 deaths; Child PIP 99 and PPIP 252; with an under-5 mortality rate of 18 deaths per 1 000 live births. The leading causes of death were pneumonia (25%); gastroenteritis (10%); prematurity (9%) and injuries (9%). There were 316 in-hospital deaths (45%) and 384 out-of-hospital deaths (55%). Among children aged etlt;1 year; there were significantly more pneumonia deaths out of hospital than in hospital (144 (49%) v. 16 (6%); petlt;0.001). Among children aged 1 - 4 years there were significantly more injury-related deaths out of hospital than in hospital (43 (47%) v. 4 (9%); petlt;0.001). In 56 (15%) of the cases of out-of-hospital death the child had visited a public healthcare facility within 1 week of death. Thirty-six (64%) of these children had died of pneumonia orgastroenteritis. CONCLUSIONS:Health interventions targeted at reducing under-5 deaths from pneumonia; gastroenteritis; prematurity and injuries need to be implemented across the service delivery platform in the Metro West GSA. It is important to consider all routine data sources in the evaluation of child mortality

Emerging Trends in Non-Communicable Disease Mortality in South Africa; 1997 - 2010

OBJECTIVES:National trends in age-standardised death rates (ASDRs) for non-communicable diseases (NCDs) in South Africa (SA) were identified between 1997 and 2010.METHODS:As part of the second National Burden of Disease Study; vital registration data were used after validity checks; proportional redistribution of missing age; sex and population group; demographic adjustments for registration incompleteness; and identification of misclassified AIDS deaths. Garbage codes were redistributed proportionally to specified codes by age; sex and population group. ASDRs were calculated using mid-year population estimates and the World Health Organization world standard.RESULTS:Of 594 071 deaths in 2010; 38.9% were due to NCDs (42.6% females). ASDRs were 287/100 000 for cardiovascular diseases (CVDs); 114/100 000 for cancers (malignant neoplasms); 58/100 000 for chronic respiratory conditions and 52/100 000 for diabetes mellitus. An overall annual decrease of 0.4% was observed resulting from declines in stroke; ischaemic heart disease; oesophageal and lung cancer; asthma and chronic respiratory disease; while increases were observed for diabetes; renal disease; endocrine and nutritional disorders; and breast and prostate cancers. Stroke was the leading NCD cause of death; accounting for 17.5% of total NCD deaths. Compared with those for whites; NCD mortality rates for other population groups were higher at 1.3 for black Africans; 1.4 for Indians and 1.4 for coloureds; but varied by condition.CONCLUSIONS:NCDs contribute to premature mortality in SA; threatening socioeconomic development. While NCD mortality rates have decreased slightly; it is necessary to strengthen prevention and healthcare provision and monitor emerging trends in cause-specific mortality to inform these strategies if the target of 2% annual decline is to be achieved

Medical certification of death in South Africa--moving forward.

Despite improvements to the Death Notification Form (DNF) used in South Africa (SA), the quality of cause-of-death information remains suboptimal. To address these inadequacies, the government ran a train-the-trainer programme on completion of the DNF, targeting doctors in public sector hospitals. Training materials were developed and workshops were held in all provinces. This article reflects on the lessons learnt from the training and highlights issues that need to be addressed to improve medical certification and cause-of-death data in SA. The DNF should be completed truthfully and accurately, and confidentiality of the information on the form should be maintained. The underlying cause of death should be entered on the lowest completed line in the cause-of-death section, and if appropriate, HIV should be entered here. Exclusion clauses for HIV in life insurance policies with Association of Savings and Investments South Africa companies were scrapped in 2005. Interactive workshops provide a good learning environment, but are logistically challenging. More use should be made of online training resources, particularly with continuing professional development accreditation and helpline support. In addition, training in the completion of the DNF should become part of the curriculum in all medical schools, and part of the orientation of interns and community service doctors in all facilities.

The 5-year outcome of multidrug resistant tuberculosis patients in the Cape Province of South Africa.

Little is known about the outcome of multidrug resistant (MDR) tuberculosis (TB) in developing countries. In this study, 443 patients with MDR-TB, defined as resistance to two or more antituberculosis drugs, were identified over the 2-year period 1987 and 1988 in the Cape Province of South Africa. The 5-year outcome of the 343 (77%) patients that could be traced by questionnaire was evaluated retrospectively during 1992 and 1993. Of these, 240 (70%) were resistant to both isoniazid (H) and rifampicin (R) with or without resistance to other first-line antituberculosis drugs and 103 (30%) were resistant to H or R and/or other antituberculosis drugs. Mortality was 116 (48%) and 28 (27%) in these groups respectively with a significantly greater risk of death in the first group. Only 114 (33%) of all the MDR-TB patients were cured after 5 years, 50 (15%) were respiratory disabled and 44 (13%) were still bacteriology positive. Twenty-four (7%) patients were lost during follow-up. Taking into account the high costs involved in treating MDR-TB patients and the scarce resources available in developing countries, more emphasis should be placed on direct observed therapy to cure newly diagnosed infectious drug sensitive tuberculosis patients, thus preventing MDR-TB rather than treating it.