Global Congress on Verbal Autopsy: State of the Science 15-17 February, 2011, Bali, Indonesia

Verbal Autopsy Americas

Integration into National Health Information System

Fatima Marinho MD, MPH, PhDInformation and Health Analysis (HSD/HA)

Pan American Health Organization (PAHO/WHO)

marinhof@paho.org

Topics

• Information and Health Analysis (HA) goals

• Mortality Data base

• Quality of death information in The Americas

% under-registration, % ill defined, % garbage codes

• Status and challenges

Countries experiences - Improving mortality data

• Strategic Plan

• Points for discussion

Goals• Technical support to the countries to build

capacity for data collection and analysis,

• Technical support to the national decision-makers translate evidence into new policy directions,

• Work directly with the countries to improve the Health Information System (HIS),

• Collect, organize and validate the health information in the Americas,

• Provide a good information,

• Make analysis of the health situation, health determinants and others,

• Monitoring the health situation.

Mortality Data

Main Variables/Annual data

requested to the countries *

• Deaths: Individual data on each death, with the following specifications:

• Sex• Underlying cause of death• Age (in hours for the first day, in days for

the first month, in months for the first year, and in complete years after one year of age)

• Other available causes

*Since 2009 this extensive set has been requested

• Major civil division of residence of the decedent• Certification of the cause (s) of death: physician

or nonmedical• Educational attainment of decedent (instruction

or education level) • Ethnicity of the decedent• Place of occurrence of the death (hospital,

residence, public thoroughfare, etc)

45/48 Countries and Territories in the Americas have a Vital Statistics System working

10%

26%

5%44%

15%

Type 1 Causes that cannot or should not be considered as ucd

Type 1 ill defined

Type 3 Immediate

Type 2 Intermediate

Type 4 Unspecified causes

• 20% of the cause of deaths are “Garbage codes”

• Intermediate causes are the most important Garbage codes (44%)

Causes ICD-10 %

     

ill -definedR00-R99 26.43

     

Heart failure I50 17.3

Other septicaemia A41 8.7

Essential (primary) hypertension I10 6.1

Chronic renal failure N18 5.4

Malignant neoplasm without specification of site C80 5.2

Exposure to unspecified factor X59 3.4

Unspecified renal failure N19 3.2

Pneumonitis due to solids and liquids J69 2.8

Respiratory failure, not elsewhere classified J96 2.7

Complications and ill-defined descriptions of heart disease I51 2.7

ill - defined and 10 causes accumulate 80%

Source: PAHO/WHO. Mortality Information System; Washington DC:2010 As of February 9 2010

Countries ExperienceImproving Mortality Data

Region / State

SIM Expected Deaths

SIM COVERA

GE

DEATH UNDER-

REGISTERED North Region

56,267 73,384 76.7 17,117

Rondônia 5,354 8,211 65.2 2,857 Acre 2,783 3,269 85.1 486 Amazonas 11,622 14,859 78.2 3,237 Roraima 1,488 2,273 65.5 785 Pará 27,543 34,250 80.4 6,707 Amapá 1,887 3,109 60.7 1,222 Tocantins 5,590 7,413 75.4 1,823 North-East Region

258,902 354,493 73.0 95,591

Maranhão 22,627 41,681 54.3 19,054 Piauí 14,838 20,654 71.8 5,816 Ceará 40,068 53,984 74.2 13,916 Rio Grande do Norte

14,225 20,659 68.9 6,434

Paraíba 21,158 28,660 73.8 7,502 Pernambuco 53,081 64,226 82.6 11,145 Alagoas 16,477 23,213 71.0 6,736 Sergipe 9,628 12,038 80.0 2,410 Bahia 66,800 89,378 74.7 22,578

Quantifying the coverage problem

Setting Priorities

In Brazil, coverage and quality are very good in the Southeast and South where 60% of the population live.

In the Central West Region the coverage is 90%. 10% of the country’s population live in this region.

Mortality Information System (SIM)

Brazil

Quantifying the Quality Problem in Brazil

Proportion of Ill-Defined causes of death, SIM

  1996 1997 1998 1999 2000 2001 2002 2003 2004

BR 15 15 15 15 14 14 14 13 12

NO 24 24 24 24 24 23 22 21 21

NE 32 31 30 30 28 28 27 26 24

SE 9 9 10 10 10 10 9 9 8

SO 9 8 8 7 6 6 6 7 6

C W 11 11 11 11 9 8 7 6 6

Source: CGIAE/DASIS/SVS/MS Feb 2009

National Goals

Diagnosis of cause of death:

- increase to 90%

Death registration system coverage:

- increase to 90% in the Northeast Region

How?4- Systematic Search of under-registered deaths at the municipality level – Verbal Autopsy5- Investigation of 100% of Ill-Defined cause of Death – Verbal Autopsy

Local Actions-Slicing the problem into small pieces

• Systematic search of burial places where people with no legal paperwork are buried

• Systematic search for illegal cemeteries

• Systematic search of deaths registered in the Civil Register office that are not part of the MoH mortality system

• The MoH has started the organization of burials, working with the District Attorneys and communities

Ceará-Mirim – Municipality – rural areaa very small piece of the problem60,000 inhabitants – 21 cemetery – 19 illegal

Área de estudo

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CGMP <4/1000 hab - 20 municípios

CGMP acima de 6/1000 hab - 30 municípios

State of Alagoas, Northern of Brazil-2004

Pop:2,947,717 Mortality coverage: 66%

Red and yellow areas are target areas

A measure was developed to estimate the coverage in small cities

Fonte: Planilha de busca ativa

Systematic Death Search Results, Alagoas, Brazil - 2005

Actions at the local level- defining the cause of death

• Investigation tools have been developed

– Health Services

– Record Linkage: hospital, surveillance, mortality data base

– Verbal Autopsy

Investigating the causes of death at the community level

Verbal Autopsy: Implementation• To improve death investigation, the MoH team field-tested

the verbal autopsy formulary (SAVVY) in a urban and rural area, partnering with MEASURE EVALUATION (2007)

• First test: 12 formularies were applied, in a municipality – adjustment of the Mozambique formulary

• Second test: 50 questionnaires applied, in different municipalities during a workshop with supervision of Measure Evaluation, one person from Mozambique and PAHO – 17 states representatives trained

• Third test: in 17 states Results: 1,238 deaths investigated 85% deaths w/underlying causes of

death determined • Evaluation with the states and PAHO

         

Verbal Autopsy as Routine in the Mortality Information System• Final version: Questionnaire implemented in the entire

country in 2009 as a routine in the Mortality Information System

• It is mandatory investigate: Maternal death, infant deaths, ill-defined cause of death and women death (age 10-49)

• Search for NO-registered death

• National Agreement Indicators

• Who is applying the VA?– Health community workers as part of the Family Health Program

activities (1 team for 4500 people)– 1 team: 1 doctor, 1 nurse (university degree), 3 nurses

assistants, and 5 community workers• The diagnose and death certificate are filled out and signed

by primary care doctors• System: Codification and incorporation in the national

system (there is a variable identifying the cause of death as a result of investigation)

Research of the underlying cause of death Analysis of Health Information System Verbal Autopsy - Pilot Test - Paraguay 2010

•Proposed PAHO/WHO and MoH, to implement a pilot test of the Verbal Autopsy (based in Brazilian experience)

•Regional Plan Strengthening Vital and Health Statistics (component of quality of data) - Analysis of % ill defined causes of death (mortality database September-December 2009) by departaments

Selection of the district: Regional Hospital Luque- Reference Center

- Review, translation and adaptation of tools (Brazil)

-Approval of local authorities

- Mapping the area

Training: interviewers and certifying physician

-Pilot test: April with support of PAHO/WHO - HA

Well accepted by the population, interviewers and hospital medical team

Documentation and revision of each case by physicians team Reviewing and coding of all deaths by coders and physician

Reclassification of ill defined causes of death

Presentation and discussion of results to all staff of the hospital and the area selected for the pilot test

Discussion on the advantages of the use of verbal autopsy with the Minister of Health

Next Step

- To establish a working group in order to implement the use of verbal autopsy as one of the alternatives for improving the quality of mortality information

Results

Points for Discussion• Why are Countries not investigating ill-defined causes of

death?

– The main problem is the absence of a operational proposal (how to do)– There is a perception that it is too difficult to improve the coverage and

quality of mortality information– There is a believe that vital statistics will improve naturally or improve

with the natural history of the vital statistics information system

• Fact: It is possible to make a good project with little budget

• The most important tangible and sustainable impact will be reached when the project promotes strategies at the local level, and activities that address the problem where it is produced/originated

• Political commitment

• Challenges - Change Behaviors related to produce and use of the

information in the countries– Change the UN– Get financial support to go on with the project