Estimating the completeness of death registration: An empirical method

Assessment of the Quality of Cause-of-Death Data in Serbia for 2005-2019 Vital Statistics Performance Index Estimation

Background

We aimed to evaluate the quality of the cause of death (COD) concerning mortality patterns and completeness of death registration to identify areas for improvement in Serbia.

Methods

COD data collected from the mortality register in Serbia from 2005 to 2019 (1540615 deaths) were analyzed with the software Analysis of National Causes of Death for Action. The Vital Statistics Performance Index for Quality (VSPI(Q)) is estimated for the overall COD data quality.

Results

The completeness of death certification was higher than 98%. Usable underlying COD was registered in 57%, 24.1% with an unusable and 18.6% with insufficiently specified COD. The VSPI(Q) was 67.2%, denoting medium quality. The typical error was using intermediate COD (24.7% of all deaths), while 13.2% and 8.5% of all garbage codes (GC) belonged to the Very High and High Severity classes. The leading underlying COD is unspecified cardiomyopathy. The analysis revealed that 39.1% of GC has been redistributed to non-communicable diseases, 2.5% to external causes and 1.1% to communicable diseases.

Conclusion

In the 15 years' worth of data analyzed, the true underlying COD, in many cases, was ill-defined, indicating that COD data at the national level could be distorted. The additional and continuous professional education of medical students as well as physicians is needed. It should focus on the most common GC among the leading COD and acquiring skills in certifying external causes of death.

Estimation and probabilistic projection of age- and sex-specific mortality rates across Brazilian municipalities between 2010 and 2030

BACKGROUND

Mortality rate estimation in small areas can be difficult due the low number of events/exposure (i.e. stochastic error). If the death records are not completed, it adds a systematic uncertainty on the mortality estimates. Previous studies in Brazil have combined demographic and statistical methods to partially overcome these issues. We estimated age- and sex-specific mortality rates for all 5,565 Brazilian municipalities in 2010 and forecasted probabilistic mortality rates and life expectancy between 2010 and 2030.

METHODS

We used a combination of the Tool for Projecting Age-Specific Rates Using Linear Splines (TOPALS), Bayesian Model, Spatial Smoothing Model and an ad-hoc procedure to estimate age- and sex-specific mortality rates for all Brazilian municipalities for 2010. Then we adapted the Lee-Carter model to forecast mortality rates by age and sex in all municipalities between 2010 and 2030.

RESULTS

The adjusted sex- and age-specific mortality rates for all Brazilian municipalities in 2010 reveal a distinct regional pattern, showcasing a decrease in life expectancy in less socioeconomically developed municipalities when compared to estimates without adjustments. The forecasted mortality rates indicate varying regional improvements, leading to a convergence in life expectancy at birth among small areas in Brazil. Consequently, a reduction in the variability of age at death across Brazil's municipalities was observed, with a persistent sex differential.

CONCLUSION

Mortality rates at a small-area level were successfully estimated and forecasted, with associated uncertainty estimates also generated for future life tables. Our approach could be applied across countries with data quality issues to improve public policy planning.

Short-term associations between fine particulate air pollution and cardiovascular and respiratory mortality in 337 cities in Latin America

Ambient air pollution is a health concern in Latin America given its large urban population exposed to levels above recommended guidelines. Yet no studies have examined the mortality impact of air pollutants in the region across a wide range of cities. We assessed whether short-term levels of fine particulate matter (PM2.5) from modeled estimates, are associated with cardiovascular and respiratory mortality among adults in 337 cities from 9 Latin American countries. We compiled mortality, PM2.5 and temperature data for the period 2009-2015. For each city, we evaluated the association between monthly changes in PM2.5 and cardiovascular and respiratory mortality for sex and age subgroups using Poisson models, adjusted for seasonality, long-term trend, and temperature. To accommodate possibly different associations of mortality with PM2.5 by age, we included interaction terms between changes in PM2.5 and age in the models. We combined the city-specific estimates using a random effects meta-regression to obtain mortality relative risks for each sex and age group. We analyzed 3,026,861 and 1,222,623 cardiovascular and respiratory deaths, respectively, from a study population that represents 41 % of the total population of Latin America. We observed that a 10 μg/m3 increase in monthly PM2.5 is associated with an increase of 1.3 % (95 % confidence interval [CI], 0.4 to 2.2) in cardiovascular mortality and a 0.9 % increase (95 % CI -0.6 to 2.4) in respiratory mortality. Increases in mortality risk ranged between -0.5 % to 3.0 % across 6 sex-age groups, were larger in men, and demonstrated stronger associations with cardiovascular mortality as age increased. Socioeconomic, environmental and health contexts in Latin America are different than those present in higher income cities from which most evidence on air pollution impacts is drawn. Locally generated evidence constitutes a powerful instrument to engage civil society and help drive actions to mitigate and control ambient air pollution.

Life expectancy inequalities between regions of China 2004-2020: contribution of age- and cause-specific mortality

Background

China's rapid economic and social development since the early 2000s has caused significant shifts in its epidemiological transition, potentially leading to health disparities across regions.

Objectives

This study employs Life Expectancy (LE) to assess health disparities and trends among China's eastern, central, and western regions. It also examines the pace of LE gains relative to empirical trends and investigates age and causes of death mortality improvement contributing to regional LE gaps.

Data and methods

Using a log-quadratic model, the study estimates LE in China and its regions from 2004 to 2020, using census and death cause surveillance data. It also utilizes the Human Mortality Database (HMD) and the LE gains by LE level approach to analyze China and its regions' LE gains in comparison to empirical trend of developed countries. The study investigates changes in LE gaps due to age and causes of death mortality improvements during two periods, 2004-2012 and 2012-2020, through the LE factor decomposition method.

Results

From 2000 to 2020, China's LE exhibited faster pace of gains compared to developed countries. While men's LE growth gradually aligns with empirical trends, women experience slightly higher growth rates. Regional LE disparities significantly reduced from 2004 to 2012, with a marginal reduction from 2012 to 2020. In the latter period, the changing LE gap aligns with expected trends in developed countries, with all Chinese regions surpassing empirical estimates. Cardiovascular diseases and malignant neoplasms emerged as the primary contributors to expanding regional LE gaps, with neurological disorders and diabetes playing an increasingly negative role.

Conclusion

LE disparities in China have consistently decreased, although at a slower pace in recent years, mirroring empirical trends. To further reduce regional LE disparities, targeted efforts should focus on improving mortality rates related to cardiovascular diseases, neoplasms, neurological disorders and diabetes, especially in the western region. Effective health interventions should prioritize equalizing basic public health services nationwide.

Comparative performance of national civil registration and vital statistics systems: a global assessment

Objective

To assess the current state of the world's civil registration and vital statistics systems based on publicly available data and to propose strategic development pathways, including priority interventions, for countries at different levels of civil registration and vital statistics performance.

Methods

We applied a performance assessment framework to publicly available data, using a composite indicator highly correlated with civil registration and vital statistics performance which we then adjusted for data incomparability and missing values.

Findings

Globally, civil registration and vital statistics systems score on average 0.70 (0-1 scale), with substantial variations across countries and regions. Scores ranged from less than 0.50 in emerging systems to nearly 1.00 in the most developed systems. Approximately one fifth of the world's population live in the 43 countries with low system performance (< 0.477). Irrespective of system development, health sector indicators consistently scored lower than other determinants of civil registration and vital statistics performance.

Conclusion

From our assessment, we provide three main recommendations for how the health sector can contribute to improving civil registration and vital statistics systems: (i) enhanced health sector engagement in birth and death notification; (ii) a more systematic approach to training cause of death diagnostics; and (iii) leadership in the implementation of verbal autopsy methods. Four different civil registration and vital statistics improvement pathways for countries at different levels of system development are proposed, that can constitute a blueprint for regional civil registration and vital statistics strengthening activities that countries can adapt and refine to suit their capabilities, resources, and particular challenges.

Assessing the policy utility of routine mortality statistics: a global classification of countries

Objective

To evaluate the utility and quality of death registration data across countries.

Methods

We compiled routine death and cause of death statistics data from 2015-2019 from national authorities. We estimated completeness of death registration using the Adair-Lopez empirical method. The quality of cause of death data was assessed by evaluating the assignment of usable causes of death among people younger than 80 years. We grouped data into nine policy utility categories based on data availability, registration completeness and diagnostic precision.

Findings

Of an estimated 55 million global deaths in 2019, 70% of deaths were registered across 156 countries, but only 52% had medically certified causes and 42% of deaths were assigned a usable cause. In 54 countries, which are mostly high-income, there is complete and high-quality mortality data. In a further 29 countries, located across different regions, death registration is complete, but cause of death data quality remains suboptimal. Additionally, 37 countries possess functional death registration systems with cause of death data of poor to moderate quality. In 30 countries, death registration ranges from limited to nascent completeness, accompanied by poor or unavailable cause of death data. Furthermore, 38 countries lack accessible data altogether.

Conclusion

By implementing more proactive death notification processes, expanding the use of digitized data collection platforms, streamlining data compilation procedures and improving data quality assessment, governments could enhance the policy utility of mortality data. Encouraging the routine application of automated verbal autopsy methods is crucial for accurately determining the causes of deaths occurring at home.

Estimating causes of community death of adults in Myanmar from a nationwide population sample: Application of verbal autopsy

In Myanmar 84% of deaths occur in the community, of which half are unregistered and none have a reliable cause of death (COD) recorded. Since 2018, Myanmar has introduced improved registration practices and verbal autopsy (VA) to assess whether such methods can produce policy relevant information on community COD. Community health midwives and public health supervisors grade II collected VAs on over 80,000 deaths which occurred between January 2018 and December 2019 in a nationwide sample of 42 townships in Myanmar. Electronic methods were used to collect and consolidate data. The most probable COD was assigned using the SmartVA Analyze 2.0 computer algorithm. Completeness of VA death reporting increased to 71% in 2019. Most adult (12+ years) deaths (82%) were due to non-communicable diseases, primarily stroke, ischemic heart disease and chronic respiratory disease, for both men and women. VA results were consistent with Global Burden of Disease (GBD) Study estimates, except for cirrhosis in men, which was more common, and had a younger age distribution of death than the GBD. Large scale implementation of improved death registration practices and COD diagnosis using VA is feasible and provides plausible, timely, disaggregated and policy relevant information on the leading causes of community death. Addressing the burden of non-communicable diseases, particularly cirrhosis in young men, is an important public health priority in Myanmar. Improving completeness of VA death reporting in poorly performing townships and in neonates, children and women will further improve the policy utility of the VA data.

Flaws and uncertainties in pandemic global excess death calculations

Several teams have been publishing global estimates of excess deaths during the COVID-19 pandemic. Here, we examine potential flaws and underappreciated sources of uncertainty in global excess death calculations. Adjusting for changing population age structure is essential. Otherwise, excess deaths are markedly overestimated in countries with increasingly aging populations. Adjusting for changes in other high-risk indicators, such as residence in long-term facilities, may also make a difference. Death registration is highly incomplete in most countries; completeness corrections should allow for substantial uncertainty and consider that completeness may have changed during pandemic years. Excess death estimates have high sensitivity to modelling choice. Therefore different options should be considered and the full range of results should be shown for different choices of pre-pandemic reference periods and imposed models. Any post-modelling corrections in specific countries should be guided by pre-specified rules. Modelling of all-cause mortality (ACM) in countries that have ACM data and extrapolating these models to other countries is precarious; models may lack transportability. Existing global excess death estimates underestimate the overall uncertainty that is multiplicative across diverse sources of uncertainty. Informative excess death estimates require risk stratification, including age groups and ethnic/racial strata. Data to-date suggest a death deficit among children during the pandemic and marked socioeconomic differences in deaths, widening inequalities. Finally, causal explanations require great caution in disentangling SARS-CoV-2 deaths, indirect pandemic effects and effects from measures taken. We conclude that excess deaths have many uncertainties, but globally deaths from SARS-CoV-2 may be the minority of calculated excess deaths.

Implementation research for developing Civil Registration and Vital Statistics (CRVS) Systems: lessons from Indonesia

Civil Registration and Vital Statistics (CRVS) systems are the optimal source for data on births, deaths and causes of death for health policy, programme evaluation and research. In Indonesia, indicators such as life expectancy at birth, childhood and maternal mortality rates and cause-specific death rates need to be routinely monitored for national health policy. However, the CRVS system is not yet producing reliable vital statistics, which creates a challenge for evidence-based health action. In 2019, the Indonesian government released a national strategy for the CRVS system, with targets for improved coverage and data quality by 2024. This article describes findings from a programme of formative and implementation research to guide the application of the national strategy. At first, a detailed CRVS assessment and gap analysis were undertaken using an international framework. The assessment findings were used to develop a revised business process model for reporting deaths and their causes at village, subdistrict and district level. In addition, a field instruction manual was also developed to guide personnel in implementation. Two field sites in Java-Malang District and Kudus Regency were selected for pilot testing the reporting procedures, and relevant site preparation and training were carried out. Data compilations for Malang in 2019 and Kudus in 2020 were analysed to derive mortality indicators. High levels of death reporting completeness (83% to 89%) were reported from both districts, along with plausible cause-specific mortality profiles, although the latter need further validation. The study findings establish the feasibility of implementing revised death reporting procedures at the local level, as well as demonstrate sustainability through institutionalisation and capacity building, and can be used to accelerate further development of the CRVS system in Indonesia.

Validating the InterVA-5 cause of death analytical tool: using mortality data from the Comprehensive Health and Epidemiological Surveillance System in Papua New Guinea

OBJECTIVE

InterVA-5 is a new version of an analytical tool for cause of death (COD) analysis at the population level. This study validates the InterVA-5 against the medical review method, using mortality data in Papua New Guinea (PNG).

DESIGN AND SETTING

This study used mortality data collected from January 2018 to December 2020 in eight surveillance sites of the Comprehensive Health and Epidemiological Surveillance System (CHESS), established by the PNG Institute of Medical Research in six major provinces.

METHODS

The CHESS demographic team conducted verbal autopsy (VA) interviews with close relatives of the deceased, who died in communities within the catchment areas of CHESS, using the WHO 2016 VA instrument. COD of the deceased was assigned by InterVA-5 tool, and independently certified by the medical team. Consistency, difference and agreement between the InterVA-5 model and medical review were assessed. Sensitivity and positive predictive value (PPV) of the InterVA-5 tool were calculated with reference to the medical review method.

RESULTS

Specific COD of 926 deceased people was included in the validation. Agreement between the InterVA-5 tool and medical review was high (kappa test: 0.72; p<0.01). Sensitivity and PPV of the InterVA-5 were 93% and 72% for cardiovascular diseases, 84% and 86% for neoplasms, 65% and 100% for other chronic non-communicable diseases (NCDs), and 78% and 64% for maternal deaths, respectively. For infectious diseases and external CODs, sensitivity and PPV of the InterVA-5 were 94% and 90%, respectively, while the sensitivity and PPV of the medical review method were both 54% for classifying neonatal CODs.

CONCLUSION

The InterVA-5 tool works well in the PNG context to assign specific CODs of infectious diseases, cardiovascular diseases, neoplasms and injuries. Further improvements with respect to chronic NCDs, maternal deaths and neonatal deaths are needed.

Enhancing the value of death registration with verbal autopsy data: a pilot study in the Senegalese urban population in 2019

BACKGROUND

There is no source of data on causes of death in Senegal that covers both community and hospital deaths. Yet the death registration system in the Dakar region is relatively complete (>80%) and could be expanded to provide information on the diseases and injuries that led to death.

METHODS

In this pilot study, we recorded all deaths that occurred over 2 months and were reported in the 72 civil registration offices in the Dakar region. We selected the deaths of residents of the region and administered a verbal autopsy to a relative of the deceased to identify the underlying causes of death. Causes of death were assigned using the InterVA5 model.

RESULTS

The age structure of deaths registered at the civil registry differed from that of the census, with a proportion of infant deaths about twice as high as in the census. The main causes of death were prematurity and obstetric asphyxia in newborns. Meningitis and encephalitis, severe malnutrition, and acute respiratory infections were the leading causes from 1 month to 15 years of age. Cardiovascular diseases accounted for 27% of deaths in adults aged 15-64 and 45% of deaths among adults above age 65, while neoplasms accounted for 20% and 12% of deaths in these two age groups, respectively.

CONCLUSIONS

This study demonstrates that the epidemiological transition is at an advanced stage in urban areas of Dakar, and underlines the importance of conducting regular studies based on verbal autopsies of deaths reported in civil registration offices.

Leading causes of deaths in the mortality transition in Papua New Guinea: evidence from the Comprehensive Health and Epidemiological Surveillance System

Background

Changing causes of deaths in the mortality transition in Papua New Guinea (PNG) are poorly understood. This study analysed community-level data to identify leading causes of death in the population and variations across age groups and sexes, urban-rural sectors and provinces.

Method

Mortality surveillance data were collected from 2018–20 as part of the Comprehensive Health and Epidemiological Surveillance System (CHESS), using the World Health Organization 2016 verbal autopsy (VA) instrument. Data from 926 VA interviews were analysed, using the InterVA-5 cause of death analytical tool to assign specific causes of death among children (0–14 years), those of working age (15–64 years) and the elderly (65+ years).

Result

Nearly 50% of the total deaths were attributed to non-communicable diseases (NCDs), followed by infectious and parasitic diseases (35%), injuries and external causes (11%) and maternal and neonatal deaths (4%). Leading causes of death among children were acute respiratory tract infections (ARTIs) and diarrhoeal diseases, each contributing to 13% of total deaths. Among the working population, tuberculosis (TB) contributed to 12% of total deaths, followed by HIV/AIDS (11%). TB- and HIV/AIDS-attributed deaths were highest in the age group 25–34 years, at 20% and 18%, respectively. These diseases killed more females of working age (n = 79, 15%) than males (n = 52, 8%). Among the elderly, the leading causes of death were ARTIs (13%) followed by digestive neoplasms (10%) and acute cardiac diseases (9%).

Conclusion

The variations in leading causes of death across the populations in PNG suggest diversity in mortality transition. This requires different strategies to address specific causes of death in particular populations.

Estimation of national and subnational all-cause mortality indicators in Nepal, 2017

BACKGROUND

Despite the civil registration and vital statistics (CRVS) system in Nepal operating for several decades, it has not been used to produce routine mortality statistics. Instead, mortality statistics rely on irregular surveys and censuses that primarily focus on child mortality. To fill this knowledge gap, this study estimates levels and subnational differentials in mortality across all ages in Nepal, primarily using CRVS data adjusted for incompleteness.

METHODS

We analyzed death registration data (offline or paper-based) and CRVS survey reported death data, estimating the true crude death rate (CDR) and number of deaths by sex and year for each province and ecological belt. The estimated true number of deaths for 2017 was used with an extension of the empirical completeness method to estimate the adult mortality (45q15) and life expectancy at birth by sex and subnational level. Plausibility of subnational mortality estimates was assessed against poverty head count rates.

RESULTS

Adult mortality in Nepal for 2017 is estimated to be 159 per 1000 for males and 116 for females, while life expectancy was estimated as 69.7 years for males and 73.9 years for females. Subnationally, male adult mortality ranges from 129 per 1000 in Madhesh to 224 in Karnali and female adult mortality from 89 per 1000 in Province 1 to 159 in Sudurpashchim. Similarly, male life expectancy is between 64.9 years in Karnali and 71.8 years in Madhesh and female male life expectancy between 69.6 years in Sudurpashchim and 77.0 years in Province 1. Mountain ecological belt and Sudurpashchim and Karnali provinces have high mortality and high poverty levels, whereas Terai and Hill ecological belts and Province 1, Madhesh, and Bagmati and Gandaki provinces have low mortality and poverty levels.

CONCLUSIONS

This is the first use of CRVS system data in Nepal to estimate national and subnational mortality levels and differentials. The national results are plausible when compared with Global Burden of Disease and United Nations World Population Prospects estimates. Understanding of the reasons for inequalities in mortality in Nepal should focus on improving cause of death data and further strengthening CRVS data.

Comparison of pandemic excess mortality in 2020-2021 across different empirical calculations

Different modeling approaches can be used to calculate excess deaths for the COVID-19 pandemic period. We compared 6 calculations of excess deaths (4 previously published [3 without age-adjustment] and two new ones that we performed with and without age-adjustment) for 2020-2021. With each approach, we calculated excess deaths metrics and the ratio R of excess deaths over recorded COVID-19 deaths. The main analysis focused on 33 high-income countries with weekly deaths in the Human Mortality Database (HMD at mortality.org) and reliable death registration. Secondary analyses compared calculations for other countries, whenever available. Across the 33 high-income countries, excess deaths were 2.0-2.8 million without age-adjustment, and 1.6-2.1 million with age-adjustment with large differences across countries. In our analyses after age-adjustment, 8 of 33 countries had no overall excess deaths; there was a death deficit in children; and 0.478 million (29.7%) of the excess deaths were in people <65 years old. In countries like France, Germany, Italy, and Spain excess death estimates differed 2 to 4-fold between highest and lowest figures. The R values' range exceeded 0.3 in all 33 countries. In 16 of 33 countries, the range of R exceeded 1. In 25 of 33 countries some calculations suggest R > 1 (excess deaths exceeding COVID-19 deaths) while others suggest R < 1 (excess deaths smaller than COVID-19 deaths). Inferred data from 4 evaluations for 42 countries and from 3 evaluations for another 98 countries are very tenuous. Estimates of excess deaths are analysis-dependent and age-adjustment is important to consider. Excess deaths may be lower than previously calculated.

Intraurban socioeconomic inequalities in life expectancy: a population-based cross-sectional analysis in the city of Córdoba, Argentina (2015-2018)

OBJECTIVES

To evaluate variability in life expectancy at birth in small areas, describe the spatial pattern of life expectancy, and examine associations between small-area socioeconomic characteristics and life expectancy in a mid-sized city of a middle-income country.

DESIGN

Cross-sectional, using data from death registries (2015-2018) and socioeconomic characteristics data from the 2010 national population census.

PARTICIPANTS/SETTING

40 898 death records in 99 small areas of the city of Córdoba, Argentina. We summarised variability in life expectancy at birth by using the difference between the 90th and 10th percentile of the distribution of life expectancy across small areas (P90-P10 gap) and evaluated associations with small-area socioeconomic characteristics by calculating a Slope Index of Inequality in linear regression.

PRIMARY OUTCOME

Life expectancy at birth.

RESULTS

The median life expectancy at birth was 80.3 years in women (P90-P10 gap=3.2 years) and 75.1 years in men (P90-P10 gap=4.6 years). We found higher life expectancies in the core and northwest parts of the city, especially among women. We found positive associations between life expectancy and better small-area socioeconomic characteristics, especially among men. Mean differences in life expectancy between the highest versus the lowest decile of area characteristics in men (women) were 3.03 (2.58), 3.52 (2.56) and 2.97 (2.31) years for % adults with high school education or above, % persons aged 15-17 attending school, and % households with water inside the dwelling, respectively. Lower values of % overcrowded households and unemployment rate were associated with longer life expectancy: mean differences comparing the lowest versus the highest decile were 3.03 and 2.73 in men and 2.57 and 2.34 years in women, respectively.

CONCLUSION

Life expectancy is substantially heterogeneous and patterned by socioeconomic characteristics in a mid-sized city of a middle-income country, suggesting that small-area inequities in life expectancy are not limited to large cities or high-income countries.

Mammography screening is associated with more favourable breast cancer tumour characteristics and better overall survival: case-only analysis of 3739 Asian breast cancer patients

BACKGROUND

Early detection of breast cancer (BC) through mammography screening (MAM) is known to reduce mortality. We examined the differential effect that mammography has on BC characteristics and overall survival and the sociodemographic determinants of MAM utilization in a multi-ethnic Asian population.

METHODS

This study included 3739 BC patients from the Singapore Breast Cancer Cohort (2010-2018). Self-reported sociodemographic characteristics were collected using a structured questionnaire. Clinical data were obtained through medical records. Patients were classified as screeners (last screening mammogram ≤ 2 years before diagnosis), non-screeners (aware but did not attend or last screen > 2years), and those unaware of MAM. Associations between MAM behaviour (MB) and sociodemographic factors and MB and tumour characteristics were examined using multinomial regression. Ten-year overall survival was modelled using Cox regression.

RESULTS

Patients unaware of screening were more likely diagnosed with late stage (OR_{stage III vs stage I (Ref)} [95% CI]: 4.94 [3.45-7.07], p < 0.001), high grade (OR_{poorly vs well-differentiated (reference)}: 1.53 [1.06-2.20], p = 0.022), nodal-positive, large size (OR_{>5cm vs ≤2cm (reference)}: 5.06 [3.10-8.25], p < 0.001), and HER2-positive tumours (OR_{HER2-negative vs HER2-positive (reference)}: 0.72 [0.53-0.97], p = 0.028). Similar trends were observed between screeners and non-screeners with smaller effect sizes. Overall survival was significantly shorter than screeners in the both groups (HR_{non-screeners}: 1.89 [1.22-2.94], p = 0.005; HR_unaware: 2.90 [1.69-4.98], p < 0.001). Non-screeners and those unaware were less health conscious, older, of Malay ethnicity, less highly educated, of lower socioeconomic status, more frequently ever smokers, and less physically active. Among screeners, there were more reported personal histories of benign breast surgeries or gynaecological conditions and positive family history of breast cancer.

CONCLUSIONS

Mammography attendance is associated with more favourable BC characteristics and overall survival. Disparities in the utility of MAM services suggest that different strategies may be needed to improve MAM uptake.

Drug-related Death low Registration in Iran: A Mixed Method Approach for Causes, Recommendations to Solve This Problem and Geographical Evaluation of an Intervention

Background

The death registration is conducted by different systems in Iran. The drug-related death registration is exclusively conducted by Ministry of Health and Medical Education (MOHME) and Legal Medicine Organization (LMO). This study investigates the causes of undercounting drug-related deaths (DRDs) in Iran, provides recommendations for addressing this issue, and provides a geographical evaluation of the integrity and quality of drug-related mortality registration (2014-2017).

Methods

This is a mix-method study. In part1, individual targeted interviews were conducted with 12 experts in death registration in MOHME and LMO to collect data on the causes of low registration in Iran and provide recommendations for resolving the issue. Part2 of the study involved an intervention in the form of a memorandum of understanding on reduction of low-registrations. This memorandum was signed to transfer information about the corpses between the MOHME and LMO. First, the number of DRDs (2014- 2017) was examined using capture-recapture method and, then, we calculated and compared the rate of pre-intervention (2014-2016) and post-intervention (2017) under-registration to assess whether this memorandum of understanding had been effective in reduction of under-registrations.

Findings

In part1, according to the participants, the causes of undercounting DRDs in LMO and MOHME were arranged and categorized into 4 categories: weak administration system, physician and personnel training problems, system constraints, and client-related problems. Also, some suggestions were presented to help resolving the problem of undercounting; these suggestions concern the administrative system, technology, and educational domains. In part 2, about half of the provinces in Iran had a positive performance in reducing the undercount.

Conclusion

At the macro level, the memorandum of understanding between the two organizations responsible for registering deaths was effective. However, increasing the quality of data registrations requires monitoring at the micro and organizational levels to lead to a positive performance in reducing death under-registration in all provinces.

Burden of non-communicable disease studies in Europe: a systematic review of data sources and methodological choices

BACKGROUND

Assessment of disability-adjusted life years (DALYs) resulting from non-communicable diseases (NCDs) requires specific calculation methods and input data. The aims of this study were to (i) identify existing NCD burden of disease (BoD) activities in Europe; (ii) collate information on data sources for mortality and morbidity; and (iii) provide an overview of NCD-specific methods for calculating NCD DALYs.

METHODS

NCD BoD studies were systematically searched in international electronic literature databases and in grey literature. We included all BoD studies that used the DALY metric to quantify the health impact of one or more NCDs in countries belonging to the European Region.

RESULTS

A total of 163 BoD studies were retained: 96 (59%) were single-country or sub-national studies and 67 (41%) considered more than one country. Of the single-country studies, 29 (30%) consisted of secondary analyses using existing Global Burden of Disease (GBD) results. Mortality data were mainly derived (49%) from vital statistics. Morbidity data were frequently (40%) drawn from routine administrative and survey datasets, including disease registries and hospital discharge databases. The majority (60%) of national BoD studies reported mortality corrections. Multimorbidity adjustments were performed in 18% of national BoD studies.

CONCLUSION

The number of national NCD BoD assessments across Europe increased over time, driven by an increase in BoD studies that consisted of secondary data analysis of GBD study findings. Ambiguity in reporting the use of NCD-specific BoD methods underlines the need for reporting guidelines of BoD studies to enhance the transparency of NCD BoD estimates across Europe.

Assessment of the national and subnational completeness of death registration in Nepal

Background

Reliable and timely mortality data from a civil registration and vital statistics (CRVS) system are of crucial importance for generating evidence for policy and monitoring the progress towards national and global development goals. In Nepal, however, the death registration system is not used to produce mortality statistics, because it does not providing data on age at death and only reporting deaths by year of registration. This study assesses the completeness of death registration in Nepal – both the existing offline system and the newer online system – as well as the completeness of death reporting from a CRVS Survey, and assesses differences by year, sex, ecological belt, and province.

Methods

The empirical completeness method is used to estimate completeness at all ages from the offline (paper-based) registration system (2013-17), the online registration system (2017-19) and the CRVS Survey (2014-15).

Results

Completeness of the offline death registration system was 69% in 2017, not increasing since 2013 and being higher for males (73%) than females (65%). Completeness of online registration was only 32% in 2019, but almost double the 2017 figure. Completeness of death reporting in the CRVS Survey was 75% in 2015. The largest subnational differentials in completeness exist for the offline registration system, ranging from 90% in Gandaki to just 39% in Karnali.

Conclusions

Improvement in the utility of the Nepalese death registration system for mortality statistics is dependent on continued roll-out of the online death registration system (which reports age at death and deaths by year of occurrence) throughout the country, focusing on areas with low registration, building a strong coordination mechanism among CRVS stakeholders and implementing public awareness programs about death registration.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-12767-z.

Estimating Child Mortality at the Sub-national Level in Papua New Guinea: Evidence From the Integrated Health and Demographic Surveillance System

Background

Child mortality is an important indication of an effective public health system. Data sources available for the estimation of child mortality in Papua New Guinea (PNG) are limited.

Objective

The objective of this study was to provide child mortality estimates at the sub-national level in PNG using new data from the integrated Health and Demographic Surveillance System (iHDSS).

Method

Using direct estimation and indirect estimation methods, household vital statistics and maternal birth history data were analysed to estimate three key child health indicators: Under 5 Mortality Rate (U5MR), Infant Mortality Rate (IMR) and Neonatal Mortality Rate (NMR) for the period 2014–2017. Differentials of estimates were evaluated by comparing the mean relative differences between the two methods.

Results

The direct estimations showed U5MR of 93, IMR of 51 and NMR of 34 per 1000 live births for all the sites in the period 2014–2017. The indirect estimations reported an U5MR of 105 and IMR of 67 per 1000 live births for all the sites in 2014. The mean relative differences in U5MR and IMR estimates between the two methods were 3 and 24 percentage points, respectively. U5MR estimates varied across the surveillance sites, with the highest level observed in Hela Province (136), and followed by Eastern Highlands (122), Madang (105), and Central (42).

Discussion

The indirect estimations showed higher estimates for U5MR and IMR than the direct estimations. The differentials between IMR estimates were larger than between U5MR estimates, implying the U5MR estimates are more reliable than IMR estimates. The variations in child mortality estimates between provinces highlight the impact of contextual factors on child mortality. The high U5MR estimates were likely associated with inequality in socioeconomic development, limited access to healthcare services, and a result of the measles outbreaks that occurred in the highlands region from 2014-2017.

Conclusion

The iHDSS has provided reliable data for the direct and indirect estimations of child mortality at the sub-national level. This data source is complementary to the existing national data sources for monitoring and reporting child mortality in PNG.

Trends and external causes of traumatic brain injury and spinal cord injury mortality in south China, 2014-2018: an ecological study

BACKGROUND

The epidemiological evidence of traumatic brain injury (TBI) and spinal cord injury (SCI) mortality in mainland China is lacking. We aimed to assess the trends of TBI and SCI mortality, and their association with sex, age, location and external causes of injury in south China.

METHODS

Mortality data were derived from the Disease Surveillance Points (DSPs) system of Guangdong province between 2014 and 2018. We examined the trends in mortality with Cochran-Armitage trend test, and the association between the socio-demographic factors and the TBI and SCI mortality by using negative binomial models. Subgroup analysis was performed by stratifying the external causes of TBI and SCI.

RESULTS

The age-standardized TBI mortality remained relatively stable (from 11.6 to 15.4 per 100,000), while the SCI mortality increased by 148.3% from 2014 to 2018. Compared with females and urban residents, the adjusted mortality rate ratios of males and rural residents were 2.3 and 2.0 for TBI, and 2.2 and 4.6 for SCI, respectively. TBI and SCI mortality increased substantially with age. Motor vehicle crashes and falls were the leading causes of TBI mortality in residents aged under 75 years and over 75 years, respectively. Falls were the most important external cause for SCI death of all ages.

CONCLUSIONS

Being male, rural and elderly residents are at higher risk of dying from TBI and SCI. The substantial burden of TBI and SCI caused by road traffic crashes and falls has called for the urgent need to improve injury prevention, pre-hospital aid, hospital treatment and recovery.

Subnational mortality estimates for India in 2019: a baseline for evaluating excess deaths due to the COVID-19 pandemic

BACKGROUND

Estimates of excess mortality are required to assess and compare the impact of the COVID-19 pandemic across populations. For India, reliable baseline prepandemic mortality patterns at national and subnational level are necessary for such assessments. However, available data from the Civil Registration System (CRS) is affected by incompleteness of death recording that varies by sex, age and location.

METHODS

Under-reporting of CRS 2019 deaths was assessed for three age groups (< 5 years, 15-59 years and ≥60 years) at subnational level, through comparison with age-specific death rates from alternate sources. Age-specific corrections for under-reporting were applied to derive adjusted death counts by sex for each location. These were used to compute life expectancy (LE) at birth by sex in 2019, which were compared with subnational LEs from the Global Burden of Disease (GBD) 2019 Study.

RESULTS

A total of 9.92 million deaths (95% UI 9.70 to 10.02) were estimated across India in 2019, about 2.28 million more than CRS reports. Adjustments to under-five and elderly mortality accounted for 30% and 56% of additional deaths, respectively. Adjustments in Bihar, Jharkhand, Madhya Pradesh, Maharashtra, Rajasthan and Uttar Pradesh accounted for 75% of all additional deaths. Adjusted LEs were below corresponding GBD estimates by ≥2 years for males at national level and in 20 states, and by ≥1 year for females in 12 states.

CONCLUSIONS

These results represent the first-ever subnational mortality estimates for India derived from CRS reported deaths, and serve as a baseline for assessing excess mortality from the COVID-19 pandemic. Adjusted life expectancies indicate higher mortality patterns in India than previously perceived. Under-reporting of infant deaths and those among women and the elderly is evident in many locations. Further CRS strengthening is required to improve the empirical basis for local mortality measurement across the country.

Are there sex differences in completeness of death registration and quality of cause of death statistics? Results from a global analysis

INTRODUCTION

Recent studies suggest that more male than female deaths are registered and a higher proportion of female deaths are certified as 'garbage' causes (ie, vague or ill-defined causes of limited policy value). This can reduce the utility of sex-specific mortality statistics for governments to address health problems. To assess whether there are sex differences in completeness and quality of data from civil registration and vital statistics systems, we analysed available global death registration and cause of death data.

METHODS

Completeness of death registration for females and males was compared in 112 countries, and in subsets of countries with incomplete death registration. For 64 countries with medical certificate of cause of death data, the level, severity and type of garbage causes was compared between females and males, standardised for the older age distribution and different cause composition of female compared with male deaths.

RESULTS

For 42 countries with completeness of less than 95% (both sexes), average female completeness was 1.2 percentage points (p.p.) lower (95% uncertainty interval (UI) -2.5 to -0.2 p.p.) than for males. Aggregate female completeness for these countries was 7.1 p.p. lower (95% UI -12.2 to -2.0 p.p.; female 72.9%, male 80.1%), due to much higher male completeness in nine countries including India. Garbage causes were higher for females than males in 58 of 64 countries (statistically significant in 48 countries), but only by an average 1.4 p.p. (1.3-1.6 p.p.); results were consistent by severity and type of garbage.

CONCLUSION

Although in most countries analysed there was no clear bias against females in death registration, there was clear evidence in a few countries of systematic undercounting of female deaths which substantially reduces the utility of mortality data. In countries with cause of death data, it was only of marginally poorer quality for females than males.

Estimation of all-cause excess mortality by age-specific mortality patterns for countries with incomplete vital statistics: a population-based study of the case of Peru during the first wave of the COVID-19 pandemic

BACKGROUND

All-cause excess mortality is a comprehensive measure of the combined direct and indirect effects of COVID-19 on mortality. Estimates are usually derived from Civil Registration and Vital Statistics (CRVS) systems, but these do not include non-registered deaths, which may be affected by changes in vital registration coverage over time.

METHODS

Our analytical framework and empirical strategy account for registered mortality and under-registration. This provides a better estimate of the actual mortality impact of the first wave of the COVID-19 pandemic in Peru. We use population and crude mortality rate projections from Peru's National Institute of Statistics and Information (INEI, in Spanish), individual-level registered COVID-19 deaths from the Ministry of Health (MoH), and individual-level registered deaths by region and age since 2017 from the National Electronic Deaths Register (SINADEF, in Spanish).We develop a novel framework combining different estimates and using quasi-Poisson models to estimate total excess mortality across regions and age groups. Also, we use logistic mixed-effects models to estimate the coverage of the new SINADEF system.

FINDINGS

We estimate that registered mortality underestimates national mortality by 37•1% (95% CI 23% - 48•5%) across 26 regions and nine age groups. We estimate total all-cause excess mortality during the period of analysis at 173,099 (95% CI 153,669 - 187,488) of which 108,943 (95% CI 96,507 - 118,261) were captured by the vital registration system. Deaths at age 60 and over accounted for 74•1% (95% CI 73•9% - 74•7%) of total excess deaths, and there were fewer deaths than expected in younger age groups. Lima region, on the Pacific coast and including the national capital, accounts for the highest share of excess deaths, 87,781 (95% CI 82,294 - 92,504), while in the opposite side regions of Apurimac and Huancavelica account for less than 300 excess deaths.

INTERPRETATION

Estimating excess mortality in low- and middle-income countries (LMICs) such as Peru must take under-registration of mortality into account. Combining demographic trends with data from administrative registries reduces uncertainty and measurement errors. In countries like Peru, this is likely to produce significantly higher estimates of excess mortality than studies that do not take these effects into account.

FUNDING

None.

Improving quality of medical certification of causes of death in health facilities in Tanzania 2014-2019

BACKGROUND

Monitoring medically certified causes of death is essential to shape national health policies, track progress to Sustainable Development Goals, and gauge responses to epidemic and pandemic disease. The combination of electronic health information systems with new methods for data quality monitoring can facilitate quality assessments and help target quality improvement. Since 2015, Tanzania has been upgrading its Civil Registration and Vital Statistics system including efforts to improve the availability and quality of mortality data.

METHODS

We used a computer application (ANACONDA v4.01) to assess the quality of medical certification of cause of death (MCCD) and ICD-10 coding for the underlying cause of death for 155,461 deaths from health facilities from 2014 to 2018. From 2018 to 2019, we continued quality analysis for 2690 deaths in one large administrative region 9 months before, and 9 months following MCCD quality improvement interventions. Interventions addressed governance, training, process, and practice. We assessed changes in the levels, distributions, and nature of unusable and insufficiently specified codes, and how these influenced estimates of the leading causes of death.

RESULTS

9.7% of expected annual deaths in Tanzania obtained a medically certified cause of death. Of these, 52% of MCCD ICD-10 codes were usable for health policy and planning, with no significant improvement over 5 years. Of certified deaths, 25% had unusable codes, 17% had insufficiently specified codes, and 6% were undetermined causes. Comparing the before and after intervention periods in one Region, codes usable for public health policy purposes improved from 48 to 65% within 1 year and the resulting distortions in the top twenty cause-specific mortality fractions due to unusable causes reduced from 27.4 to 13.5%.

CONCLUSION

Data from less than 5% of annual deaths in Tanzania are usable for informing policy. For deaths with medical certification, errors were prevalent in almost half. This constrains capacity to monitor the 15 SDG indicators that require cause-specific mortality. Sustainable quality assurance mechanisms and interventions can result in rapid improvements in the quality of medically certified causes of death. ANACONDA provides an effective means for evaluation of such changes and helps target interventions to remaining weaknesses.

Motivations and barriers to death registration in Dakar, Senegal

Strengthening civil registration systems requires a better understanding of motivations and barriers related to the registration of deaths. We used data from the 2013 Senegalese census to identify deaths that are more likely to be registered in the Dakar region, where the completeness of death registration is higher than 80%. We also interviewed relatives of the deceased whose death had been registered to collect data on reasons for registration and sources of information about the process. The likelihood of death registration was positively associated with age at death and household wealth. Death registration was also more likely in households whose head was older, had attended school, and had a birth certificate. At the borough commune level, the geographical accessibility of civil registration centres and population density were both positively associated with completeness of death registration. The main motivations for registering deaths were compliance with the legal obligation to do so and willingness to obtain a burial permit and a death certificate. Families, health facilities, and friends were the primary sources of information about death registration. Further research is needed to identify effective interventions to increase death registration completeness in Dakar, particularly amongst the poorest households and neighbourhoods on the outskirts of the city.

Who dies where? Estimating the percentage of deaths that occur at home

Introduction

The majority of low-income and middle-income countries (LMICs) have incomplete death registration systems and so the proportion of deaths that occur at home (ie, home death percentage) is generally unknown. However, home death percentage is important to estimate population-level causes of death from integration of data of deaths at home (verbal autopsies) and in hospitals (medical certification), and to monitor completeness of death notification and verbal autopsy data collection systems. This study proposes a method to estimate home death percentage using data readily available at the national and subnational level.

Methods

Data on place of death from 152 country-years in 49 countries from 2005 to 2019, predominantly from vital registration systems, were used to model home death percentage standardised for population age and cause distribution. A national-level model was developed using Bayesian model averaging to estimate national, regional and global home death percentage. A subnational-level model was also developed and assessed in populations where alternative data on home death percentage were available.

Results

Globally, it is estimated that 53.4% (95% uncertainty interval (UI) 50.8%–55.9%) of deaths occur at home, slightly higher (59.7%, 95% UI 56.5%–62.7%) in LMICs, substantially higher in low-income countries (79.5%, 95% UI 77.3%–81.5%) and much lower (27.3%, 95% UI 25.2%–29.6%) in high-income countries. Countries with the highest home death percentage are mostly found in South, East and Southeast Asia and sub-Saharan Africa (above 90% in Ethiopia, Chad and South Sudan). As expected, the national model has smaller error than the subnational model.

Conclusion

The study demonstrates substantial diversity in the location of deaths in LMICs and fills a significant gap in knowledge about where people die, given its importance for health systems and policies. The high proportion of deaths in LMICs that occur at home reinforces the need for routine verbal autopsy to determine the causes of death.

Have inequalities in completeness of death registration between states in India narrowed during two decades of civil registration system strengthening?

Background

In India the number of registered deaths increased substantially in recent years, improving the potential of the civil registration and vital statistics (CRVS) system to be the primary source of mortality data and providing more families of decedents with the benefits of possessing a death certificate. This study aims to identify whether inequalities in the completeness of death registration between states in India, including by sex, have narrowed during this period of CRVS system strengthening.

Methods

Data used in this study are registered deaths by state and year from 2000 to 2018 (and by sex from 2009 to 2018) reported in the Civil Registration Reports published by the Office of Registrar General of India. Completeness of death registration is calculated using the empirical completeness method. Levels and trends inequalities in completeness are measured in each state a socio-economic indicator – the Socio-Demographic Index (SDI).

Results

Estimated completeness of death registration in India increased from 58% in 2000 to 81% in 2018. Male completeness rose from 60% in 2009 to 85% in 2018 and was much higher than female completeness, which increased from 54 to 74% in the same period. Completeness remained very low in some states, particularly from the eastern (e.g. Bihar) and north-eastern regions. However, in states from the northern region (e.g. Uttar Pradesh) completeness increased significantly from a low level. There was a narrowing of inequalities in completeness according to the SDI during the period, however large inequalities between states remain.

Conclusions

The increase in completeness of death registration in India is a substantial achievement and increases the potential of the death registration system as a routine source of mortality data. Although narrowing of inequalities in completeness demonstrates that the benefits of higher levels of death registration have spread to relatively poorer states of India in recent years, the continued low completeness in some states and for females are concerning. The Indian CRVS system also needs to increase the number of registered deaths with age at death reported to improve their usability for mortality statistics.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12939-021-01534-y.

Mortality amenable to healthcare in Latin American cities: a cross-sectional study examining between-country variation in amenable mortality and the role of urban metrics

Background

This study examined the variation in city-level amenable mortality, i.e. mortality due to conditions that can be mitigated in the presence of timely and effective healthcare, in 363 Latin American cities and measured associations between amenable-mortality rates and urban metrics.

Methods

We used death records from 363 cities with populations of >100 000 people in nine Latin American countries from 2010 to 2016. We calculated sex-specific age-adjusted amenable-mortality rates per 100 000. We fitted multilevel linear models with cities nested within countries and estimated associations between amenable mortality and urban metrics, including population size and growth, fragmentation of urban development and socio-economic status.

Results

Cities in Mexico, Colombia and Brazil had the highest rates of amenable mortality. Overall, >70% of the variability in amenable mortality was due to between-country heterogeneity. But for preventable amenable mortality, those for which the healthcare system can prevent new cases, most of the variability in rates occurred between cities within countries. Population size and fragmentation of urban development were associated with amenable mortality. Higher fragmentation of urban development was associated with lower amenable mortality in small cities and higher amenable mortality in large cities. Population growth and higher city-level socio-economic status were associated with lower amenable mortality.

Conclusions

Most of the variability in amenable mortality in Latin American cities was due to between-county heterogeneity. However, urban metrics such as population size and growth, fragmentation of urban development and city-level socio-economic status may have a role in the distribution of amenable mortality across cities within countries.

Monitoring progress with national and subnational health goals by integrating verbal autopsy and medically certified cause of death data

Introduction

The measurement of progress towards many Sustainable Development Goals (SDG) and other health goals requires accurate and timely all-cause and cause of death (COD) data. However, existing guidance to countries to calculate these indicators is inadequate for populations with incomplete death registration and poor-quality COD data. We introduce a replicable method to estimate national and subnational cause-specific mortality rates (and hence many such indicators) where death registration is incomplete by integrating data from Medical Certificates of Cause of Death (MCCOD) for hospital deaths with routine verbal autopsy (VA) for community deaths.

Methods

The integration method calculates population-level cause-specific mortality fractions (CSMFs) from the CSMFs of MCCODs and VAs weighted by estimated deaths in hospitals and the community. Estimated deaths are calculated by applying the empirical completeness method to incomplete death registration/reporting. The resultant cause-specific mortality rates are used to estimate SDG Indicator 23: mortality between ages 30 and 70 years from cardiovascular diseases, cancers, chronic respiratory diseases and diabetes. We demonstrate the method using nationally representative data in Myanmar, comprising over 42 000 VAs and 7600 MCCODs.

Results

In Myanmar in 2019, 89% of deaths were estimated to occur in the community. VAs comprised an estimated 70% of community deaths. Both the proportion of deaths in the community and CSMFs for the four causes increased with older age. We estimated that the probability of dying from any of the four causes between 30 and 70 years was 0.265 for men and 0.216 for women. This indicator is 50% higher if based on CSMFs from the integration of data sources than on MCCOD data from hospitals.

Conclusion

This integration method facilitates country authorities to use their data to monitor progress with national and subnational health goals, rather than rely on estimates made by external organisations. The method is particularly relevant given the increasing application of routine VA in country Civil Registration and Vital Statistics systems.

The civil registration system is a potentially viable data source for reliable subnational mortality measurement in India

Introduction

The Indian national Civil Registration System (CRS) is the optimal data source for subnational mortality measurement, but is yet under development. As an alternative, data from the Sample Registration System (SRS), which covers less than 1% of the national population, is used. This article presents a comparison of mortality measures from the SRS and CRS in 2017, and explores the potential of the CRS to meet these subnational data needs.

Methods

Data on population and deaths by age and sex for 2017 from each source were used to compute national-level and state-level life tables. Sex-specific ratios of death probabilities in five age categories (0–4, 5–14, 15–29, 30–69, 70–84) were used to evaluate CRS data completeness using SRS probabilities as reference values. The quality of medically certified causes of death was assessed through hospital reporting coverage and proportions of deaths registered with ill-defined causes from each state.

Results

The CRS operates through an extensive infrastructure with high reporting coverage, but child deaths are uniformly under-reported, as are female deaths in many states. However, at ages 30–69 years, CRS death probabilities are higher than the SRS values in 15 states for males and 10 states for females. SRS death probabilities are of limited precision for measuring mortality trends and differentials. Data on medically certified causes of death are of limited use due to low hospital reporting coverage.

Conclusions

The Indian CRS is more reliable than the SRS for measuring adult mortality in several states. Targeted initiatives to improve the recording of child and female deaths, to strengthen the reporting and quality of medically certified causes of death, and to promote use of verbal autopsy methods can establish the CRS as a reliable source of subnational mortality statistics in the near future.

Generating age-specific mortality statistics from incomplete death registration data: two applications of the empirical completeness method

Background

The study aims to assess two approaches that apply the empirical completeness method to generate age-specific mortality statistics from incomplete death registration systems.

Methods

We use the empirical completeness method to calculate all-age death registration completeness, which is used with a model life table to generate mortality statistics and age-specific completeness using (1) the conventional method and (2) the equivalent deaths method. The results are compared with a capture-recapture (C-RC) study and three alternative mortality estimates for Brazilian states, and C-RC studies in Thailand, Oman and Vietnam, which independently estimate the level and age pattern of mortality or completeness.

Results

The empirical completeness method produces similar estimates of all-age completeness of registration to the C-RC studies. Compared with C-RC studies, at 15-59 years, the conventional method’s estimates of mortality and completeness are more concordant, while at 60-84 years the equivalent death method’s estimates are closer. Estimates of life expectancy from the two approaches each have similar concordance with the C-RC studies. For male adult mortality in Brazilian states, there is relatively strong average correlation of this study's estimates with three alternative estimates.

Conclusions

The two approaches produce mortality statistics from incomplete data that are mostly concordant with C-RC studies, and can be most usefully applied to subnational populations.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12963-021-00262-3.

Trends of injury mortality during the COVID-19 period in Guangdong, China: a population-based retrospective analysis

OBJECTIVE

We aimed to ascertain the trends of injury mortality during the COVID-19 period in southern China.

METHODS

We conducted a population-based retrospective analysis to compare the mortality changes of all-cause injury and transport injuries, poisoning, falls, fire/heat/hot substances, drowning, self-harm and interpersonal violence, which were further stratified by sex and age. Comparisons were made between the COVID-19 period (between January 2020 and June 2020) and control period (between January 2019 and June 2019) in Guangdong province. We used the negative binomial models to explore the associations of deaths during the COVID-19 period, according to the different sex and age strata.

RESULTS

The all-cause injury mortality in Guangdong province decreased significantly from 28.65 per 100 000 population during the control period to 23.24 per 100 000 population during COVID-19 pandemic period. Similar results were found in specific injury categories. Mortality of self-harm increased by 139.26% in the 10-14 year group during the COVID-19 period as compared with the control period. Although mortality changes in some groups were not statistically significant, some increases were noteworthy during the COVID-19 period (ie, self-harm, transport injury and falls) in the 70-79 year group. The corresponding increase in mortality rate was 16.83%, 3.32% and 4.92%, respectively.

CONCLUSION

The mortality of all-cause injury, transport injury and drowning during the COVID-19 pandemic was consistently decreased. However, the increase in mortality associated with falls, fire/heat/hot substance injury and self-harm in specific age populations warrant the targeted control and prevention measures for the population at risk.

Years of Life Lost Due to Main Causes of Deaths in Yazd Province, Iran

AIM

One approach to measure the demographic impacts of death is to examine the number of lost years of life. The present paper aims to estimate the "Years of Lost Life" (YLL) due to the main causes of death in Yazd province of Iran.

METHOD

The present study is an epidemiological examination for which the statistical population included all the death incidents in Yazd province (excluding stillbirth cases) over two time periods of 2011 and 2016 with a 5-year distance. The required data were obtained based on the Comprehensive System of Mortality Registration maintained by the Ministry of Health and Medical Education; while the standard life expectancy data were based on the World Health Organization standards using standard life table, level 26 of the West model (Coale and Demeny) for Japanese men and women. The standard YLL was calculated according to the WHO standard using a 0.03 relaxation rate for the future time and weighting coefficient for various ages and life years through the formula using the Microsoft Excel software.

RESULTS

The findings of the present study suggest that two main causes of YLL in Yazd province during the year of 2011 were cardiovascular difficulties with the rates of 31.6 per 1000 persons for women and 27.1 per 1000 persons for men, and cancers with the rates of 14.9 per 1000 persons for women and 16.2 per 1000 persons for men. While the above numbers in 2016 were, respectively 22.5 per 1000 persons for women and 25.5 per 1000 persons for men due to cardiovascular difficulties; and 18 per 1000 persons for women and 15.5/1000 for men due to various types of cancers.

CONCLUSIONS

Our findings suggest that cardiovascular diseases and cancers are the main factors leading to Years of Lost Lifetime for the residents of Yazd province in Iran.

Routine mortality surveillance to identify the cause of death pattern for out-of-hospital adult (aged 12+ years) deaths in Bangladesh: introduction of automated verbal autopsy

BACKGROUND

In Bangladesh, a poorly functioning national system of registering deaths and determining their causes leaves the country without important information on which to inform health programming, particularly for the 85% of deaths that occur in the community. In 2017, an improved death registration system and automated verbal autopsy (VA) were introduced to 13 upazilas to assess the utility of VA as a routine source of policy-relevant information and to identify leading causes of deaths (COD) in rural Bangladesh.

METHODS

Data from 22,535 VAs, collected in 12 upazilas between October 2017 and August 2019, were assigned a COD using the SmartVA Analyze 2.0 computer algorithm. The plausibility of the VA results was assessed using a series of demographic and epidemiological checks in the Verbal Autopsy Interpretation, Performance and Evaluation Resource (VIPER) software tool.

RESULTS

Completeness of community death reporting was 65%. The vast majority (85%) of adult deaths were due to non-communicable diseases, with ischemic heart disease, stroke and chronic respiratory disease comprising about 60% alone. Leading COD were broadly consistent with Global Burden of Disease study estimates.

CONCLUSIONS

Routine VA collection using automated methods is feasible, can produce plausible results and provides critical information on community COD in Bangladesh. Routine VA and VIPER have potential application to countries with weak death registration systems.

Death registration in Nigeria: a systematic literature review of its performance and challenges

Background

Death registration provides an opportunity for the legal documentation of death of persons. Documentation of deaths has several implications including its use in the recovery of inheritance and insurance benefits. It is also an important input for construction of life tables which are crucial for national planning. However, the registration of deaths is poor in several countries including Nigeria.

Objective

This paper describes the performance of death registration in Nigeria and factors that may affect its performance.

Methods

We conducted a systematic literature review of death registration completeness in Nigeria to identify, characterize issues as well as challenges associated with realizing completeness in death registration.

Results

Only 13.5% of deaths in Nigeria were registered in 2007 which regressed to 10% in 2017. There was no data reported for Nigeria in the World Health Organization database between 2008 and 2017. The country scored less than 0.1 (out of a maximum of 1) on the Vital Statistics Performance Index. There are multiple institutions with parallel constitutional and legal responsibilities for death registration in Nigeria including the National Population Commission, National Identity Management Commission and Local Government Authorities, which may be contributing to its overall poor performance.

Conclusions

We offer proposals to substantially improve death registration completeness in Nigeria including the streamlining and merger of the National Population Commission and the National Identity Management Commission into one commission, the revision of the legal mandate of the new agency to mainly coordination and establishment of standards. We recommend that Local Government authorities maintain the local registries given their proximity to households. This arrangement will be enhanced by increased utilization of information and communications technology in Civil Registration and Vital Statistics processes that ensure records are properly archived.

Life expectancy and mortality in 363 cities of Latin America

The concept of a so-called urban advantage in health ignores the possibility of heterogeneity in health outcomes across cities. Using a harmonized dataset from the SALURBAL project, we describe variability and predictors of life expectancy and proportionate mortality in 363 cities across nine Latin American countries. Life expectancy differed substantially across cities within the same country. Cause-specific mortality also varied across cities, with some causes of death (unintentional and violent injuries and deaths) showing large variation within countries, whereas other causes of death (communicable, maternal, neonatal and nutritional, cancer, cardiovascular disease and other noncommunicable diseases) varied substantially between countries. In multivariable mixed models, higher levels of education, water access and sanitation and less overcrowding were associated with longer life expectancy, a relatively lower proportion of communicable, maternal, neonatal and nutritional deaths and a higher proportion of deaths from cancer, cardiovascular disease and other noncommunicable diseases. These results highlight considerable heterogeneity in life expectancy and causes of death across cities of Latin America, revealing modifiable factors that could be amenable to urban policies aimed toward improving urban health in Latin America and more generally in other urban environments.

City-level analysis of data from the SALURBAL project shows vast heterogeneity in life expectancy across cities within the same country, in addition to substantive differences in causes of death among nine Latin American countries, revealing modifiable factors that could be leveraged by municipal-level policies aimed toward improving health in urban environments.

Local Burden of Disease HIV Collaborators. Mapping subnational HIV mortality in six Latin American countries with incomplete vital registration systems

BACKGROUND

Human immunodeficiency virus (HIV) remains a public health priority in Latin America. While the burden of HIV is historically concentrated in urban areas and high-risk groups, subnational estimates that cover multiple countries and years are missing. This paucity is partially due to incomplete vital registration (VR) systems and statistical challenges related to estimating mortality rates in areas with low numbers of HIV deaths. In this analysis, we address this gap and provide novel estimates of the HIV mortality rate and the number of HIV deaths by age group, sex, and municipality in Brazil, Colombia, Costa Rica, Ecuador, Guatemala, and Mexico.

METHODS

We performed an ecological study using VR data ranging from 2000 to 2017, dependent on individual country data availability. We modeled HIV mortality using a Bayesian spatially explicit mixed-effects regression model that incorporates prior information on VR completeness. We calibrated our results to the Global Burden of Disease Study 2017.

RESULTS

All countries displayed over a 40-fold difference in HIV mortality between municipalities with the highest and lowest age-standardized HIV mortality rate in the last year of study for men, and over a 20-fold difference for women. Despite decreases in national HIV mortality in all countries-apart from Ecuador-across the period of study, we found broad variation in relative changes in HIV mortality at the municipality level and increasing relative inequality over time in all countries. In all six countries included in this analysis, 50% or more HIV deaths were concentrated in fewer than 10% of municipalities in the latest year of study. In addition, national age patterns reflected shifts in mortality to older age groups-the median age group among decedents ranged from 30 to 45 years of age at the municipality level in Brazil, Colombia, and Mexico in 2017.

CONCLUSIONS

Our subnational estimates of HIV mortality revealed significant spatial variation and diverging local trends in HIV mortality over time and by age. This analysis provides a framework for incorporating data and uncertainty from incomplete VR systems and can help guide more geographically precise public health intervention to support HIV-related care and reduce HIV-related deaths.

Temporal and spatial trends of adult mortality in small areas of Brazil, 1980–2010

To determine the variations and spatial patterns of adult mortality across regions, over time, and by sex for 137 small areas in Brazil, we first apply TOPALS to estimate and smooth mortality rates and then use death distribution methods to evaluate the quality of the mortality data. Lastly, we employ spatial autocorrelation statistics and cluster analysis to identify the adult mortality trends and variations in these areas between 1980 and 2010. We find not only that regions in Brazil’s South and Southeast already had complete death registration systems prior to the study period, but that the completeness of death count coverage improved over time across the entire nation—most especially in lesser developed regions—probably because of public investment in health data collection. By also comparing adult mortality by sex and by region, we document a mortality sex differential in favor of women that remains high over the entire study period, most probably as a result of increased morbidity from external causes, especially among males. This increase also explains the concentration of high male mortality levels in some areas.

Comparative analysis of completeness of death registration, adult mortality and life expectancy at birth in Brazil at the subnational level

Background

Estimates of completeness of death registration are crucial to produce estimates of life tables and population projections and to estimate the burden of disease. They are an important step in assessing the quality of data. In the case of subnational data analysis in Brazil, it is important to consider spatial and temporal variation in the quality of mortality data. There are two main sources of data quality evaluation in Brazil, but there are few comparative studies and how they evolve over time. The aim of the paper is to compare and discuss alternative estimates of completeness of death registration, adult mortality (45q15) and life expectancy estimates produced by the National Statistics Office (IBGE), Institute for Health Metrics and Evaluation (IHME), and estimates presented in Queiroz et al. (2017) and Schmertmann and Gonzaga (2018), for 1980 and 2010.

Methods

We provide a descriptive and comparative analysis of aforementioned estimates from four (4) sources of estimates at subnational level (26 states and one Federal District) in Brazil from two different points in time.

Results

We found significant differences in estimates that affect both levels and trends of completeness of adult mortality in Brazil and states. IHME and Queiroz et al. (2017) estimates converge by 2010, but there are large differences when compared to estimates from the National Statistics Office (IBGE). Larger differences are observed for less developed states. We have showed that the quality of mortality data in Brazil has improved steadily overtime, but with large regional variations. However, we have observed that IBGE estimates show the lowest levels of completeness for the Northern of the country compared to other estimates. Choice of methods and approaches might lead to very unexpected results.

Conclusion

We produced a detailed comparative analysis of estimates of completeness of death registration from different sources and discuss the main results and possible explanations for these differences. We have also showed that new improved methods are still needed to study adult mortality in less developed countries and at a subnational level. More comparative studies are important in order to improve quality of estimates in Brazil.

Estimating completeness of national and subnational death reporting in Brazil: application of record linkage methods

Background

In Brazil, both the Civil Registry (CR) and Ministry of Health (MoH) Mortality Information System (SIM) are sources of routine mortality data, but neither is 100% complete. Deaths from these two sources can be linked to facilitate estimation of completeness of mortality reporting and measurement of adjusted mortality indicators using generalized linear modeling (GLM).

Methods

The 2015 and 2016 CR and SIM data were linked using deterministic methods. GLM with covariates of the deceased’s sex, age, state of residence, cause of death and place of death, and municipality-level education decile and population density decile, was used to estimate total deaths and completeness nationally, subnationally and by population sub-group, and to identify the characteristics of unreported deaths. The empirical completeness method and Global Burden of Disease (GBD) 2017 estimates were comparators at the national and state level.

Results

Completeness was 98% for SIM and 95% for CR. The vast majority of deaths in Brazil were captured by either system and 94% were reported by both sources. For each source, completeness was lowest in the north. SIM completeness was consistently high across all sub-groups while CR completeness was lowest for deaths at younger ages, outside facilities, and in the lowest deciles of municipality education and population density. There was no clear municipality-level relationship in SIM and CR completeness, suggesting minimal dependence between sources. The empirical completeness method model 1 and GBD completeness estimates were each, on average, less than three percentage points different from GLM estimates at the state level. Life expectancy was lowest in the northeast and 7.5 years higher in females than males.

Conclusions

GLM using socio-economic and demographic covariates is a valuable tool to accurately estimate completeness from linked data sources. Close scrutiny of the quality of variables used to link deaths, targeted identification of unreported deaths in poorer, northern states, and closer coordination of the two systems will help Brazil achieve 100% death reporting completeness. The results also confirm the validity of the empirical completeness method.

Are cause of death data fit for purpose? evidence from 20 countries at different levels of socio-economic development

BACKGROUND AND OBJECTIVE

Many countries have used the new ANACONDA (Analysis of Causes of National Death for Action) tool to assess the quality of their cause of death data (COD), but no cross-country analysis has been done to verify how different or similar patterns of diagnostic errors and data quality are in countries or how they are related to the local cultural or epidemiological environment or to levels of development. Our objective is to measure whether the usability of COD data and the patterns of unusable codes are related to a country's level of socio-economic development.

METHODS

We have assessed the quality of 20 national COD datasets from the WHO Mortality Database by assessing their completeness of COD reporting and the extent, pattern and severity of garbage codes, i.e. codes that provide little or no information about the true underlying COD. Garbage codes were classified into four groups based on the severity of the error in the code. The Vital Statistics Performance Index for Quality (VSPI(Q)) was used to measure the overall quality of each country's mortality surveillance system.

FINDINGS

The proportion of 'garbage codes' varied from 7 to 66% across the 20 countries. Countries with a high SDI generally had a lower proportion of high impact (i.e. more severe) garbage codes than countries with low SDI. While the magnitude and pattern of garbage codes differed among countries, the specific codes commonly used did not.

CONCLUSIONS

There is an inverse relationship between a country's socio-demographic development and the overall quality of its cause of death data, but with important exceptions. In particular, some low SDI countries have vital statistics systems that are as reliable as more developed countries. However, in low-income countries, where most people die at home, the proportion of unusable codes often exceeds 50%, implying that half of all cause-specific mortality data collected is of little or no use in guiding public policy. Moreover, the cause of death pattern identified from the data is likely to seriously under-represent the true extent of the leading causes of death in the population, with very significant consequences for health priority setting. Garbage codes are prevalent at all ages, contrary to expectations. Further research into effective strategies deployed in these countries to improve data quality can inform efforts elsewhere to improve COD reporting systems.

Trends and seasonality in cause-specific mortality among children under 15 years in Guangzhou, China, 2008-2018

BACKGROUND

This study analyzed the trends and seasonality in mortality among children aged 0-14 years in Guangzhou, China during 2008-2018. Understanding the epidemiology of this public health problem can guide policy development for children mortality prevention.

METHODS

A population-based epidemiological retrospective study was conducted. Seven thousand two hundred sixty-five individual data of children mortality were obtained from the Guangzhou Center for Disease Control and Prevention (CDC). The Poisson regression was used to quantify the annual average reduction rate and the difference in mortality rate between sex and age groups. Incidence ratio with 95% confidence interval (CI) was estimated to determine the temperaol variations in mortality by month, season, school term, day of the week and between holidays and other days.

RESULTS

Between 2008 and 2018, the children mortality rate in Guangzhou decreased from 54.0 to 34.3 per 100,000 children, with an annual reduction rate of 4.6% (95% CI: 1.1%-8.1%), especially the under-5 mortality rate decreased by 8.3% (95% CI: 4.8%-11.6%) per year. Decline trends varied by causes of death, even with an upward trend for the mortality of asphyxia and neurological diseases. The risk of death among males children was 1.33 times (95% CI: 1.20-1.47) of that of females. The distribution of causes of death differed by age group. Maternal and perinatal, congenital and pneumonia were the top three causes of death in infants and cancer accounted for 17% of deaths in children aged 1-14 years. Moreover, the injury-related mortality showed significant temporal variations with higher risk during the weekend. And there was a summer peak for drowning and a winter peak for asphyxia.

CONCLUSIONS

Guangzhou has made considerable progress in reducing mortality over the last decade. The findings of characteristics of children mortality would provide important information for the development and implementation of integrated interventions targeted specific age groups and causes of death.

Measuring the completeness of death registration in 2844 Chinese counties in 2018

BACKGROUND

Death registration completeness has never been assessed at the county level in China. Such analyses would provide critical intelligence to monitor the performance of the vital registration system and yield adjustment factors to correct death registration data, thereby increasing their policy utility.

METHODS

We estimated the completeness of death registration for 31 provinces and 2844 counties of China in 2018 based on death data from the China Cause of Death Reporting System (CDRS) by using the empirical completeness method. We computed the root mean square difference (RMSD) of county-level completeness compared with provincial-level completeness to study intra-provincial variations. A two-level (province and county) logistic regression model was fitted to explore the association between county-level registration completeness and a set of covariates reflecting socioeconomic status, healthcare quality, and specific strategies and regulations designed to improve registration.

RESULTS

In 2018, the overall death registration completeness for the CDRS in China was 74.2% (95% uncertainty interval [UI] 66.2-80.4), with very little difference for males and females. Geographical differences in completeness were higher across counties than across provinces. The county-level completeness ranged from 2.4% (95% UI 1.0-5.0%) in Burang County, Tibet, to 100.0% (95% UI 99.9-100.0%) in Guandu District, Yunnan. The coastal provinces of Jiangsu, Guangdong, and Fujian, with higher overall completeness, contained counties with low completeness; conversely, the underdeveloped provinces of Guangxi and Guizhou, with lower overall completeness, included some counties with high completeness. GDP, education, population density, minority population, healthcare access, and registration strategies were important drivers of the geographical differences in registration completeness.

CONCLUSIONS

There are marked inequalities in registration completeness at the county level and within provinces in China. The socioeconomic condition, the implementation of specific registration-enhancing initiatives, and the availability and quality of medical care were the primary drivers of the observed geographical variation. A more strategic approach, with more research, is required to identify the main reasons for death under-reporting, especially in the poorer performing counties, to guide remedial action.

Spatial analysis of completeness of death registration in Egypt

PURPOSE

Civil registration and vital statistics (CRVS) systems should be the primary source of routine mortality data. However, there is lack of information about the completeness of death registration at the sub-national level of Egypt. The current study was conducted to estimate the completeness of death registration at the national and sub-national levels of Egypt, to investigate the spatial patterns of the completeness, and to examine the factors that influence it.

METHODS

Data from the Central Agency for Public Mobilization and Statistics (CAPMAS, 2018) and Egypt Demographic and Health Survey (EDHS 2008, 2014) were used to estimate the completeness of death registration using an empirical method (random-effects models); hot spot analysis was conducted using Moran's I and Getis-Ord Gi*; and the geographically weighted regression (GWR) model has been also carried out.

RESULTS

The study estimates show that Egypt has 96% completeness of death registration, and all governorates have completeness of more than 90% except for Beni-Suef, Menia, Aswan, Suhag, Luxor, ELWadi ELGidid, and South Sinai. According to sex, the death registration of females is slightly better than that of males (96.8% compared to 95.4%). Concerning residence, urban area has almost complete death registration compared to rural area (99.5% and 85.4%, respectively). Hot spot analysis shows that all hot spots are centered on the north of Egypt, while all cold spots are focused on the south. However, according to the geographically weighted regression (GWR) model, poverty, illiteracy, and health office density are considered major factors for the completeness of death registration.

CONCLUSION

Although the completeness in Egypt is almost 100%, this analysis suggests that it may not be, and that it could be somewhat lower in some rural areas. However, there is uncertainty in the sub-national estimates because deaths are only reported by place of occurrence and not place of usual residence. Thus, efforts should focus on improving the quality of data of the vital registration system in some rural areas and in lower Egyptian governorates.