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Nabukalu D, Calazans JA, Marston M, Calvert C, Nakawooya H, Nansereko B, Sekubugu R, Nakigozi G, Serwadda D, Sewankambo N, Kigozi G, Gray RH, Nalugoda F, Makumbi F, Lutalo T, Todd J. Estimation of cause-specific mortality in Rakai, Uganda, using verbal autopsy 1999-2019. Glob Health Action 2024; 17:2338635. [PMID: 38717826 PMCID: PMC11080674 DOI: 10.1080/16549716.2024.2338635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 03/31/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND There are scant data on the causes of adult deaths in sub-Saharan Africa. We estimated the level and trends in adult mortality, overall and by different causes, in rural Rakai, Uganda, by age, sex, and HIV status. OBJECTIVES To estimate and analyse adult cause-specific mortality trends in Rakai, Uganda. METHODOLOGY Mortality information by cause, age, sex, and HIV status was recorded in the Rakai Community Cohort study using verbal autopsy interviews, HIV serosurveys, and residency data. We estimated the average number of years lived in adulthood. Using demographic decomposition methods, we estimated the contribution of each cause of death to adult mortality based on the average number of years lived in adulthood. RESULTS Between 1999 and 2019, 63082 adults (15-60 years) were censused, with 1670 deaths registered. Of these, 1656 (99.2%) had completed cause of death data from verbal autopsy. The crude adult death rate was 5.60 (95% confidence interval (CI): 5.33-5.87) per 1000 person-years of observation (pyo). The crude death rate decreased from 11.41 (95% CI: 10.61-12.28) to 3.27 (95% CI: 2.89-3.68) per 1000 pyo between 1999-2004 and 2015-2019. The average number of years lived in adulthood increased in people living with HIV and decreased in HIV-negative individuals between 2000 and 2019. Communicable diseases, primarily HIV and Malaria, had the biggest decreases, which improved the average number of years lived by approximately extra 12 years of life in females and 6 years in males. There were increases in deaths due to non-communicable diseases and external causes, which reduced the average number of years lived in adulthood by 2.0 years and 1.5 years in females and males, respectively. CONCLUSION There has been a significant decline in overall mortality from 1999 to 2019, with the greatest decline seen in people living with HIV since the availability of antiretroviral therapy in 2004. By 2020, the predominant causes of death among females were non-communicable diseases, with external causes of death dominating in males.
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Affiliation(s)
- Dorean Nabukalu
- Data management, Rakai Health Sciences Program, Rakai, Uganda
- Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Júlia Almeida Calazans
- Centre for Demographic Studies (CED), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Milly Marston
- Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Clara Calvert
- Usher Institute, University of Edinburgh, Edinburgh, UK
| | | | | | - Robert Sekubugu
- Data management, Rakai Health Sciences Program, Rakai, Uganda
| | | | - David Serwadda
- Data management, Rakai Health Sciences Program, Rakai, Uganda
- Epidemiology and Biostatistics, Makerere University School of Public Health, Kampala, Uganda
| | - Nelson Sewankambo
- Data management, Rakai Health Sciences Program, Rakai, Uganda
- College of Health Sciences, Makerere University School of Medicine, Kampala, Uganda
| | - Godfrey Kigozi
- Data management, Rakai Health Sciences Program, Rakai, Uganda
| | - Ronald H Gray
- Epidemiology and International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Fred Nalugoda
- Data management, Rakai Health Sciences Program, Rakai, Uganda
| | - Fredrick Makumbi
- Data management, Rakai Health Sciences Program, Rakai, Uganda
- Epidemiology and Biostatistics, Makerere University School of Public Health, Kampala, Uganda
| | - Tom Lutalo
- Data management, Rakai Health Sciences Program, Rakai, Uganda
- Epidemiology and Biostatistics, Makerere University School of Public Health, Kampala, Uganda
| | - Jim Todd
- Population Health, London School of Hygiene and Tropical Medicine, London, UK
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Whitaker J, Edem I, Amoah AS, Dube A, D'Ambruoso L, Rickard RF, Leather AJM, Davies J. Understanding the health system utilisation and reasons for avoidable mortality after fatal injury within a Three-Delays framework in Karonga, Northern Malawi: a retrospective analysis of verbal autopsy data. BMJ Open 2024; 14:e081652. [PMID: 38684258 PMCID: PMC11086451 DOI: 10.1136/bmjopen-2023-081652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 04/10/2024] [Indexed: 05/02/2024] Open
Abstract
OBJECTIVES To use verbal autopsy (VA) data to understand health system utilisation and the potential avoidability associated with fatal injury. Then to categorise any evident barriers driving avoidable delays to care within a Three-Delays framework that considers delays to seeking (Delay 1), reaching (Delay 2) or receiving (Delay 3) quality injury care. DESIGN Retrospective analysis of existing VA data routinely collected by a demographic surveillance site. SETTING Karonga Health and Demographic Surveillance Site (HDSS) population, Northern Malawi. PARTICIPANTS Fatally injured members of the HDSS. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome was the proportion of fatal injury deaths that were potentially avoidable. Secondary outcomes were the delay stage and corresponding barriers associated with avoidable deaths and the health system utilisation for fatal injuries within the health system. RESULTS Of the 252 deaths due to external causes, 185 injury-related deaths were analysed. Deaths were predominantly among young males (median age 30, IQR 11-48), 71.9% (133/185). 35.1% (65/185) were assessed as potentially avoidable. Delay 1 was implicated in 30.8% (20/65) of potentially avoidable deaths, Delay 2 in 61.5% (40/65) and Delay 3 in 75.4% (49/65). Within Delay 1, 'healthcare literacy' was most commonly implicated barrier in 75% (15/20). Within Delay 2, 'communication' and 'prehospital care' were the most commonly implicated in 92.5% (37/40). Within Delay 3, 'physical resources' were most commonly implicated, 85.7% (42/49). CONCLUSIONS VA is feasible for studying pathways to care and health system responsiveness in avoidable deaths following injury and ascertaining the delays that contribute to deaths. A large proportion of injury deaths were avoidable, and we have identified several barriers as potential targets for intervention. Refining and integrating VA with other health system assessment methods is likely necessary to holistically understand an injury care health system.
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Affiliation(s)
- John Whitaker
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- School of Life Course and Population Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
| | - Idara Edem
- Insight Institute of Neurosurgery & Neuroscience, Flint, Michigan, USA
- Michigan State University, East Lansing, Michigan, USA
| | - Abena S Amoah
- Department of Parasitology, Leiden University Medical Center, Leiden, The Netherlands
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
- Malawi Epidemiological and Intervention Research Unit, Chilumba, Malawi
| | - Albert Dube
- Malawi Epidemiological and Intervention Research Unit, Chilumba, Malawi
| | - Lucia D'Ambruoso
- Aberdeen Centre for Health Data Science, Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
- Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit, Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Surgery, Stellenbosch University, Stellenbosch, South Africa
- Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden
- Public Health, National Health Service (NHS) Grampian, Grampian, Scotland
| | - Rory F Rickard
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
| | - Andy J M Leather
- School of Life Course and Population Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Justine Davies
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit, Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Surgery, Stellenbosch University, Stellenbosch, South Africa
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Chisumpa VH, Odimegwu CO, Saikia N. Adult mortality in sub-Saharan Africa: cross-sectional study of causes of death in Zambia. Trop Med Int Health 2019; 24:1208-1220. [PMID: 31420929 DOI: 10.1111/tmi.13302] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECTIVE To describe the age-sex pattern and socio-economic differentials in causes of death among adults between the ages of 15 and 59 years in Zambia. METHODS Using data from the 2010-2012 Zambia sample vital registration with verbal autopsy survey, we calculated the percentage share of causes of death, the age-/sex cause-specific death ratio and cause-eliminated life expectancy at age 15. RESULTS HIV/AIDS was the leading cause of death across all socio-economic subgroups contributing 40.7% of total deaths during the study period. This was followed by deaths due to injury and accidents (11.2%). Cause-specific death ratios due to HIV/AIDS increased by age and peaked in the 35-39 age group and were higher among females than males. The second-leading cause of death was injuries and accidents for males and tuberculosis for females. The third-leading cause of death was cardiovascular diseases for females and tuberculosis for males. Cause of death patterns varied notably by socio-economic characteristics. Deaths attributable to non-communicable diseases were more evident in adults aged 45-59 years. Eliminating HIV/AIDS in Zambia as a cause of death could raise life expectancy at age 15 by 5.7 years for males and by 6.4 years for females. CONCLUSION HIV/AIDS-related health programmes and interventions should be further supported and strengthened, as they would significantly contribute to the reduction in adult mortality in Zambia.
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Affiliation(s)
- Vesper H Chisumpa
- Demography and Population Studies Programme, Schools of Public Health and Social Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Department of Population Studies, School of Humanities and Social Sciences, University of Zambia, Lusaka, Zambia
| | - Clifford O Odimegwu
- Demography and Population Studies Programme, Schools of Public Health and Social Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Nandita Saikia
- School of Social Sciences, Centre for the Study of Regional Development, Jawaharlal Nehru University, New Delhi, India.,International Institute for Applied Systems Analysis, Laxenburg, Austria
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Karat AS, Maraba N, Tlali M, Charalambous S, Chihota VN, Churchyard GJ, Fielding KL, Hanifa Y, Johnson S, McCarthy KM, Kahn K, Chandramohan D, Grant AD. Performance of verbal autopsy methods in estimating HIV-associated mortality among adults in South Africa. BMJ Glob Health 2018; 3:e000833. [PMID: 29997907 PMCID: PMC6035502 DOI: 10.1136/bmjgh-2018-000833] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Revised: 06/02/2018] [Accepted: 06/04/2018] [Indexed: 01/14/2023] Open
Abstract
INTRODUCTION Verbal autopsy (VA) can be integrated into civil registration and vital statistics systems, but its accuracy in determining HIV-associated causes of death (CoD) is uncertain. We assessed the sensitivity and specificity of VA questions in determining HIV status and antiretroviral therapy (ART) initiation and compared HIV-associated mortality fractions assigned by different VA interpretation methods. METHODS Using the WHO 2012 instrument with added ART questions, VA was conducted for deaths among adults with known HIV status (356 HIV positive and 103 HIV negative) in South Africa. CoD were assigned using physician-certified VA (PCVA) and computer-coded VA (CCVA) methods and compared with documented HIV status. RESULTS The sensitivity of VA questions in detecting HIV status and ART initiation was 84.3% (95% CI 80 to 88) and 91.0% (95% CI 86 to 95); 283/356 (79.5%) HIV-positive individuals were assigned HIV-associated CoD by PCVA, 166 (46.6%) by InterVA-4.03, 201 (56.5%) by InterVA-5, and 80 (22.5%) and 289 (81.2%) by SmartVA-Analyze V.1.1.1 and V.1.2.1. Agreement between PCVA and older CCVA methods was poor (chance-corrected concordance [CCC] <0; cause-specific mortality fraction [CSMF] accuracy ≤56%) but better between PCVA and updated methods (CCC 0.21-0.75; CSMF accuracy 65%-98%). All methods were specific (specificity 87% to 96%) in assigning HIV-associated CoD. CONCLUSION All CCVA interpretation methods underestimated the HIV-associated mortality fraction compared with PCVA; InterVA-5 and SmartVA-Analyze V.1.2.1 performed better than earlier versions. Changes to VA methods and classification systems are needed to track progress towards targets for reducing HIV-associated mortality.
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Affiliation(s)
- Aaron S Karat
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Mpho Tlali
- The Aurum Institute, Johannesburg, South Africa
| | - Salome Charalambous
- The Aurum Institute, Johannesburg, South Africa
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Violet N Chihota
- The Aurum Institute, Johannesburg, South Africa
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Gavin J Churchyard
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK
- The Aurum Institute, Johannesburg, South Africa
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Katherine L Fielding
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Yasmeen Hanifa
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - Suzanne Johnson
- Foundation for Professional Development, Pretoria, South Africa
| | - Kerrigan M McCarthy
- The Aurum Institute, Johannesburg, South Africa
- Division of Public Health, Surveillance and Response, National Institute for Communicable Diseases of the National Health Laboratory Service, Johannesburg, South Africa
| | - Kathleen Kahn
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- INDEPTH Network, Accra, Ghana
- Epidemiology and Global Health Unit, Department of Public Health and Clinical Medicine, Umeâ University, Umeâ, Sweden
| | - Daniel Chandramohan
- Department of Disease Control, London School of Hygiene & Tropical Medicine, London, UK
| | - Alison D Grant
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Africa Health Research Institute, Somkhele, South Africa
- School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
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Joshi R, Faruqui N, Nagarajan SR, Rampatige R, Martiniuk A, Gouda H. Reporting of ethics in peer-reviewed verbal autopsy studies: a systematic review. Int J Epidemiol 2018; 47:255-279. [PMID: 29092034 DOI: 10.1093/ije/dyx216] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/02/2017] [Indexed: 11/14/2022] Open
Abstract
Introduction Verbal autopsy (VA) is a method that determines the cause of death by interviewing a relative of the deceased about the events occurring before the death, in regions where medical certification of cause of death is incomplete. This paper aims to review the ethical standards reported in peer-reviewed VA studies. Methods A systematic review of Medline and Ovid was conducted by two independent researchers. Data were extracted and analysed for articles based on three key areas: Institutional Review Board (IRB) clearance and consenting process; data collection and management procedures, including: time between death and interview; training and education of interviewer, confidentiality of data and data security; and declarations of funding and conflict of interest. Results The review identified 802 articles, of which 288 were included. The review found that 48% all the studies reported having IRB clearance or obtaining consent of participants. The interviewer training and education levels were reported in 62% and 21% of the articles, respectively. Confidentiality of data was reported for 14% of all studies, 18% did not report the type of respondent interviewed and 51% reported time between death and the interview for the VA. Data security was reported in 8% of all studies. Funding was declared in 63% of all studies and conflict of interest in 42%. Reporting of all these variables increased over time. Conclusions The results of this systematic review show that although there has been an increase in ethical reporting for VA studies, there still remains a large gap in reporting.
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Affiliation(s)
- Rohina Joshi
- George Institute for Global Health
- University of New South Wales
- University of Sydney, Sydney, NSW, Australia
| | - Neha Faruqui
- George Institute for Global Health
- University of Sydney, Sydney, NSW, Australia
| | | | | | - Alex Martiniuk
- George Institute for Global Health
- University of Sydney, Sydney, NSW, Australia
| | - Hebe Gouda
- School of Public Health
- Queensland Centre for Mental Health Research, University of Queensland, Brisbane, QLD, Australia
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Reniers G, Blom S, Lieber J, Herbst AJ, Calvert C, Bor J, Barnighausen T, Zaba B, Li ZR, Clark SJ, Grant AD, Lessells R, Eaton JW, Hosegood V. Tuberculosis mortality and the male survival deficit in rural South Africa: An observational community cohort study. PLoS One 2017; 12:e0185692. [PMID: 29016619 PMCID: PMC5634548 DOI: 10.1371/journal.pone.0185692] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Accepted: 09/18/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Women live on average five years longer than men, and the sex difference in longevity is typically lower in populations with high mortality. South Africa-a high mortality population with a large sex disparity-is an exception, but the causes of death that contribute to this difference are not well understood. METHODS Using data from a demographic surveillance system in rural KwaZulu-Natal (2000-2014), we estimate differences between male and female adult life expectancy by HIV status. The contribution of causes of death to these life expectancy differences are computed with demographic decomposition techniques. Cause of death information comes from verbal autopsy interviews that are interpreted with the InSilicoVA tool. RESULTS Adult women lived an average of 10.4 years (95% confidence Interval 9.0-11.6) longer than men. Sex differences in adult life expectancy were even larger when disaggregated by HIV status: 13.1 (95% confidence interval 10.7-15.3) and 11.2 (95% confidence interval 7.5-14.8) years among known HIV negatives and positives, respectively. Elevated male mortality from pulmonary tuberculosis (TB) and external injuries were responsible for 43% and 31% of the sex difference in life expectancy among the HIV negative population, and 81% and 16% of the difference among people living with HIV. CONCLUSIONS The sex differences in adult life expectancy in rural KwaZulu-Natal are exceptionally large, atypical for an African population, and largely driven by high male mortality from pulmonary TB and injuries. This is the case for both HIV positive and HIV negative men and women, signalling a need to improve the engagement of men with health services, irrespective of their HIV status.
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Affiliation(s)
- Georges Reniers
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Sylvia Blom
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Charles H. Dyson School of Applied Economics and Management, Cornell University, Ithaca, New York, United States of America
| | - Judith Lieber
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Abraham J. Herbst
- Africa Health Research Institute, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Clara Calvert
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Jacob Bor
- Department of Global Health, Boston University, Boston, Massachusetts, United States of America
| | - Till Barnighausen
- Africa Health Research Institute, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
- Department of Global Health and Population, T. H. Chan School of Public Health, Harvard University, Cambridge, Massachusetts, United States of America
- Institute of Public Health, University of Heidelberg, Heidelberg, Germany
| | - Basia Zaba
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Zehang R. Li
- Department of Statistics, University of Washington, Seattle, United States of America
| | - Samuel J. Clark
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- Department of Sociology, The Ohio State University, Columbus, Ohio
| | - Alison D. Grant
- Africa Health Research Institute, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Richard Lessells
- Africa Health Research Institute, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Jeffrey W. Eaton
- Department of Infectious Disease Epidemiology, School of Public Health, Imperial College, London, United Kingdom
| | - Victoria Hosegood
- Africa Health Research Institute, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
- Social Statistics and Demography, University of Southampton, Southampton, United Kingdom
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Karat AS, Tlali M, Fielding KL, Charalambous S, Chihota VN, Churchyard GJ, Hanifa Y, Johnson S, McCarthy K, Martinson NA, Omar T, Kahn K, Chandramohan D, Grant AD. Measuring mortality due to HIV-associated tuberculosis among adults in South Africa: Comparing verbal autopsy, minimally-invasive autopsy, and research data. PLoS One 2017; 12:e0174097. [PMID: 28334030 PMCID: PMC5363862 DOI: 10.1371/journal.pone.0174097] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Accepted: 03/04/2017] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND The World Health Organization (WHO) aims to reduce tuberculosis (TB) deaths by 95% by 2035; tracking progress requires accurate measurement of TB mortality. International Classification of Diseases (ICD) codes do not differentiate between HIV-associated TB and HIV more generally. Verbal autopsy (VA) is used to estimate cause of death (CoD) patterns but has mostly been validated against a suboptimal gold standard for HIV and TB. This study, conducted among HIV-positive adults, aimed to estimate the accuracy of VA in ascertaining TB and HIV CoD when compared to a reference standard derived from a variety of clinical sources including, in some, minimally-invasive autopsy (MIA). METHODS AND FINDINGS Decedents were enrolled into a trial of empirical TB treatment or a cohort exploring diagnostic algorithms for TB in South Africa. The WHO 2012 instrument was used; VA CoD were assigned using physician-certified VA (PCVA), InterVA-4, and SmartVA-Analyze. Reference CoD were assigned using MIA, research, and health facility data, as available. 259 VAs were completed: 147 (57%) decedents were female; median age was 39 (interquartile range [IQR] 33-47) years and CD4 count 51 (IQR 22-102) cells/μL. Compared to reference CoD that included MIA (n = 34), VA underestimated mortality due to HIV/AIDS (94% reference, 74% PCVA, 47% InterVA-4, and 41% SmartVA-Analyze; chance-corrected concordance [CCC] 0.71, 0.42, and 0.31, respectively) and HIV-associated TB (41% reference, 32% PCVA; CCC 0.23). For individual decedents, all VA methods agreed poorly with reference CoD that did not include MIA (n = 259; overall CCC 0.14, 0.06, and 0.15 for PCVA, InterVA-4, and SmartVA-Analyze); agreement was better at population level (cause-specific mortality fraction accuracy 0.78, 0.61, and 0.57, for the three methods, respectively). CONCLUSIONS Current VA methods underestimate mortality due to HIV-associated TB. ICD and VA methods need modifications that allow for more specific evaluation of HIV-related deaths and direct estimation of mortality due to HIV-associated TB.
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Affiliation(s)
- Aaron S. Karat
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, United Kingdom
- * E-mail:
| | - Mpho Tlali
- The Aurum Institute, Johannesburg, South Africa
| | - Katherine L. Fielding
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Salome Charalambous
- The Aurum Institute, Johannesburg, South Africa
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Violet N. Chihota
- The Aurum Institute, Johannesburg, South Africa
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Gavin J. Churchyard
- The Aurum Institute, Johannesburg, South Africa
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Yasmeen Hanifa
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Suzanne Johnson
- Foundation for Professional Development, Pretoria, South Africa
| | - Kerrigan McCarthy
- The Aurum Institute, Johannesburg, South Africa
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Division of Public Health, Surveillance and Response, National Institute for Communicable Disease of the National Health Laboratory Service, Johannesburg, South Africa
| | - Neil A. Martinson
- Perinatal HIV Research Unit, and Medical Research Council Soweto Matlosana Collaborating Centre for HIV/AIDS and TB, University of the Witwatersrand, Johannesburg, South Africa
- Johns Hopkins University Center for TB Research, Baltimore, United States of America
- Department of Science and Technology / National Research Foundation Centre of Excellence for Biomedical TB Research, University of the Witwatersrand, Johannesburg, South Africa
| | - Tanvier Omar
- Department of Anatomical Pathology, National Health Laboratory Service and University of the Witwatersrand, Johannesburg, South Africa
| | - Kathleen Kahn
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- INDEPTH Network, Accra, Ghana
- Epidemiology and Global Health Unit, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Daniel Chandramohan
- Department of Disease Control, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Alison D. Grant
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, United Kingdom
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Africa Health Research Institute, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
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Reniers G, Blom S, Calvert C, Martin-Onraet A, Herbst AJ, Eaton JW, Bor J, Slaymaker E, Li ZR, Clark SJ, Bärnighausen T, Zaba B, Hosegood V. Trends in the burden of HIV mortality after roll-out of antiretroviral therapy in KwaZulu-Natal, South Africa: an observational community cohort study. Lancet HIV 2017; 4:e113-e121. [PMID: 27956187 PMCID: PMC5405557 DOI: 10.1016/s2352-3018(16)30225-9] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Revised: 10/13/2016] [Accepted: 10/24/2016] [Indexed: 01/10/2023]
Abstract
BACKGROUND Antiretroviral therapy (ART) substantially decreases morbidity and mortality in people living with HIV. In this study, we describe population-level trends in the adult life expectancy and trends in the residual burden of HIV mortality after the roll-out of a public sector ART programme in KwaZulu-Natal, South Africa, one of the populations with the most severe HIV epidemics in the world. METHODS Data come from the Africa Centre Demographic Information System (ACDIS), an observational community cohort study in the uMkhanyakude district in northern KwaZulu-Natal, South Africa. We used non-parametric survival analysis methods to estimate gains in the population-wide life expectancy at age 15 years since the introduction of ART, and the shortfall of the population-wide adult life expectancy compared with that of the HIV-negative population (ie, the life expectancy deficit). Life expectancy gains and deficits were further disaggregated by age and cause of death with demographic decomposition methods. FINDINGS Covering the calendar years 2001 through to 2014, we obtained information on 93 903 adults who jointly contribute 535 42 8 person-years of observation to the analyses and 9992 deaths. Since the roll-out of ART in 2004, adult life expectancy increased by 15·2 years for men (95% CI 12·4-17·8) and 17·2 years for women (14·5-20·2). Reductions in pulmonary tuberculosis and HIV-related mortality account for 79·7% of the total life expectancy gains in men (8·4 adult life-years), and 90·7% in women (12·8 adult life-years). For men, 9·5% is the result of a decline in external injuries. By 2014, the life expectancy deficit had decreased to 1·2 years for men (-2·9 to 5·8) and to 5·3 years for women (2·6-7·8). In 2011-14, pulmonary tuberculosis and HIV were responsible for 84·9% of the life expectancy deficit in men and 80·8% in women. INTERPRETATION The burden of HIV on adult mortality in this population is rapidly shrinking, but remains large for women, despite their better engagement with HIV-care services. Gains in adult life-years lived as well as the present life expectancy deficit are almost exclusively due to differences in mortality attributed to HIV and pulmonary tuberculosis. FUNDING Wellcome Trust, the Bill & Melinda Gates Foundation, and the National Institutes of Health.
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Affiliation(s)
- Georges Reniers
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK; School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.
| | - Sylvia Blom
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Clara Calvert
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | | | | | - Jeffrey W Eaton
- Department of Infectious Disease Epidemiology, Imperial College London, London, UK
| | - Jacob Bor
- Department of Global Health, Boston University, Boston, MA, USA
| | - Emma Slaymaker
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Zehang R Li
- Department of Statistics, University of Washington, Seattle, WA, USA
| | - Samuel J Clark
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa; Department of Sociology, The Ohio State University, Columbus, OH, USA
| | - Till Bärnighausen
- Africa Health Research Institute, Durban, South Africa; Institute of Public Health, University of Heidelberg, Heidelberg, Germany; Harvard TH Chan School of Public Health, Harvard University, Boston, MA, USA
| | - Basia Zaba
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Victoria Hosegood
- Africa Health Research Institute, Durban, South Africa; Social Statistics and Demography, University of Southampton, Southampton, UK
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9
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Nliwasa M, MacPherson P, Mukaka M, Mdolo A, Mwapasa M, Kaswaswa K, Msefula C, Chipungu G, Mwandumba HC, Corbett EL. High mortality and prevalence of HIV and tuberculosis in adults with chronic cough in Malawi: a cohort study. Int J Tuberc Lung Dis 2016; 20:202-10. [PMID: 26792472 PMCID: PMC4711670 DOI: 10.5588/ijtld.15.0388] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Accepted: 08/28/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Adults with suspected tuberculosis (TB) in health facilities in Africa have a high risk of death. The risk of death for adults with suspected TB at community-level is not known but may also be high. METHODS Adults reporting cough of ⩾ 2 weeks (coughers) during a household census of 19,936 adults in a poor urban setting in Malawi were randomly sampled and age-frequency matched with adults without cough ⩾ 2 weeks (controls). At 12 months, participants were traced to establish vital status, offered human immunodeficiency virus (HIV) testing and investigated for TB if symptomatic (sputum for Xpert(®) MTB/RIF, smear microscopy and culture). RESULTS Of 345 individuals with cough, 245 (71%) were traced, as were 243/345 (70.4%) controls. TB was diagnosed in 8.9% (16/178) of the coughers and 3.7% (7/187) of the controls (P = 0.039). HIV prevalence among coughers was 34.6% (56/162) and 18.8% (32/170) in controls (P = 0.005); of those who were HIV-positive, respectively 26.8% and 18.8% were newly diagnosed. The 12-month risk of death was 4.1% (10/245) in coughers and 2.5% (6/243) in controls (P = 0.317). CONCLUSION Undiagnosed HIV and TB are common among adults with chronic cough, and mortality is high in this urban setting. Interventions that promote timely seeking of HIV and TB care are needed.
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Affiliation(s)
- M. Nliwasa
- *Helse Nord Tuberculosis Initiative, Department of Pathology, College of Medicine, Blantyre, Malawi
| | - P. MacPherson
- †Department of Public Health and Policy, University of Liverpool, Liverpool
- ‡Department of Clinical Science, Liverpool School of Tropical Medicine, Liverpool, UK
| | - M. Mukaka
- *Helse Nord Tuberculosis Initiative, Department of Pathology, College of Medicine, Blantyre, Malawi
- §School of Public Health, College of Medicine, Blantyre
| | - A. Mdolo
- ¶Malawi-Liverpool-Wellcome Trust Research Programme, College of Medicine, Blantyre, Malawi
| | - M. Mwapasa
- *Helse Nord Tuberculosis Initiative, Department of Pathology, College of Medicine, Blantyre, Malawi
| | - K. Kaswaswa
- *Helse Nord Tuberculosis Initiative, Department of Pathology, College of Medicine, Blantyre, Malawi
| | - C. Msefula
- *Helse Nord Tuberculosis Initiative, Department of Pathology, College of Medicine, Blantyre, Malawi
| | - G. Chipungu
- *Helse Nord Tuberculosis Initiative, Department of Pathology, College of Medicine, Blantyre, Malawi
| | - H. C. Mwandumba
- ¶Malawi-Liverpool-Wellcome Trust Research Programme, College of Medicine, Blantyre, Malawi
| | - E. L. Corbett
- *Helse Nord Tuberculosis Initiative, Department of Pathology, College of Medicine, Blantyre, Malawi
- ¶Malawi-Liverpool-Wellcome Trust Research Programme, College of Medicine, Blantyre, Malawi
- #Clinical Research Department, London School of Hygiene & Tropical Medicine, London, UK
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10
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Chasimpha S, McLean E, Chihana M, Kachiwanda L, Koole O, Tafatatha T, Mvula H, Nyirenda M, Crampin AC, Glynn JR. Patterns and risk factors for deaths from external causes in rural Malawi over 10 years: a prospective population-based study. BMC Public Health 2015; 15:1036. [PMID: 26449491 PMCID: PMC4599750 DOI: 10.1186/s12889-015-2323-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Accepted: 09/22/2015] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Little is known about the pattern or risk factors for deaths from external causes in sub-Saharan Africa: there is a lack of reliable data, and public health priorities have been focussed on other causes. This study assessed the prevalence and risk factor for deaths from external causes in rural Malawi. METHODS We analysed data from 2002-2012 from the Karonga demographic surveillance site which covers ~35,000 people in rural northern Malawi. Verbal autopsies with clinician coding are used to assign cause of death. Repeated annual surveys capture data on socio-economic factors. Using Poisson regression models we calculated age, sex and cause-specific rates and rate ratios of external deaths. We used a nested case-control study, matched on age, sex and time period, to investigate risk factors for these deaths, using conditional logistic regression. RESULTS In 315,580 person years at risk (pyar) there were 2673 deaths, including 143 from external causes. The mortality rate from external causes was 47.1/100,000 pyar (95 % CI 32.5-68.2) among under-fives; 20.1/100,000 pyar (95 % CI 13.1-32.2) among 5-14 year olds; 46.3/100,000 pyar (95 % CI 35.8-59.9) among 15-44 year olds; and 98.7/100,000 pyar (95 % CI 71.8-135.7) among those aged ≥45 years. Drowning (including four deaths in people with epilepsy), road injury and suicide were the leading external causes. Adult males had the highest rates (100.7/100,000 pyar), compared to 21.8/100,000pyar in adult females, and the rate continued to increase with increasing age in men. Alcohol contributed to 21 deaths, all in adult males. Children had high rates of drowning (9.2/100,000 pyar, 95 % CI 5.5-15.6) but low rates of road injury (2.6/100,000 pyar, 95 % CI 1.0-7.0). Among 5-14 year olds, attending school was associated with fewer deaths from external causes than among those who had never attended school (adjusted OR 0.15, 95 % CI 0.08-0.81). Fishermen had increased risks of death from drowning and suicide compared to farmers. DISCUSSION In this population the rate of deaths from external causes was lowest at age 5-14 years. Adult males had the highest rate of death from external causes, 5 times the rate in adult females. Drowning, road injury and suicide were the leading causes of death; alcohol consumption contributed to more than one quarter of the deaths in men CONCLUSIONS The high proportion of alcohol-related deaths in men, the predominance of drowning, deaths linked to uncontrolled epilepsy, and the possible protective effect of school attendance suggest areas for intervention.
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Affiliation(s)
- Steady Chasimpha
- Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, Keppel St, London, WC1E 7HT, UK.
- Malawi National Cancer Registry, Blantyre, Malawi.
| | - Estelle McLean
- Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, Keppel St, London, WC1E 7HT, UK.
| | | | | | - Olivier Koole
- Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, Keppel St, London, WC1E 7HT, UK.
| | | | | | - Moffat Nyirenda
- Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, Keppel St, London, WC1E 7HT, UK.
| | - Amelia C Crampin
- Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, Keppel St, London, WC1E 7HT, UK.
- Karonga Prevention Study, Chilumba, Malawi.
| | - Judith R Glynn
- Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, Keppel St, London, WC1E 7HT, UK.
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11
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Church K, Kiweewa F, Dasgupta A, Mwangome M, Mpandaguta E, Gómez-Olivé FX, Oti S, Todd J, Wringe A, Geubbels E, Crampin A, Nakiyingi-Miiro J, Hayashi C, Njage M, Wagner RG, Ario AR, Makombe SD, Mugurungi O, Zaba B. A comparative analysis of national HIV policies in six African countries with generalized epidemics. Bull World Health Organ 2015; 93:457-67. [PMID: 26170503 PMCID: PMC4490813 DOI: 10.2471/blt.14.147215] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Revised: 12/16/2014] [Accepted: 01/23/2015] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE To compare national human immunodeficiency virus (HIV) policies influencing access to HIV testing and treatment services in six sub-Saharan African countries. METHODS We reviewed HIV policies as part of a multi-country study on adult mortality in sub-Saharan Africa. A policy extraction tool was developed and used to review national HIV policy documents and guidelines published in Kenya, Malawi, South Africa, Uganda, the United Republic of Tanzania and Zimbabwe between 2003 and 2013. Key informant interviews helped to fill gaps in findings. National policies were categorized according to whether they explicitly or implicitly adhered to 54 policy indicators, identified through literature and expert reviews. We also compared the national policies with World Health Organization (WHO) guidance. FINDINGS There was wide variation in policies between countries; each country was progressive in some areas and not in others. Malawi was particularly advanced in promoting rapid initiation of antiretroviral therapy. However, no country had a consistently enabling policy context expected to increase access to care and prevent attrition. Countries went beyond WHO guidance in certain areas and key informants reported that practice often surpassed policy. CONCLUSION Evaluating the impact of policy differences on access to care and health outcomes among people living with HIV is challenging. Certain policies will exert more influence than others and official policies are not always implemented. Future research should assess the extent of policy implementation and link these findings with HIV outcomes.
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Affiliation(s)
- Kathryn Church
- Department of Population Health, London School of Hygiene & Tropical Medicine, Keppel St, London, WC1E 7HT, England
| | - Francis Kiweewa
- Makerere University School of Public Health, Kampala, Uganda
| | - Aisha Dasgupta
- Department of Population Health, London School of Hygiene & Tropical Medicine, Keppel St, London, WC1E 7HT, England
| | - Mary Mwangome
- Ifakara Health Institute, Ifakara, United Republic of Tanzania
| | | | - Francesc Xavier Gómez-Olivé
- Agincourt, Rural Public Health and Health Transitions Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Samuel Oti
- African Population Health Research Center, Nairobi, Kenya
| | - Jim Todd
- London School of Hygiene & Tropical Medicine, London, England
| | - Alison Wringe
- Department of Population Health, London School of Hygiene & Tropical Medicine, Keppel St, London, WC1E 7HT, England
| | | | - Amelia Crampin
- London School of Hygiene & Tropical Medicine, London, England
| | | | | | | | - Ryan G Wagner
- Agincourt, Rural Public Health and Health Transitions Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | | | | | - Basia Zaba
- Department of Population Health, London School of Hygiene & Tropical Medicine, Keppel St, London, WC1E 7HT, England
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12
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Abstract
Background: Joint United Nations Programme on HIV/AIDS (UNAIDS) and Murray et al. have both produced sets of estimates for worldwide HIV incidence, prevalence and mortality. Understanding differences in these estimates can strengthen the interpretation of each. Methods: We describe differences in the two sets of estimates. Where possible, we have drawn on additional published data to which estimates can be compared. Findings: UNAIDS estimates that there were 6 million more people living with HIV (PLHIV) in 2013 (35 million) compared with the Murray et al. estimates (29 million). Murray et al. estimate that new infections and AIDS deaths have declined more gradually than does UNAIDS. Just under one third of the difference in PLHIV is in Africa, where Murray et al. have relied more on estimates of adult mortality trends than on data on survival times. Another third of the difference is in North America, Europe, Central Asia and Australasia. Here Murray et al. estimates of new infections are substantially lower than the number of new HIV/AIDS diagnoses reported by countries, whereas published UNAIDS estimate tend to be greater. The remaining differences are in Latin America and Asia where the data upon which the UNAIDS methods currently rely are more sparse, whereas the mortality data leveraged by Murray et al. may be stronger. In this region, however, anomalies appear to exist between the both sets of estimates and other data. Interpretation: Both estimates indicate that approximately 30 million PLHIV and that antiretroviral therapy has driven large reductions in mortality. Both estimates are useful but show instructive discrepancies with additional data sources. We find little evidence to suggest that either set of estimates can be considered systematically more accurate. Further work should seek to build estimates on as wide a base of data as possible.
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13
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Todd J, Slaymaker E, Zaba B, Mahy M, Byass P. Measuring HIV-related mortality in the first decade of anti-retroviral therapy in sub-Saharan Africa. Glob Health Action 2014; 7:24787. [PMID: 24852247 PMCID: PMC4032059 DOI: 10.3402/gha.v7.24787] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Jim Todd
- London School of Hygiene and Tropical Medicine, Keppel Street, WC1E 7HT, London, UK
| | - Emma Slaymaker
- London School of Hygiene and Tropical Medicine, Keppel Street, WC1E 7HT, London, UK
| | - Basia Zaba
- London School of Hygiene and Tropical Medicine, Keppel Street, WC1E 7HT, London, UK
| | - Mary Mahy
- Epidemiology Section, UNAIDS, Geneva, Umeå Centre for Global Health Research, Department of Public
| | - Peter Byass
- Health and Clinical Medicine, Umeå University, Umeå, Sweden
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