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Measuring Vital Events in African Communities
1. Measuring Vital Events in the Communities in Africa ROBERT MSWIA, MEASURE Evaluation GHC International Conference June 14-18, 2010, Omni Shoreham Hotel, Washington, DC
26. Uganda: Newborn, Infant and Child Deaths Age Group Deaths 0 to < 28 days Deaths 28 days to < 5yrs Sample (n) 122 419 Prop of all deaths (%) 23% 77% Place of death (%) Health facility: 40% Home: 51% Health facility: 39% Home: 48% Top 5 COD (%) Peri. & early neon: 77% Meningitis: 8% Tetanus: 4% Congenital malform.: 2% Malaria: 1% Malaria: 41% Meningitis: 11% Pneumonia: 10% HIV/AIDS: 7% Malnutrition: 6% Sex (%) Male: 64% Female: 36% Male: 53% Female: 47%
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28. Ghana: Newborn, Infant and Child Deaths Age Group Deaths 0 to < 28 days Deaths 28 days to < 5yrs Sample (n) 68 131 Prop of all deaths (%) 36% 64% Place of death (%) Hosp: 49% Home: 49% Hosp: 37% Home: 57% Top 5 COD (%) Perin. & early neon.: 79% Birth asphyxia: 7% Tetanus: 5% Birth trauma: 3% Prem & LBW: 2% Malaria: 43% Malnutrition: 12% Diarrhoeal diseases: 8% External causes: 6% Pneumonia: 5% Sex (%) Male: 66% Female: 34% Male: 56% Female: 44%
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Hinweis der Redaktion
I would like to recognize and acknowledge co-authors of this presentation from MEASURE Evaluation: Dr. Sian Curtis, Director - MEASURE Evaluation Stirling Cummings, Research Associate – MEASURE Evaluation
A quote from the Minister of Justice and Constitutional Affairs, Mr, Mathias Chikawe, on the need for an improved, well functioning vital events registration system in Tanzania in particular, and in Africa as a whole. RITA (Registration, Insolvency and Trustees Agency) program in Tanzania, only 15% of Tanzanians have utilized the services
1 st bullet: gap between mortality information and current VR systems, which lack complete coverage or are otherwise low-functioning 2 nd bullet: … which will be a benefit to both individuals and to communities 3 rd bullet: Recognize there are long-term goals of VR systems, but there are also more immediate needs for information for decision making in Health Programs
Having complete and universal Civil / Vital Events Registration is long-term goal…but in the meantime:
Evolution of SAVVY: (Lessons learned from Sample Registration System (India) Disease Surveillance Point System (China) National Sentinel Surveillance System (Tanzania) Health and Demographic Surveillance Systems (INDEPTH Network) Households Surveys (DHS, HBS, LSMS) National Censuses
Main difference between SAVVY and HDSS: SAVVY is nationally representative based on sampling techniques at cluster level. Also tools implemented with SAVVY have been extensively reviewed and validated
Sources: Improving death registration and statistics in developing countries: Lessons from sub-Saharan Africa (Chalapati Rao, Debbie Bradshaw, Colin Mathers). South African Journal of Demography 9(2): 79-97 SAVVY – MEASURE Evaluation website
For example, according to the 2007 INCAM study in Mozambique, roughly 73% of all deaths identified occurred at home. What can be done? Do more to enumerate and register deaths in communities Use appropriate techniques to determine likely causes of death Create and use mortality statistics derived from all available information
Steps 3,4 actually recommended by WHO, not everyone does this...
Types of VA questionnaires Form 1: Stillbirths, perinatal and neonatal deaths Form 2: Post-neonatal and child deaths Form 3: Adult deaths
Death Certification and ICD-10 coding training: DC and ICD-10 coding training (about 2 weeks) Takes place after VA data collection is completed 1 week - review of ICD volumes and processes 1 week - actual death certification and ICD-coding work Physicians review of VAQ Each VA independently reviewed by 2 MDs Write death certificates and ICD-10 codes, with tentative UCOD Reconciliation of death certificates 2 DCs are compared – if agree, UCOD reached If do not agree – 2 MDs sit together to reconcile
Direct may speak to issues of providing TREATMENT Underlying may speak to issues of PREVENTION
Some of the last items are still in very preliminary stages.
Kenya: Snow RW, Winstanley MT, Marsh VM, Newton CRJC, Waruiru C and others, 1992. “Childhood deaths in Africa: uses and limitations of verbal autopsies”. The Lancet Vol 340 Issue 8815, August 1992. Common causes of childhood deaths were detected with specificities >80%, Sensitivity was >75% for measles, neonatal tetanus, malnutrition, and injury-related deaths. However sensitivity less than 50% for malaria, anaemia, ARI, gastroenteritis and meningitis Zimbabwe: Ben Lopman, Adrian Cook, Jennifer Smith, Godwin Chawira, et al, 2009. “VA can consistently measure AIDS mortality: A validity study in Tanzania and Zimbabwe”. The Journal of Epidemiology and Community Health (JECH). October 23, 2009. Results High Sensitivity and Specificity of AIDS death among age group 15-44 (79% or higher) Namibia: Mobley CC, Boerma JT, Titus S, Lohrke B, Shangula K, Black RE, 1996. “Validation study of a verbal autopsy method for causes of childhood mortality in Namibia”. Results:An algorithm for cerebral malaria (fever, loss of consciousness or convulsions) – sensitivity 72%, specificity 85%. All malaria deaths (sensitivity 45%, specificity 87%. Proportion 33/243. Tanzania: Philip Setel, David Whiting, yusuf Hemed, D. Chnadramohan, Lara wolfson, KGMM Alberti and Alan Lopez, 2006 ”Validity of VA procedures for determining cause of death in Tanzania:. Tropical Medicine and International Health, Vol 11, No 5, May 2009.
Uganda: Field work conducted between March and April 2007. Analyzed sample = 541 of 641 Ghana: Field work conducted between September and November 2008. Analyzed sample = 199 of 226 Rwanda: Field work conducted between May and June 2008. Analyzed sample = 431 of 462 wanda
One of the highest child mortality rates in the world: under-5 mortality rates of 168 per 1,000 live births, the infant mortality rate of 115 per 1,000 live births.
Response Rates Uganda Initial count in the death frame = 724 including 83 stillbirths identified by the 2006 UDHS Stillbirths were excluded and hence remained with 641 child deaths in the death frame. Of the 641 deaths: VAs were not completed for 87 cases Also, in the process of coding, 13 deaths were identified by medical coders to have been stillbirths, and hence excluded in the analysis. Final count in the death frame complete with VA and ICD codes was 541. This is equivalent to a response rate of 84.4%
Formal health services in Uganda include: Government and private hospitals, health centers, clinics and dispensaries
Response Rates Ghana 226 in the death frame. VA completed – 199. VA not completed – 27 This is equivalent to a response-rate of 88.1%.
Formal health services in Ghana include: government, private, and faith-based hospitals, health centers and clinics
Verbal autopsy methods are a crude but replicable and moderately reliable method for estimating cause-specific mortality. The validity of verbal autopsy methods to identify specific causes of mortality in children and adults is influenced by prevalence data which can differ from one area to the other. Although the point estimates of cause-specific mortality data requires some type of adjustments, verbal autopsy methods offers reliable estimates for ascertaining mortality trends. VA presents the best option for assessing and responding to deaths deaths and theirs causes in many African countries where there is a paucity of reliable information and most deaths occur away from health facilities, or without formal health care contact in the period before death. This is especially true for deaths occurring in poorer communities. The use of validated verbal autopsy procedures in assessing the impact of burden of disease is an emerging procedure, and produces results that can be validated, and are useful for informing policies and monitoring interventions at all levels. Verbal autopsy methods are indispensable in monitoring the progress toward the achievement of global and local initiatives.
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