Beyond the virus: Examining the impact of COVID-19 on violent fatalities

INTRODUCTION

The COVID-19 pandemic has had a significant impact on various aspects of society, including crime rates. In Serbia, it is important to examine the changes in violent deaths before and during the pandemic to inform public health and safety policies.

MATERIALS AND METHODS

We conducted a retrospective, epidemiological, cross-sectional analytical study of medico-legal autopsies in the Department of Forensic Medicine and Toxicology at the University Clinical Center of Kragujevac. Our study sample comprises all forensic autopsy cases examined from January 2017 to December 2019 (151 cases), labeled as "Before," and from January 2020 to December 2022 (192 cases), labeled as "During" the pandemic period. Natural deaths, skeletal remains, and undetermined cases were excluded from our sample.

RESULTS

The data show an increase in the total number of incidents reported from 152 in the "Before" period to 191 in the "During" period. The proportion of incidents involving males remained relatively stable at around 70%, while the proportion of incidents involving females increased. There was no statistically significant change in the proportion of incidents classified as accidental, while the proportion of incidents classified as homicide and suicide increased. The results show a statistically significant association between gender and incident type for both the "Before" and "During" periods. Deaths due to domestic violence have increased by 22.2% during the pandemic, which is cause for concern. In terms of demographic characteristics, males and younger individuals were more likely to be victims of violent deaths both before and during the pandemic.

CONCLUSIONS

The COVID-19 pandemic had a significant impact on violent deaths in the Šumadija region (Central Serbia), with an overall increase in the number of violent deaths and a major impact on deaths due to domestic violence. Policies to address domestic violence should be prioritized during the pandemic and beyond, and strategies should be developed to mitigate the effects of future pandemics or lockdowns.

[The accuracy of the causes of death with judicial intervention in Catalonia in the period 2015-2020. Effect of declaration through IML-Web application]

OBJECTIVE

On January first, 2020, the Institutes of Legal Medicine and Forensic Sciences (IMLCF) began to inform the causes of death directly to the National Statistics Institute (INE) through a web application (IML-Web). The objective of this study was to evaluate the impact of the implementation of this application on the quality of the data collected.

METHODS

A descriptive study using deaths data with judicial intervention that occurred in Catalonia was carried out. The data of the period 2015-2018 and 2019 was compared with 2020. The percentages, with confidence intervals, of the causes of death that were not specific, according to different classifications, were calculated on the total of cases by period and territory.

RESULTS

The total percentage of non-specific deaths had decreased, not significantly, by 1.6 points between the period 2015-2018 and 2020. The same indicator between 2019 and 2020 had decreased by 13.4 points. The percentage of non-specific deaths from external causes showed significant drops between both periods and 2020. In general, the indicators displayed territorial differences.

CONCLUSIONS

The roll-out of the IML-Web implies, compared to 2019, an improvement in the quality of the data. On the other hand, compared to the period 2015-2018, the data show a similar level of quality. Generally, it is assessed that the information provided by IMLCF of Catalonia through the IML-Web is accurate, but still has room for improvement.

Legal Frameworks: A Starting Point for Strengthening Medicolegal Death Investigation Systems and Improving Cause and Manner of Death Statistics in Civil Registration and Vital Statistics Systems

Medicolegal death investigation systems, which generally fall within one of three types-medical examiner, coroner, or law-enforcement-led systems-investigate deaths that are unnatural or suspicious. The current quality of cause of death statistics on deaths investigated within medicolegal death investigation systems globally limits effective public health response. A starting point to strengthening global medicolegal death investigation systems and improving the quality of cause and manner of death reported to civil registration systems is through a strong legal framework. Two resources, the United Nations Statistics Division Guidelines on the Legislative Framework for Civil Registration, Vital Statistics and Identity Management and the Global Health Advocacy Incubator Legal and Regulatory Toolkit for Civil Registration, Vital Statistics and Identity Management, present recommendations and provide guidance to country stakeholders in reviewing and revising their medicolegal death investigation legal frameworks. Physician determination of cause and manner of death, defined criteria for case referral to the medicolegal death investigation system, an amendment process, and investigation collaboration are four core considerations for medicolegal death investigation system legal frameworks. A strong medicolegal death investigation legal framework is a necessary starting point, but it is not sufficient for ensuring the timely, accurate, and complete reporting of cause and manner of death in national vital statistics.

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.

Is the role of forensic medicine in the covid-19 pandemic underestimated?

We believe that forensic medicine should play a significant role in the COVID-19 pandemic. Forensic pathologists should ask and answer various questions through autopsy cases during the COVID-19 period, thus providing a significant contribution to science. Some of the potential roles of forensic medicine in this issue include: determining the exact cause of death among the deceased who were SARS-CoV-2 positive, contribution to the accuracy of mortality statistics, understanding pathological mechanisms of COVID-19, tracking the presence of the virus over time, survival of the virus after death as well as dealing with medicolegal issues. A detailed multidisciplinary analysis of autopsy samples would undoubtedly help understand this new illness and its clinical management. Therefore, autopsies during the COVID-19 pandemic should not be an exception, but certainly a rule.

Cause of Death Certification in COVID-19 Deaths

Introduction

Appropriate cause of death reporting is vital in the pandemic circumstance for effective planning of the control measures. Accurate reporting and registration of the reason for death are crucial in planning of health programs in turn contributing for the national development.

Background

All births and deaths occurring across India should be mandatorily registered per the Registration of Births and Deaths Act passed in the year 1969. The act also requires the issuance of cause of death certificate by the doctor attending the departed during his last illness. Data obtained from the cause of death certificate provides cause-specific mortality profile, which is required to analyze the health trends of the population.

Review results

This article discusses the available guidelines on the appropriate documentation of cause of death in the confirmed or suspected coronavirus disease-2019 (COVID-19) infection resulting into death.

Conclusion

Proper certification of the cause of death leads to better epidemic surveillance. Scrutiny of the clinical sequences from the cause of death certificate is useful to prioritize the allocation of resources for critical care management and to augment our knowledge about underlying causes resulting in mortality from COVID-19.

Clinical significance

Dissemination of available guidelines on proper documentation of the cause of death in confirmed/suspected COVID-19 cases will reduce the errors in cause of death reporting.

How to cite this article

Veeranna CH, Rani S. Cause of Death Certification in COVID-19 Deaths. Indian J Crit Care Med 2020;24(9):863-867.

Reliable mortality statistics in Myanmar: a qualitative assessment of challenges in two townships

Background

The vital registration system is universally recognized as the main source of mortality data which is essential for policy formulation, proper interventions and resource allocation to address priority health challenges. To improve availability and quality of mortality statistics by strengthening the vital registration system, understanding the current vital registration system is essential. This study identified challenges in generating reliable mortality statistics in the vital registration system of Myanmar.

Methods

Qualitative methods were used to collect data in two selected townships of Mandalay Region. Grey literature related to the management of mortality registration was reviewed; in-depth interviews of sixteen key informants and fourteen focus group discussions were conducted with those involved in death registration at the local level, such as healthcare providers, local administrators and knowledgeable adults in households where deaths occurred during the past three years. Thematic analysis was performed to identify system barriers in the death registration process.

Results

Weaknesses in the death registration system are classified in three areas: a) administrative which includes the lack of enforcement of mandatory death registration, limited issuance of death certificates and no formal mandatory notification of death events by households and; b) technical which includes absence of proper and regular on-the-job trainings, ineffective cause-of-death certification practice for deaths in the communities and the absence of routine data plausibility checks at the local level; and c) societal which includes poor community awareness and inadequate participation in death registration.

Conclusion

The study highlighted challenges in the death registration system at the operational level, which undermines the achievement of a satisfactory level of completeness and accuracy of mortality data. We recommend establishing a strong legal framework, improving technical capacities and raising public awareness and cooperation to strengthen the system that can generate reliable mortality statistics.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-6671-y) contains supplementary material, which is available to authorized users.

Evaluation of coding ill-defined and unknown causes of death in the Republic of Serbia

One of the most frequently used indicators for the quality of mortality statistics is the use of R-codes as the cause of death (COD) in death certificates. The aim of this study was to analyse the coding of ill-defined and unknown causes of death in the Republic of Serbia (RS). The data for this descriptive study, covering a ten-year period (2006-2015), were obtained from the National Mortality Register. Since population and economic features differ widely between regions in RS, we compared the Belgrade region (BR) with other regions (Or). We estimated the frequency of certain types of death investigation methods regarding R00-99-coded deaths. The frequency of R-codes, by subcategories, and code-specific mortality rates were calculated by region for each year. The use of R-codes was significantly lower in BR than in Or (OR 0.85; 95% CI, 0.84-0.66; p < 0.001). The most frequent method of determining COD was external examination of the body, both in BR and Or (60.7% and 85.5%, respectively). The rate of forensic autopsies in BR was 38.1% while in Or it was only 3.6%. Clinical autopsies were performed in 1% of deaths in BR, compared to 0.5% in Or. Our results suggest that in BR the use of R-codes compared to other CODs has decreased over the past years while there has been an increasing trend in autopsy proportions; in Or the frequency of R-codes, as well as of autopsy proportions, has remained unchanged.

An index of fatal toxicity for new psychoactive substances

An index of fatal toxicity for new psychoactive substances has been developed based solely on information provided on death certificates. An updated index of fatal toxicity (T_f), as first described in 2010, was calculated based on the ratio of deaths to prevalence and seizures for the original five substances (amphetamine, cannabis, cocaine/crack, heroin and 3,4-methylenedioxymethylamphetamine)^*. These correlated well with the 2010 index. Deaths were then examined for cases both where the substance was and was not found in association with other substances. This ratio (sole to all mentions; S/A) was then calculated for deaths in the period 1993 to 2016. This new measure of fatal toxicity, expressed by S/A, was well-correlated with the index L_n (T_f) of the original reference compounds. The calculation of S/A was then extended to a group of new psychoactive substances where insufficient prevalence or seizure data were available to directly determine a value of T_f by interpolation of a graph of T_f versus S/A. Benzodiazepine analogues had particularly low values of S/A and hence T_f. By contrast, γ-hydroxybutyrate/γ-butyrolactone, α-methyltryptamine, synthetic cannabinoid receptor agonists and benzofurans had a higher fatal toxicity.

[More than a decade improving medical and judicial certification in mortality statistics of death causes]

OBJECTIVE

After the return of Spain to democracy and the regional assumption of government powers, actions were initiated to improve the mortality statistics of death causes. The objective of this work was to describe the evolution of the quality activities improvements into the statistics of death causes on Murcia's region during 1989 to 2011.

METHODS

Descriptive epidemiological study of all death documents processed by the Murcia mortality registry. Use of indicators related to the quality of the completion of death in medical and judicial notification; recovery of information on the causes and circumstances of death; and impact on the statistics of ill-defined, unspecific and less specific causes.

RESULTS

During the study period, the medical notification without a temporary sequence on the death certificate (DC) has decreased from 46% initial to 21% final (p less than 0.001). Information retrieval from sources was successful in 93% of the cases in 2001 compared to 38%, at the beginning of the period (p less than 0.001). Regional rates of ill-defined and unspecific causes fell more than national ones, and they were in the last year with a differential of 10.3 (p less than 0.001) and 2.8 points (p=0.001), respectively.

CONCLUSIONS

The medical death certification improved in form and suitability. Regulated recovery of the causes of death and circumstances corrected medical and judicial information. The Murcia's region presented lower rates in less specified causes and ill-defined entities than national averages.

Identifying potential differences in cause-of-death coding practices across Russian regions

BACKGROUND

Reliable and comparable data on causes of death are crucial for public health analysis, but the usefulness of these data can be markedly diminished when the approach to coding is not standardized across territories and/or over time. Because the Russian system of producing information on causes of death is highly decentralized, there may be discrepancies in the coding practices employed across the country. In this study, we evaluate the uniformity of cause-of-death coding practices across Russian regions using an indirect method.

METHODS

Based on 2002-2012 mortality data, we estimate the prevalence of the major causes of death (70 causes) in the mortality structures of 52 Russian regions. For each region-cause combination we measured the degree to which the share of a certain cause in the mortality structure of a certain region deviates from the respective inter-regional average share. We use heat map visualization and a regression model to determine whether there is regularity in the causes and the regions that is more likely to deviate from the average level across all regions. In addition to analyzing the comparability of cause-specific mortality structures in a spatial dimension, we examine the regional cause-of-death time series to identify the causes with temporal trends that vary greatly across regions.

RESULTS

A high level of consistency was found both across regions and over time for transport accidents, most of the neoplasms, congenital malformations, and perinatal conditions. However, a high degree of inconsistency was found for mental and behavioral disorders, diseases of the nervous system, endocrine disorders, ill-defined causes of death, and certain cardiovascular diseases. This finding suggests that the coding practices for these causes of death are not uniform across regions. The level of consistency improves when causes of death can be grouped into broader diagnostic categories.

CONCLUSION

This systematic analysis allows us to present a broader picture of the quality of cause-of-death coding at the regional level. For some causes of death, there is a high degree of variance across regions in the likelihood that these causes will be chosen as the underlying causes. In addition, for some causes of death the mortality statistics reflect the coding practices, rather than the real epidemiological situation.

Coding ill-defined and unknown cause of death is 13 times more frequent in Denmark than in Finland

Exact cause and manner of death determination improves legislative safety for the individual and for society and guides aspects of national public health. In the International Classification of Diseases, codes R00-R99 are used for "symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified" designated as "ill-defined" or "with unknown etiology". The World Health Organisation recommends avoiding the use of ill-defined and unknown causes of death in the death certificate as this terminology does not give any information concerning the possible conditions that led to the death. Thus, the aim of the study was, firstly, to analyse the frequencies of R00-R99-coded deaths in mortality statistics in Finland and in Denmark and, secondly, to compare these and the methods used to investigate the cause of death. To do so, we extracted a random 90% sample of the Finnish death certificates and 100% of the Danish certificates from the national mortality registries for 2000, 2005 and 2010. Subsequently, we analysed the frequencies of forensic and medical autopsies and external clinical examinations of the bodies in R00-R99-coded deaths. The use of R00-R99 codes was significantly higher in Denmark than in Finland; OR 18.6 (95% CI 15.3-22.4; p<0.001) for 2000, OR 9.5 (95% CI 8.0-11.3; p<0.001) for 2005 and OR 13.2 (95% CI 11.1-15.7; p<0.001) for 2010. More than 80% of Danish deaths with R00-R99 codes were over 70 years of age at the time of death. Forensic autopsy was performed in 88.3% of Finnish R00-R99-coded deaths, whereas only 3.5% of Danish R00-R99-coded deaths were investigated with forensic or medical autopsy. The codes that were most used in both countries were R96-R99, meaning "unknown cause of death". In Finland, all of these deaths were investigated with a forensic autopsy. Our study suggests that if all deaths in all age groups with unclear cause of death were systematically investigated with a forensic autopsy, only 2-3/1000 deaths per year would be coded as an ill-defined and unknown cause of death in national mortality statistics. At the same time the risk to overlook unnatural deaths is decreased to a minimum. To achieve this in Denmark requires that the existing legislation on cause of death investigation would need to be changed to ensure that all deaths with unknown cause of death are investigated with a forensic autopsy.

Medical Certification of Cause of Death

Medical Certificate of Cause of Death, commonly called Death Certificate, is the most frequently issued certificate, at least by a government employed medical officer, if not by a private practitioner. It is common knowledge that many medical officers, even some of those with incomparable medical knowledge and expertise, do not fill up this document of immense medical and legal importance correctly. The reasons may be many, ranging from ignorance to indifference. Medical officers of Armed Forces Medical Services attending refresher courses (MOJC) have always requested the authors for a class on this topic. Considering these aspects, the authors have tried to clarify different issues concerning the question.