Review of the WHO Verbal Autopsy (VA) Instruments Meeting Report  19‐20 December 2011 and workshop 21‐22 December 2011                                               Geneva, Switzerland   

Executive Summary The goal of themeetingwas to reach consensus on a simplified verbal autopsy (VA)instrumentforroutineuseaspartofcivilregistrationsystemsinsettingswheremanydeathsarenotmedicallycertified.Theinstrumentshouldcompriseashortbuteffectivelist of diagnoses that could be ascertained by way of a limited number of questionssuitable for use in interviews and amenable to software analysis to automate theascertainmentofcauseofdeath.Prior to the meeting, a review was undertaken to compile evidence from researchstudies including VA using physician review and diagnosis, andmachine derived VA.Review of the materials, and inputs from the participants provided evidence on thefeasibilityandrelevanceofcausesofdeaththatcanbereliablyascertainedbyVA.Theoutcomewasagreementonalistof62causesofdeath.During thereview, itbecameclear that there isonly limitedevidenceontheutilityofindividualquestions included inVA forms.Nonetheless, there issolidexperiencewithregard to the feasibility of individual questions and the reliability of the responses.Reviewbyexpertgroups–forrelevancetothelistofcauses,reliability,andfeasibility–andcomparisonwithmachineassessmentanalysis(Tariff;PHMRC)resultedinatotalof221items,subdividedinto4sectionsand93subgroupsthatwereconsolidatedduringafollow‐onworkingsessioninthetwodaysfollowingthemainmeeting.Withinsectionsandsubgroups,skippatternsaredrivenbyage,maternalandperinatalinformation.Asaresult,themaximumnumberofquestionstobeaskedrangesfrom101foraneonataldeath,and140 forawomanofreproductiveage. Furtherworkwillbecarriedout tomodifyexistingsoftwaretoassesscauseofdeathonthisbasisofthelistofquestionsinthis instrument.Localusersmayaddquestionsbutshouldalwaysusethis instrumentasthecore.Theinstrumentwillpermitthecollectionofuniformsetsofindicatorsfromthefield. Mergingthisstandardinformationfromdatabaseswillprovidetheevidenceforeditingthetoolinthefuture.

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Table of Contents 

Executive Summary ............................................................................................................ 3

Acronyms ........................................................................................................................... 6

Introduction ....................................................................................................................... 7

Objectives and Expected Outcomes .................................................................................... 7

Summary of proceedings .................................................................................................... 7

Opening .............................................................................................................................. 8

HMN MoVE IT initiative ...................................................................................................... 9

Revising the WHO VA instrument and its uses .................................................................... 9

Experiences with VA and InterVA for cause‐of‐death determination ................................ 10

Population Health Metrics Research Consortium (PHMRC): Use of Gold Standards in Studying the Validity of Verbal Autopsy Methods ............................................................ 11

VA Country experiences ................................................................................................... 12Thailand..................................................................................................................................................................................12India..........................................................................................................................................................................................12Brazil.........................................................................................................................................................................................13PapuaNewGuinea.............................................................................................................................................................14

Item Reduction from INDEPTH Sites ................................................................................. 15

Item reduction of the PHMRC Instrument ........................................................................ 15

Proposed simplified causes of death and verbal autopsy questions ................................. 16

Summary discussion ......................................................................................................... 18

Simplified Cause of Death List .......................................................................................... 18Infectiousandparasiticdiseases.................................................................................................................................19Neoplasms..............................................................................................................................................................................21Nutritionalandendocrinedisorders.........................................................................................................................21Diseasesofthecirculatorysystem.............................................................................................................................21Respiratorydisorders.......................................................................................................................................................22Gastrointestinaldisorders..............................................................................................................................................22Renaldisorders....................................................................................................................................................................22Mentalandnervoussystemdisorders......................................................................................................................22Pregnancy‐,childbirthandpuerperium‐relateddisorders............................................................................23Perinatalcausesofdeath................................................................................................................................................24Stillbirths................................................................................................................................................................................24Externalcauses....................................................................................................................................................................25

Simplified questionnaire................................................................................................... 26

Implementation and IT Issues: Applying probabilistic model of VA for Surveillance and Response .......................................................................................................................... 27

Closure ............................................................................................................................. 28

Annex 1: List of participants ............................................................................................. 29

Annex 2: Agenda .............................................................................................................. 32

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Annex 3: Review process and outcomes of the WHO verbal autopsy cause of death list. . 36

Annex 4: Mapping of CoD between WHO, InterVA and PHMRC VA instruments, reduced 44

Annex 5 List of indicators – see separate PDF document .................................................. 53

 

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Acronyms CoDCOPDCSMF

CauseofdeathChronicobstructivepulmonarydiseaseCausespecificmortalityfractions

CRVS CivilregistrationandvitalstatisticsDSS DemographicsurveillancesitesGBD GlobalBurdenofDiseaseHCE HealthcareexperienceHDSSHMN

HealthandDemographicSurveillanceSitesHealthMetricsNetwork

HIS HealthInformationSystemsICD10INDEPTH

International Statistical Classification of Diseases and Related HealthConditions,10thRevisionInternationalNetworkfortheDemographicEvaluationofPopulationsandTheirHealthinDevelopingCountries

LSHTM LondonSchoolofHygieneandTropicalMedicineMoH MinistryofHealthPHMRC PopulationHealthMetricsResearchConsortiumPNG PapuaNewGuineaPCVA PhysiciancertifiedverbalautopsyQ&A QuestionsandanswersSAVVYSPICEUQ

SampleregistrationandverbalautopsyUniversityofQueensland

WHO WorldHealthOrganization

 

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Introduction TheWorldHealthOrganization (WHO) standard verbal autopsy (VA) instrumentwaspublished in 2007 and has been successfully applied inmany research settings sincethen. Inrecentyears, therehasbeengrowinginterest instrengtheningcountries’civilregistrationandvitalstatistics(CRVS)systems,andthishasledtodemandforamoresimplifiedandpracticalVAinstrumentandassociatedITapplicationsfordatacollectionandanalysisthatcanbeusedroutinelyaspartofthecivilregistrationsystem.Inresponse,ameetingtoreviewtheWHOVAinstrumentswasorganizedbytheWHODepartmentofHealthStatisticsandHealthInformationSystemsandtheHealthMetricsNetwork (HMN), in collaboration with the University of Queensland (UQ) and theINDEPTH Network. Themeeting took place on the 19 and 20 of December 2011 atWHO, Geneva, Switzerland, and was attended by 37 participants from 15 countries.Participants included key stakeholders, researchers and those who work day to daywithVAtools.Adetailedlistofparticipantsandtheirrespectiveinstitutionalaffiliationscan be found in Annex 1. Themeetingwas followed by a two day workshop duringwhich a small group consolidated the outcomes of the discussions and prepared thefinaloutcomesdescribedinthisreport.

Objectives and Expected Outcomes Theobjectivesandexpectedoutcomesofthemeetingwerethefollowing:

1. ToreviewevidenceandexperiencesintheuseofVAinstrumentsincommunitysettings,especiallyaspartofthedeathrecordingandcivilregistrationsystems;

2. Toreviewandassess the relevanceandsuitabilityof the causeofdeath (CoD)listsindifferentVAinstrumentsandproposeasimplified/reducedlistofcausesandindicators;

3. To review and assess the suitability and performance of the modules andquestionsincludedintheVAinstruments;and

4. Toformulaterecommendationsforthefurtherdevelopmentoftheinstruments,validation,utilizationandimplementation,includingappropriateITapplications.

Summary of proceedings Themeetingopenedwithanoverviewoftherationaleforthemeetinganditsgoals.Asummary was provided of preparatory work undertaken on the relevance andeffectivenessof specificquestionson signs and symptoms, specifically a reportof theevidence (background document1) and experiences of field projects using VAinstruments. Following discussions on the implication of the evidence and further

1 Leitao,  JC.,  Chandramohan,  D.,  Byass,  P.,  Jakob,  R.  Revising  and  simplifying  the  WHO  verbal  autopsy 

instrument for routine cause‐of‐death monitoring. 2011.  

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inputsfrommeetingparticipants,anadhocsubgroupwastaskedtoreviewtheinitiallistofcausesofdeathandproposeashortenedlist.Thiswaspresentedinplenarythefollowing day, further edited, and consensus achieved. The next step involved thepresentationofevidenceforaproposedlistofindicatorstobeincludedinthesimplifiedVAinstrument.Afinallistwasdiscussedinplenaryandcomparedwithindicatorsthatemerged following an item reduction undertaken by the Population Health MetricsResearchConsortium(PHMRC)usingtheTariffmethod,asimpleadditivealgorithmforanalysisofVA. Theresultsofthesediscussionswereconsolidatedbyasmallworkinggroup in the two days following the main meeting, and assessed for suitability insoftwaretools.

Opening The meeting was formally opened by Dr. Ties Boerma, Director, Department ofMeasurementandHealth InformationSystemsatWHOandcollaboratingpartnersDr.Alan Lopez, School of Population Health at the University of Queensland, Dr. OsmanSankoh, Executive Director at INDEPTH Network, and Dr Marc Amexo of the HealthMetricsNetwork.In summarising experiences in the use of the standardWHOVA instrument since itsinception it was pointed out that VA has been used mainly in research settings.However, demand is growing for simplified and shorter VA instruments that can beused to ascertain causes of death routinely in civil registration systems. This wouldgenerate statistics on patterns ofmortality in settings wheremedical certification ofcauseofdeathisnotwidelyavailable.Itwasacknowledgedbyallparticipantsthatthedevelopment of a simplified VA instrument should be based on strong evidence offeasibilityandeffectivenessandshouldtakeintoaccounttheneedsofusers, includingatlocallevels.There was agreement that the accurate determination of CoD at the level of theindividualrequiresexaminationbyamedicallytrainedpersonfamiliarwiththerulesofthe International Statistical Classification of Diseases and Related Health Conditions,10thRevision (ICD10). However,whilemedical certificationof CoD is considered the“goldstandard,”inpracticerelianceonclinicaljudgementaloneisofteninsufficientandneeds to be supplemented by diagnostic tests and medical autopsy. Verbal autopsytechniques cannot attain the levels of accuracy and precision in individual CoDascertainment thatarepossibleusingphysiciandiagnosis. Instead, thepurposeof themeetingwastodevelopaVAinstrumentthatwouldbesufficientlyrobusttogeneratereliableCoD information at thepopulation level andproduce cause‐specificmortalityfractions through the application of automated diagnostic methods such as machinelearning.Dr. Sankoh pointed out thatmuch of the long‐term experience in the use of VAwasthrough health and demographic surveillance sites (HDSS) established as part ofbroaderresearchefforts.Manyof theseHDSSsitesarepartof theINDEPTHNetwork.HehighlightedthecentralimportanceofVAfortheINDEPTHNetworkandpointedoutthatprior to thedevelopmentof theWHOVA instrument in2007,manyof theHDSSsites had been using different instruments, thus reducing the temporal and cross

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sectoral comparability of the results. Dr. Sankoh informed that all INDEPTH sites areusingthe2007WHOVAinstrument.

HMN MoVE IT initiative Dr.Mark Amexo introduced the HMN priority strategic initiative,Monitoring of VitalEvents,includingthroughtheuseofInformationTechnology(MOVE‐IT).Thisinitiativeaims to improve the monitoring of vital events and strengthen country informationsystems through innovation and use of information technologies. He described thegrowing political commitment and institutional support for improvement of civilregistration and vital statistics systems, and the high demand for tools to permit theproductionofimproveddataonCoD.HMNhasbeencollaboratingwithWHOtodevelopstandards and instruments that facilitate collection, analysis and reporting ofpregnancy,birthanddeathdata.Fordatacollection,anautomatedVAinstrumentwillbringneededinnovationincivilregistrationandstatisticssystems.Participantscommentedthat thatgenerationofevidence fordesigningand improvinginstruments takestime.The implementationofautomatedVAinstruments inthe fieldneeds to take into account also issues of coordinating the necessary infrastructure,identifyingrelevantstaff,andselectingadequatesoftwarecompanies.

Revising the WHO VA instrument and its uses Dr.Daniel Chandramohanpresented the preparatoryworkwhich compareddifferentVAinstruments,includingthosedevelopedbyWHO,theINDEPTHNetwork,theSampleregistrationandverbalautopsy (SAVVY) instrumentdevelopedbyMEASURE, and theVA instrument developed by the London School of Hygiene and Tropical Medicine(LSHTM).Atotalof368publishedVAstudieswerereviewed,ofwhich98notedtheuseoftheVAinstrumentsofinterest.However,themajorityofstudiesdidnotreportwhichVAinstrumenthadbeenutilized.Fromthereview, itemergedthatthemost frequentlyusedVAinstrumentshavebeenthe WHO VA instrument and its adaptations, followed by the INDEPTH VA and itsadaptations,theLSHTMVAanditsadaptations,andtheSAVVYtoolanditsadaptations.Intermsofgeographicaldistribution,relevantVAstudieshavebeenmainlyconductedinAfrica(55%)andAsia(36%),withasignificantlysmallernumberofstudiescarriedoutinCentralandSouthAmerica.ApostalsurveywasconductedamongresearchersknowntohaveusedVAtechniquesto identifywhichquestions generated themost reliable information inVA interviewsandwhichmodificationshadbeenmadetoVAinstruments,andtoascertainthemostimportantquestionsforCoDascertainment.Atotalof27VAuserswerecontactedand10responded.AlldescribedthequestionsincludedintheWHOVAinstrumentasusefuland reliable but mentioned that a shorter andmore simplified instrument would beeasiertoimplementinthefield.Themajorityoftheresearcherswhorespondedcouldnot identifywhich questions provided themost reliable and relevant information forCoDascertainmentorwhichquestionscouldbedropped.

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The need for physician review of completed VA questionnaires was described asresource intense and time‐consuming.Moreover, themethod is subject to significantvariability between coders, across sites and over time. Respondents and a literaturereview confirmed that someof theCoD included in theWHOVACoD list have rarelybeencertifiedfromVA.Discussion:

ThereisdemandforsimplifiedVAinstrumentsforuseinroutinedatacollectionsystems; automated CoDmethods are feasible, and the results from validationstudiesofsuchinstrumentsarepromising.

Thereisverylimitedevidenceabouttheutilityofindividualquestions. ThereisevidenceaboutuseandfeasibilityofspecificCoDinVA. The contribution of VA to global mortality estimates is unknown but in non‐

medicallycertifieddeaths,CoDinformationcanbecollectedwithVA. Open narrative input on VA questionnaires is not necessary for automated

systems,butitisessentialforphysicianreview. The VA questionnaire should be designed to be usable by physicians and

automated systems,but the aim is tomove away fromphysician reviewofVAquestionnaires.

Experiences with VA and InterVA for cause‐of‐death determination Dr.PeterByassintroducedtheALPHAnetwork,acollaborativenetworkfortheanalysisofpopulation‐basedHIV/AIDSdatainAfrica.TheALPHAandINDEPTHnetworksworkcloselytogetherandshare8/10centres.ThecollaborationlargelydrawsonInterVAfortheassessmentofcausesofdeath.InterVA is software that uses input to a set of dichotomous questions followed by aBayesian approach for interpreting the responses. It uses a priori estimations ofprobabilities related todiseasesand symptoms to calculate theprobabilityof specificCoD.ItwasemphasizedthatInterVAisnotanalgorithm,butamodel,withprobabilitiesinformedbyseriesofconsultationswithpanelsofphysiciansandadjustmentwithdatafromthefield. ThelatestInterVAmodelversion, InterVA‐4β,combinesInterVA‐3andInterVA‐M(Maternal).InterVA is robust; it is not sensitive to small variations in probabilities. A study hadassessed the extent of InterVA’s ability to characterize population mortalitycompositionusingdifferentaprioriprobabilities.Thecausespecificmortalityfractions(CSMF)weresimilarbetweentheoriginalInterVAmodelandthemodelswithmodifiedaprioriprobabilities.ThedurationofVA interviewswithInterVAmakesVA feasible inroutineuse. Apilotstudy in Indonesia showed that in average it took 11 minutes to carry out a VAinterviewwith80itemsusinghandhelddevices(InterVA‐M,excludingintroductionandthanking).Dr.ByassproposedtheinclusionintherevisedVAinstrumentofacoresetof key background questions that would provide information about the context ofdeaths.Discussion

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In a short VA instrument for routine use, the accuracy in assessing a CSFM ismoreimportantthanascertainingtheCoDatindividuallevel.

Population Health Metrics Research  Consortium  (PHMRC): Use of Gold Standards in Studying the Validity of Verbal Autopsy Methods Dr.IanRileypresentedthePHMRCstudyongoldstandardVAvaliditythatwasfundedas part of the Bill &Melinda Gates Foundation Grand Challenges in Global Health toInstituteforHealthMetricsandEvaluation,JohnsHopkinsSchoolofPublicHealthandUQ.Thestudycommencedin2007andcompleteditsdatacollectionin2011inAndhraPradesh,India,UttarPradesh,India,Bohol,Philippines,DaresSalaam,Tanzania,PembaIsland,Tanzania,andMexicoCity,Mexico.The gold standard VA validity study aimed to overcome common issues affecting VAvalidationstudies,suchasthelimitednumberofcausesofdeathassessed,thequalityofmedicalrecords,andthediagnosticcapacitiesofhealthfacilities. InmanyVAstudies,metricsofsuccessactuallyrelatetoconvergentvalidity(comparisonsofVAcauseswithphysiciandiagnosisofcauseofdeath)ratherthanconstructvalidity(comparisonwithagoldstandard). Thepurposesofthestudyweretodevelopcomprehensible,objectivevalidation standards independent from physicians, and to compare computer drivenanalysis of symptom patterns against diagnoses that had been ascertained in healthfacilitiesandthatwerecompliantwithasetofdiagnosticproceduresandresults thatweredeterminedbyagroupofexperts(goldstandarddiagnoses).AtargetCoDlistforadults,childrenandneonateswasdevelopedandderivedfromtheGlobal Burden of Disease (GBD). Subsequently, diagnostic criteria were defined toestablish “gold standards” for each CoD, and corresponding deaths in participatinginstitutions that met “gold standard” criteria were selected. The VA was conductedusing a modified version of the WHO VA instrument. The PHMRC VA instrument iscomposedof3modules: general informationmodule,neonatal andchildmodule, andadultandadolescentmodule. InpreparationofthePHMRCtool,170differenceswereidentified between the WHO and PHMRC VA instruments, including among others,addition and deletion of certain chronic diseases, differences in terminology andremovalofsomequestions.Dr.Rileydescribedtheanalyticalprocedureinvolved invalidatingtheperformanceofthemethod. First, the dataset is randomly split into two sets, namedTrain and Test;second, the deaths in Test set are resampled to have 1000 deaths; and third, thealgorithmistrainedonthedeathsintheTrainset,andtheperformanceofthealgorithmis assessed by predicting the CoD for the deaths in Test dataset. This procedure isrepeatedover500times.Forthistobevalid,itisnecessarytohaveatleast20deathsper CoD. Themedian accuracy formachine learning for CSMFs and chance‐correctedconcordancewerepresented.ThetalkwasconcludedwiththepresentationofthefinalCoDlist,comprising46adultCoD,21ChildCoDand11neonatalCoD.Discussion:

Inclusion/removalandimportanceoftheopennarrativesectioninthesimplifiedVA instrument: Itwasnoted that physicians prefer to have access to the opennarrativeasitprovidesthemwiththesequenceofevents,signsandsymptomsandresemblestheirusualmethodsofdifferentialdiagnosis.However,theopen

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narrativerendersautomatedcauseofdeathascertainmentmuchmorecomplexthanclosedquestions.

Field implementation of the PHMRC VA instrument: The instrument has onlybeenusedbythesameresearchteamthatdesignedit.Thereareseveralongoingstudies, including a large one in Vietnam and another in Indonesia beingimplementedin9DSS.

Durationofaninterview:OnaverageaninterviewwiththePHMRCinstrumentlasts20‐40minutes.

The importance of the interaction process and communication of ascertainedCoDback to the familywasstresseddue to itsethical relevanceand its role inconfirmingadiagnosis.

Difference between the WHO VA instrument for routine surveillance andresearchcontexts:Itwasagreedbyallparticipantsthatcomplementarymodulescould be added to the coremodules of the simplifiedWHOVA instrument forresearchpurposesorspecificlocalcontexts.

AddingCoDtothePHMRCVAinstrument:Theinstrumentwasdesignedtosolelydifferentiate theCoD included in the target list. Itwasargued that thePHMRCinstrument should be able to differentiate between maternal CoD and thatspecificmaternalCoDshouldbeaddedtotheCoDlist.

VA Country experiences VA experts from Thailand, India, Brazil and Papua New Guinea presented their fieldexperienceintheuseofVAinstruments,withemphasisonitemreduction.

Thailand Dr.KanittaBundhamcharoenpresentedtheexperienceofThailand inusingVAandinreducingVAinstrument‐itemsandtargetCoDlist.Since1999,ThailandhasbeenusingaVAquestionnaireinaresearchstudySPICEinseveralprovinces,withatotalpopulationof63millionpeople,inthecontextoftheroutinesurveillanceofvitalevents.ThedatagatheredthroughVAhasbeensuccessfullyusedforpolicyanddecision‐makingattheprovinciallevel.ThegreatestchallengeintheuseoftheVAwastheconfusionbetweenlay language and medical terminology. For example, in Thailand the term ‘fever’ isinterpretedasmeaninggeneralillness.

Discussion:

ThesuccessofVAinThailandwasduetothegoodlevelofcooperationbetweentheMinistryofInteriorandMinistryofHealth(MoH).

Thailand’sVACoDlistincludedbetween30‐50CoD. The questionnaires have not been reviewed for the utility of individual

questions.

India Dr. Vishwajeet Kumar presented the experiences of VA use in Uttar Pradesh, a stateaccounting for 25%of India’s disease burden. The Shivgarh research group has beenadministering the neonatal and stillbirth modules of the WHO VA instrument, thePHMRCVA,andtheRegistrarGeneralofIndiaVAmodule.ThepurposeandlimitationsofaVA instrumentneed tobeclearlydefined. TheVA instrumentshavebeenwidely

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usedwithalimitedunderstandingoftherelevantdiagnosticapproachanditspractice,particularlyinthecaseofmaternalCoD.VAinstrumentshouldbemademodularsotoimprovetheirusability. TheVA instrumentshavebeenusedwithsingleandmultiplerespondents. Multiple respondents were shown to reconstruct events better. VAinterviewusuallylastedlessthan45minutes.ThetimingofadministrationoftheVAisdependentonreligiousandculturalpreferences,butingeneral, ithasbeenconductedbetween2to12weeksfollowingadeath. Incaseofamaternaldeath,VAtendstobeconductedafter6weeksto6months.

MaternalindicatorsarefrequentlyspreadacrossvariousmodulesofadultVAtools. AseparateVAinstrumentcouldbedevelopedformaternaldeaths,andthereproductivehistory for maternal VA should be incorporated. For stillbirth modules, furtherharmonizationwouldbeneeded.Itwasemphasizedthatstillbirth‐relatedconfirmatoryquestionsshouldbeposedbeforequestionsrelatedtolivingnewborns.Thereisaneedforassessmentoftheunderlyingcausesofstillbirth.Possiblebiascomingfromfacility,family and respondents should be taken into account. A proven preference forobserving and reporting more visible signs (e.g. excessive bleeding) and communityperceived danger signs (e.g. fever) results in over reporting, whereas symptoms likefoulsmellingvaginaldischargeareprobablyunder‐perceivedandunder‐reported.Signsandsymptoms thataremoreskill‐dependent tend toelicit subjective responses(e.g. fast breathing, hypothermia, diarrhoea and vomiting for deaths of newborns).Relyingonvisiblesignsandshowingpicturesintheinterviewmaybeawaytoimproverecallandcorrectreportingofsignsandsymptoms.Dr.KumaralsopresentedtheoutcomesofthevalidationofthePHMRCVAinstrumentinKGMUTertiaryCareHospital,andtheCoDdistributionandfrequenciesofkeysignsbyCoDforneonatalandmaternaldeaths.Discussion:

Thequestionnairethatwasusedinthestudycomprisedonlyonepage. IthadonlyfewquestionsrelatingtomaternalCoD. The importance of the open narrative for physician review was highlighted

again.

Brazil Dr. Elisabeth França introduced the Mortality Information System (MIS) from Brazil. In 2003, it had a high coverage (87%) with a high proportion of medically certified CoD in the South and Southeast regions but a low coverage in North and Northeast regions. Data were shown on the proportion of ill-defined CoD in Brazil from 1996 up to 2004. Between 2004 and 2008, the MoH did systematic research of non-registered deaths with the project “Reorganization and qualification of health information systems”. To introduce VA instruments into the investigation of ill-defined CoD occurring at home, a study was conducted in 2007/2008 in three phases, first adapting the VA instrument in use in Mozambique (SAVVY) and testing it in one urban and one rural area, and presenting it to 15 priority states (n=25). After review, a second test was carried out in the selected 15 states (n=271). Upon satisfactory completion, in a 3rd round, 14 states participated in a pilot study with a total of 1444 cases investigated.

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Differences and modifications made to the SAVVY instruments included: Different structure of age groups: under 1 year old, from 1 to 9 years old and 10 years

old and above; Data abstracted from health records and from the death certificate were not included

in VA instruments, but were captured by extra forms used in addition to the VA questionnaires; and

Questions that were removed from the SAVVY instrument related to history of injuries/accidents, signs and symptoms noted during the final illness, as cough severity, ability to open mouth, having red eyes.

The resulting version of the VA instrument was implemented throughout the country in 2009, as routine procedure in the MIS for the investigation of ill-defined deaths occurring at home, and as supplementary information for the assessment of maternal and infant deaths in home interviews. The VA has been routinely implemented as part of the Epidemiology Surveillance activities and also within the Family Health Program with teams (1 team/3500 people) that include 1 doctor, 1 nurse, 3 nurse assistants and 5 community workers. VA data interpretation and CoD assignment is carried out by physician review, and follows ICD-10 rules. Advantages of using physician review include synergies with promotion of health strategies at the local level and possibility of training of physicians in certification of CoD. The introduction of VA resulted in decline of the proportion of ill-defined CoD. Dr. Franca informed that a pilot phase of an evaluation project was implemented in 2011 and the global project is planned for 2012. Challenges of using VA in routine surveillance are the additional workload for health professionals, lack of qualified staff, and lack of funding.Discussion:

Questionsonsensitiveorstigmatizingtopicsmaynotprovidereliableanswers.Thismaybeparticularlytrueforsuicideinreligioussettings.

The open narrative may be the best way to attain information on culturallysensitivecircumstancesrelatedtoCoD.

Questions on sensitive topics should be included but rephrased in a way thatwouldnotoffendorintimidatetherespondent.

WhereVAbecomesaninstrumentforroutineuseandinformationoftheMoH,itis important to have questions on the context of the death (e.g. health systemuse).

Papua New Guinea Dr. IanRileydescribedtheexperiences inthedevelopmentanduseofasimplifiedVAinstrument in Papua New Guinea (PNG) highlands in 1970/71. The instrument wasdeveloped in order to provide endpoints of trials of pneumococcal polysaccharidevaccine against pneumonia in adults and children; and to add to data from smallpopulationstudiesofmortality,whichhadrunfrom1949throughthe1960s.TheVAinstrumentwastargetedforthespecificcontextofthePNGhighlands.Severaldiseaseswerenotincluded,suchasmyocardialinfarctionandlungcancer.Incontrast,unusualdiseaseswerecommonintheareasuchas“pig‐bel”andaformofchroniclungdisease. The instrument was very simple because the questions targeted the specificepidemiological context and due to the high level of illiteracy and absence of on‐sitecomputers. To classify theCoD, theWHOLayReportingClassificationwasusedwithsomerefinement forbetterapplicationto thePNGHighlandsdiseasepattern. IncaseswhereaspecificCoDcouldnotbeassigned,asymptom‐basedcausewasattributed.An

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excerptoftheusedCoDclassificationsystem,abreakdownofhealthcareexperiencebyhealthcareprovideranddiagnosis, anddataonALRImortalityand specificCoDwereshowntotheparticipants.TheevidencepresentedindicatesthatthissimplifiedformofVAwasausefulandvalid instrument. Dr.Rileyarguedthattheexperienceswiththisinstrumentalsoindicatethatsymptomrelatedquestionscanbekeptataminimumduetoourabilitytodrawassumptionaboutspecificdiseasepatternsataparticularperiodoftime.Discussion:

It is important for VA instruments to target the communities they are beingappliedto.

Qualitycontrolproceduresneedtobeimplemented. Opennarrativesectionshouldalwaysbeassessedagainstspecificquestionsfor

consistency.

Item Reduction from INDEPTH Sites Dr. Byass briefly shared some outcomes on the utilization of VA instruments inINDEPTHsites.Results fromseveral INDEPTHsiteshaveshownthat theextractionofsmall subsets of closed‐question data from longer VA questionnaires and theirinterpretation via probabilistic models leads to accurate CoD assignment. Longquestionnaires and physician review are time consuming, involve high costs and arehumanresourceintensive.Discussion

ItemreductionneedstotakeintoaccountrelevanceandfeasibilityoftheCoDtobeascertainedinVA.

Item reduction of the PHMRC Instrument Dr. Hernandez presented a comparison between VA instruments used in the field(General Registrar of India, SAVVY andWHO) and the PHMRC VA instrument. ThisshowedthattheSAVVYhadthehighestnumberofquestions,closelyfollowedbyWHOandPHMRCVAinstruments.HenotedthatashortVAinstrumentwidensthescopeofuseofVA inhouseholdsurveys,enables itsuse in routinedeath registrationsystems,andincreasesresponseratesbycuttingdownrespondents’load.AnempiricalapproachtoreduceVAinstrumentitemswasdescribedthroughtheuseofavalidationdatasetandthetestingoftheeffectofdroppingitemsonchance‐correctedconcordance and CSMF accuracy. This empirical assessment of the potential for itemreduction was undertaken on the PHMRC gold standard VA database using theempiricalapproachoftheTariffmethod.Inthismethod,atariffisascoringsystemthatreflectstheimportanceanduniquenessofeachsymptomtoeachCoD(Figure1).IntheTariffmethod,thetariffscoresforeachCoDaresummed,andthesummedtariffscoresareusedtoassigntheCoDortop2,3,4…nCoD.Thisapproachenablesuserstoassesstariff symptoms foreachCoD,anddoesnotrequireanystatisticalmodeloradvancedcomputer‐basedalgorithm.

Figure1‐Tariffdetermination

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Dr.Hernandezencouragedtheuseofnewmetricsthatprovidemorerobustinformationon CoD ascertainment and CSMF estimation, and that are less sensitive to the causecomposition of the test sample. Chance‐corrected concordance across causes wasexplainedandrecommended forassessinghowwellamethoddoesat individualCoDassignment.FortheevaluationofCSMFestimation,CSMFaccuracywasproposedasameasure independentof thenumberofcauses.Medianchance‐correctedconcordancevalues using Tariff as compared to physician certified VA (PCVA) including andexcludinghealthcareexperience(HCE)wereshown.TheTariffmethodscoredhigherchance‐corrected concordance values than the PCVA for adult and neonatal deaths.PCVA scored higher chance‐corrected concordance values for child deaths. Anotherinteresting point was that the performance of both methods was similar with theinclusionofHCE,buttheefficacyofthePCVAexcludingHCEdecreasedsignificantlyincomparisontotheTariffwithoutHCE.TheitemreductionprocessbasedontheTariffMethodconsistedof:

1. SelectingitemstobedroppedbasedonTariffscore;2. AssigningCoDbasedonTariffmethod;and3. Assessing performance based on chance‐corrected concordance and CSMF

accuracy.Dr. Hernandez showed the results of the progressive reduction of symptom‐relatedquestions from 100 to 20 in adults without HCE information, and the reduction ofsymptom‐relatedquestionsfrom60to50inneonateswithHCEinput.HealsoshowedthattheperformanceoftheVAinstrumentdecreaseswiththenumberofquestions.Heconcluded that good performance levels could be achieved by using shorter VAinstrumentswithincertainlimits.Datapresentedshowedthatforadults,reducediteminstruments performed better than a complete version of the PCVA questionnaire,althoughnotaswellasPCVAwithHCE.Forchildren,overallperformancewas lower,althoughremovingupto22%ofitemsstillachievedbetterperformancethancompletePCVAordeathcertificates.The presentation concluded with Dr. Hernandez highlighting the contribution andusefulness that shorter VA instruments can have, and stressing the tension betweenquality,resourcesandcoverageduringtheitemreductionprocess.Discussion

Criteria for dropping specific items during the item‐reduction process and theexternalvalidityofthemethodwereaddressed.

TheaverageTariffscoremaycompromisespecific itemsthatare important forspecificCoDbutnotforfrequentCoD.

Proposed simplified causes of death and verbal autopsy questions Dr.ChandramohanpresentedandexplainedtheprocessusedtoreduceandsimplifytheCoDandthequestionnairestodevelopashorterversionoftheWHOVAinstrument.Insummary, the simplification of the CoD list (starting from the first WHO VA reviewmeeting)wasbasedonthefollowing:

FeasibilityofCoDforVAcertification;

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– Physicianreviewstudies– InterVAstudies– PHMRCVAgoldstandardstudies

Publichealthimportance;– Expertopinion– GBDestimates

Therevisionandsimplificationofthequestionnairesofthe2007WHOVAinstrumentwasbasedonthefollowing:

RelevanceofquestionsfordiagnosingCoDincludedinthereducedWHOVACoDlist;

– InclusioninInterVA– InclusioninPHMRCVAquestionnaires– ExpertopinionofphysicianswhohavecertifiedcausesofdeathfromVA

Likelihood that the item will be recognized, recollected and reported in VAinterviews;

– Expertopinion– FieldexperienceofVAusers

AsummaryoftheworkconductedonthesimplificationoftheWHOVAinstrumentwaspresented (all details available in themeeting backgrounddocument2).WHOVACoDweremappedagainstCoDfromInterVAandPHMRCVAinstrumentsandGBD,andtheproportionofWHOVACoDthathavesofarbeenreportedinpublishedVAstudieswerealsopresented.Datashowedthatcausesofdeathinitiallyremovedfromthe2007WHOVACoD listhaverarelybeenreported inpublishedstudies; themajorityare includedneither in theGBD, nor in InterVA, nor in thePHMRCVA instrument, supporting thedecisiontoremovethesecauses.FromtheCoDcurrentlyincludedintheWHOVACoDlist,thefollowingwerethetopmostreportedbyVAstudies:

1. Cardiovasculardiseases2. Diarrhoealdiseases3. Neoplasms,unspecified4. Pneumonia5. Unspecifiedevent,undeterminedintent6. Tuberculosis7. Malaria8. Prematurity9. Congenitalmalformation10. HIV/AIDS‐relateddeath

Incontrast,thetop10leastreportedCoDbyVAstudieshavebeen:

1. Typhoidandparatyphoid2. Oralneoplasms;

2 Leitao, JC., Chandramohan, D., Byass, P., Jakob, R. Revising and simplifying the WHO verbal autopsy instrument for routine cause-of-death monitoring. 2011.

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3. Pertussis4. Nutritionalandendocrinedisorders,unspecified5. Diseaseofcirculatorysystem,unspecified6. Ectopicpregnancy7. Mentaldisorder8. Anaemiaofpregnancy9. Ruptureduterus10. Tetanus

Dr.Chandramohanalsopresenteddatacomparingthe105itemsandtheirsubdivisionsfrom the reducedWHO VA instrument with the items from InterVA and PHMRC VAinstruments.PrintoutsofthepreparatoryworkpresentedbyDr.Chandramohanservedas basis for the revision of the CoD and questions to produce the simplified VAinstrument.

Summary discussion  The meeting agreed that item reduction of the VA instrument needs to maintain abalancebetweenthedesirabletimeofinterviewconduction(suggestionof15minutes)andtheperformanceoftheVAinstrument.Further,theimplementationinroutinesurveillanceshouldbeconsidered.Whendeathsare recorded in civil registration systems, there is no guarantee that the personwhoregistersthedeathandrespondstotheVAquestionnaireisthesamepersonwhotookcareofthedeceasedpersonandisfamiliarwithsignsandsymptomsprecedingdeath.Therearedifferentwaysofcollectinginformationinlowresourcesettings,forexamplethrough registrars of births and deaths, through local government administrators orthroughhealthcareoutreachorsocialworkers.Thus,theitemreductionprocessneedstoconsiderboththenumberofitemsandthecomplexityoftheitems.

Simplified Cause of Death List Asmallgroup(seeLoP)reviewedandmadethenecessarymodificationstothereducedCoD list, taking into account the preparatorywork, experience from PHMRCVA, andInterVA and the discussions held throughout the meeting for presentation to theplenaryontheseconddayofthemeeting.TheCoDwerereviewedbearinginmind:

TheimportanceandrelevanceofCoDforglobalmortalitylevels; TheCoDcanbeaddressedbypublichealthinterventions;and ThefeasibilityoftheCoDbeingascertainedthroughVA.

The outcomes of the small groupworkwere reviewed by the plenary, discussed andagreed.ThereviewedCoDandthereasonsfordropping,keepingandeditingarelistedbelow.

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Removedcausesofdeath:

1. TyphoidandparatyphoidTheascertainmentoftyphoidandparatyphoidasCoDwasconsideredtobenotfeasibleandunreliablethroughVA.

2. OtherdigestivediseaseRelevant lethal conditions affecting the digestive system are already covered bydiarrhoealdiseasesandCoDincludedinthecategoryofgastrointestinaldisorders.

3. ViralhepatitisViral hepatitis was dropped due to the difficulty in differentiating it from any otherconditionresulting in liver failure. Inaddition,viralhepatitishashada lowreportinglevelinpublishedVAstudies.

4. LeishmaniasisLeishmaniasisisarelevantcauseofillnessinsomeregions,asforpartsofIndiathecutaneousleishmaniasis,butitisrareatthegloballevel.Further,visceralleishmaniasisisverydifficulttodifferentiatefromotherdiseasesviaVA.ForthesereasonsthisCoDwasremovedfromtheCoDlist.

5. Non‐communicableacuterespiratorydisease6. Non‐communicablechronicrespiratorydisease

ThesetwoCoDweredroppedfromtheCoDlistbecausetheyarenot feasible throughVA. The only relevant CoD that are reliably derivable through VA are chronicobstructivepulmonarydisease(COPD)andasthma.

7. MentaldisordersThere was strong agreement among participants that mental disorders cannot befeasiblyandreliablyderivedthroughVA.

8. DiseasesofnervoussystemThemeeting concurred that it was not possible to feasibly ascertain diseases of thenervoussystemthroughVA.Retainedandaddedcausesofdeath:

Infectious and parasitic diseases 1.HIV/AIDSrelateddeath2.Measles3.Tetanus The above CoD were retained due to their significant contribution to mortality, their feasible ascertainment via VA and the existing public health strategies for their containment.   4.Acuterespiratoryinfection,includingpneumonia

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Theseconditionsweregrouped,asitisdifficulttodifferentiatebetweenthemthroughVA.5.DiarrhealdiseasesAcuteandchronicdiarrhoeasweregrouped,asthepublichealthresponseisthesamefor both conditions. In addition, acute diarrhoea/gastroenteritis are likely lethalinfectiousdiseases,whereaschronicdiarrhoeaisasymptomofotherdiseases.6.PulmonarytuberculosisThe use of generic tuberculosis is not sufficiently defined, so it was modified topulmonarytuberculosis.7.PertussisAlthoughpertussiswasconsideredaconditiondifficulttodiagnosethroughVA,itwasretainedduetoitspublichealthimportance.8.HaemorrhagicfeverThis condition was added to the CoD list due to its relevance and easily identifiablesignsandsymptomsthroughVA.9.MalariaMalaria is notoriously difficult to identify through VA. Users of the VA instrumentshould be cautioned that the assignment of this CoD is dependent on local context(geographical and seasonal), due to significant differences inmalaria prevalence. Formore specific studies, further differentiation on the certainty of diagnosis could beadded(e.g.bloodsmear),butthesewouldnotbepartofthecoreVAinstrument.10.SepsisSepsis ismorerelevant forneonates. It is included in the infectiousdiseasescategoryduetoitscausation.AtthestageofCoDassignment,itisdifferentiatedbyagegroupandmaternal circumstances. The VA instrument collects the necessary information fordiscriminationoftheagegroupsandrelevantcircumstances.11.MeningitisandencephalitisDifferentiatingbetweenmeningitisandencephalitisisverydifficultthroughVA,andsothetwoconditionsweregrouped.12.OtherandunspecifiedinfectiousdiseaseThisresidualcategoryaccommodatesallCoDthatsymptomsandsingscollectedbyVAindicateaninfectiousoriginbutit isnotpossibletoattainfurtherdifferentiation.ThisCoDhasbeenhighlyreportedinthefieldbypublishedVAstudies.13.Otherandunspecifiednon‐communicablediseaseThisgeneralcategoryaccommodatesCoDthatcannotbeassignedaspecificcause,andthatsignsandsymptomsindicateanon‐communicableaetiology.Alcoholinducedconditionswouldbeclassifiedasaccidentalpoisoningandexposuretonoxious substance in the external causes of death category. Aetiological linkagebetweentheidentifiedCoDandchronicexposuretosomeriskfactors(e.g.alcoholandtobacco)wouldbedifficult.Specificquestionscouldaddresstheseriskfactors,butthe

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meetingdiscussedthattherateoftruepositivesattainedwiththeseindicatorsindicatethattheyarenotreliable.

Neoplasms 14.Oralneoplasms15.Digestiveneoplasms16.Respiratoryneoplasms17.Breastneoplasms18.Femalereproductiveneoplasms19.Malereproductiveneoplasms20.OtherandunspecifiedneoplasmsMeetingparticipantsagreedthat itwaspreferable tomaintain thebroadgroupingsofneoplasms by organ system, because the specific neoplasms (e.g. oesophageal andcolorectal cancer) cannot be differentiated by their symptomatic presentation andespeciallybythequestionsincludedinVA.Anexceptionwherefurtherdifferentiationwasagreedwasforreproductiveneoplasms,whereitwasdecidedtohaveadistinctionbetweenfemalereproductiveneoplasmsandmalereproductiveneoplasms.AresidualcategoryofotherandunspecificneoplasmswasaddedtoaccommodateallneoplasmswherefurtherspecificationisnotpossibleviaVA.

Nutritional and endocrine disorders 21.DiabetesmellitusItwasdecidedthatdiabeteswastoberenamedtodiabetesmellitus.22.SevereanaemiaCoDwasretainedduetoitspublichealthrelevanceandfeasiblederivationthroughVA. 23.SeveremalnutritionDifferentiationofseveremalnutritionintoinacuteandchronicwasdiscussedinviewoftheimportantroleinco‐morbidity.However,thelatterisnotidentifiablethroughVA.

Diseases of the circulatory system 24.SicklecellwithcrisisMeetingagreedthathaemoglobinopathywastoberenamedtosicklecellwithcrisis.25.StrokeParticipantsagreedthatstrokewasamoreappropriate term, lesstechnicalandmoreconcisethancerebrovasculardisease. 26.AcutecardiacdiseaseAcutecardiacdiseasemainlyreferstoischemicheartdisease/myocardialinfarction.ItwasagreedthathavingamoregeneralCoDwouldbeabetterrepresentationofother

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less common acute cardiac diseases that cannot be differentiated by their signs andsymptomsinVA.27.OtherandunspecifiedcardiacdiseaseThisresidualcategorywasadded toaccount forotherandunspecifiedcardiovasculardiseases.

Respiratory disorders 28.Chronicobstructivepulmonarydisease(COPD)29.Asthma TheseCoDwereaddedtothelistduetotheirpublichealthrelevanceandtheirfeasibleascertainmentthroughVA.

Gastrointestinal disorders 30.AcuteabdomenAcute abdomenwas thought to be a better‐suited term for the condition than acuteabdominalcondition.31.LivercirrhosisChronicliverdisorderwasrenamedtolivercirrhosis,asthisistheconditionthatcanbediagnosedbyVA.

Renal disorders 32.RenalfailureDiseaseofthekidneywaschangedintorenalfailure,asthisistheonlyCoDthatcanbeaddressedbyVA.InplenaryitwasdiscussedwhethertoaddnephrolithiasistotheCoDlist. ArgumentsincludedthatthisisaCoDspecifictocertaingeographicallocations,andwouldnotbeeasily diagnosed through VA. To ascertain this CoD, a set of additional specific pain‐related questions that are difficult to ask would need to be added to the VAquestionnaire.Asaresult,itwasagreedthatthisconditionshouldnotbeaddedtotheinternationalcoresimplifiedVAinstrument.

Mental and nervous system disorders 33.EpilepsyIt was agreed that epilepsy is the only neurological condition that can be reliablyidentifiedviaVA.ThemeetingparticipantsdiscussedifdementiashouldbeaddedtotheCoDlist.Theargumentsproandconincluded:

Dementia is an increasingly frequent condition and is of public healthimportance;

Peoplewithdementiadonotusuallydieofdementia;

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As abehavioural disorder itwouldbe verydifficult to be ascertained throughVA;

Dementiaisaconditionaffectingtheovertheageof60,andfewVAstudieshavebeenconductedonelderly,sofar;and

InthePHMRCgoldstandarddataset, from13000casestheVAinstrumentonlyidentified1caseofdementia.

ThemeetingrecommendedaddingaquestionaboutdementiatotheVAinstrument,butit was agreed that dementia should not be added as a CoD to this version of thesimplifiedWHOVAinstrument.Outcomesoffurtherresearchmayallowrevisitingthatdecision in the following years. Another CoD pondered to be added to the list wasAlzheimerdueto its importance,butduetothedifficulty in its identificationviaVAitwasnotincludedintheCoDlist.

Pregnancy‐, childbirth and puerperium‐related disorders 34.Ectopicpregnancy35.Abortion‐relateddeath36.Pregnancy‐inducedhypertension37.Obstetrichaemorrhage38.Obstructedlabour39.Pregnancy‐relatedsepsis40.Anaemiaofpregnancy41.Ruptureduterus42.OtherandunspecifiedmaternalcauseNochangewasdonetothepreviouslyagreedreducedCoDlistapartfromtheinclusionofotherandunspecifiedmaternalcausetoaccountformaternity‐relatedcausesthatVAcannotspecify.Afteradiscussionontherelationshipbetweenprolongedandobstructedlabour,itwasdecidedtokeepthecurrentscheme.The matrix of events and sequences and the reporting was considered asheterogeneous. Usuallydeath is causedby sepsis andhaemorrhage. No informationwasavailableaboutthereliabilityofprolongedlabourreporting.Prolapsed chord is not reliably reported, and would also be reported rather as aperinatalcondition.Differentiationofhaemorrhagebetweenpost‐andpre‐partumwasconsideredrelevantfor treatment, but less for public health decisions and was therefore consideredunnecessaryforVApurposes.Concerns were raised over the reliability of differentiating ectopic pregnancies fromotherabdominalconditions,buttheCoDwaskeptduetoitspublichealthimportance.

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Perinatal causes of death 43.Neonataltetanus44.Prematurity45.Perinatalasphyxia46.Neonatalpneumonia47.Neonatalsepsis48.Congenitalmalformation49.OtherandunspecifiedperinatalcauseofdeathInthissection,allCoDpreviouslyagreedonthe1stWHOreviewmeetingwereretained.DiscussionswereheldoversubdividingprematurityintofurtherclassificationsasconductedinPHMRCCoDlist(Annex4).PHMRCclassificationassociatesprematuritywithrespiratorydistresssyndrome,birthasphyxiaandsepsis.Althoughthepublichealthimportanceofmakingthesedifferentiationswasrecognized,astheobjectivewastosimplifytheVAinstrumentandastheCoDlistalreadyindividuallycoverstheseCoD,itwasdecidedtoretainprematurity.Otherdiscussionswereheldoverperinatalasphyxia,withsomeparticipantsarguingthatperinatalasphyxiaisnotaCoDpersebutitconsistsinsteadofaCoDmechanism.ConsensuswasachievedthatperinatalasphyxiawouldremainasaperinatalCoD.ConcernswereraisedovertheVAfeasibilityofascertainingneonatalpneumoniaanddifferentiatingitfromrespiratorydisorders.UntiltheVAinstrumentisvalidatedandfieldinformationcollectedonreliabilityofVAtoascertainneonatalpneumonia,theparticipantsagreedtoprovisionallyretainneonatalpneumoniaasthetimingofonsetofsymptomsenablesthedistinctionbetweentheseCoD.

Stillbirths 50.Freshstillbirth51.MaceratedstillbirthTheconceptof“stillbirth”(separatedintofreshandmaceratedstillbirths)hasbeenincludedintheoverallcause‐of‐deathlistfortheWHOVAtool,eventhoughstillbirthisnotnormallyconsideredasacause‐of‐death.ThisdoesnotimplythatdataforstillbirthswillnecessarilybeincludedinallseriesofVAs,nordoesitmeanthat,wherestillbirthsareincludedinVAdata,theyshouldbeanalysedtogetherwithothercauses.Togathermorein‐depthinformationonthetimingoffoetaldeathandpossibleprenatalinterventions,itwasdecidedthatitisimportanttodifferentiatefreshfrommaceratedstillbirthsastheseserveasakeyproxyfordiagnosis.Freshstillbirthsarethoseoccurringaftertheonsetoflabour(withskinstillintact,implyingdeathoccurredlessthan12hoursbeforedelivery)weighingmorethan1,000gramsandmorethan28weeksofgestation,butexcludeseverelethalcongenitalabnormalities.Maceratedstillbirthistheintrauterinedeathofafetussometimebeforetheonsetoflabor,wherethefetusshoweddegenerativechanges..Stillbirthsarenotcountedinneonatalorinfantmortalityrates.However,theincidenceoffreshstillbirthsisanimportantindicatorofobstetricoutcomes,andinsomesettingstherearelikelytobegoodreasonsfortrackingnumbersoffreshandmaceratedstillbirths.Furthermore,theindicatorsusedintheWHOVAtooltoidentifystillbirthsarealsoimportantfordiscriminating

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betweenfreshstillbirthsandbabieswhodiewithinaveryshorttimeafterbirth.Althoughthetermsfreshandmaceratedwereprovisionallyaccepted,itwassuggestedthattheuseofthesetermsshouldberevised.Inaddition,itwassuggestedthatthepercentageofreportedasphyxiashouldbeverifiedintheliterature.

External causes 52.Roadtrafficaccident53.Othertransportaccident54.Accidentalfall55.Accidentaldrowningandsubmersion56.Accidentalexposuretosmoke,fireandflames57.Contactwithvenomousanimalsandplants58.Exposuretoforceofnature59.Accidentalpoisoningandexposuretonoxioussubstance60.Intentionalself‐harm61.Assault62.OtherandunspecifiedexternalcauseofdeathTheonlychangemadetothethisgroupofCoDwasthegroupingofthecausesotherandunspecified event, undetermined intent with unspecified event, undetermined intentintothecauseotherandunspecifiedexternalcauseofdeath.TheCoDwerethoughttoalignwellwiththequestionsthatcorrectlyaddressthecircumstancesleadingtodeathandallowaneasyCoDcertification.Annex3presentstheoutcomesoftherevisionprocessoftheWHOVACoDlist.Annex4shows the correlation of the CoD from theWHO 2007 instrument with the reducedWHOVACoD,InterVACoD,PHMRCVACoDandGBD.CodesforconversiontoICDhavebeenattributedtoCoD,whereascodesetsformappingfromICDtotheVAinstrumentneedtobeadded.Table1showstheoutcomeofthereviewprocessoftheWHOVACoDlist and the number of CoD from the cause lists of the other VA instruments. Theoutcomes of themeeting resulted approximately in a 9% reduction of the number ofCoD from the reduced WHO VA CoD list (generated from the 1st WHO VA reviewmeeting).Overall,thereviewprocesshasledapproximatelytoa42%reductioninthenumberofCoDfromthe2007WHOVACoDlist,resultinginasimplifiedlistof62CoD.Table1‐Numberofcausesofdeathbyverbalautopsyinstrument.

2007WHOVACoDlist

ReducedWHOVACoDlist

SimplifiedWHOVACoDlist

InterVACoDlist3

PHMRCVAinstrumentCoDlist

TotalNumberofCauses‐of‐Death

106 68 63 48 51

3 InterVAlist includes information from the InterVA-3 and InterVA-M models

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Simplified questionnaire AreducedquestionnairewaspreparedprevioustothemeetingbasedontheWHO2007VA instrument,with indicators’ reduction informed by the reduced list of conditions,PHMRC VA instrument, InterVA indicators and VA studies. However, the availableevidenceon relevanceof specificquestions frompublishedVAstudies is very limited(backgrounddocument4).Thiswasconfirmedbythepresentationsandinthefollowingdiscussions.Toreviewtheproposedsimplifiedquestionnaire, themeetingparticipantssplit into4groups(adult,children,neonatal,maternal)andreviewedthequestionnairesbearinginmind:

TheagreedsimplifiedlistofCoD; Thereliabilityofanswersattainedfromquestions; TheoutcomesofitemreductionobtainedwiththeTariffmethod;and TheroutinefeasibilityoftheVAinstrument.

Summaryfeedbackfromthefourreviewgroups:

Thevalidityoftime‐relatedquestionsdependsoncut‐offtimes; Throughopen‐endedquestions,thequestionnairewouldallowtheenteringand

storing of continuous variables. The instrument would then carry out thedichotomizationaccordingtocut‐offpoints.Thisapproachfacilitatesthetestingand changing of threshold values without compromising the data collectionprocess;

Modificationsmadeincludedtheremovalofoverlappingindicatorscapturingthesameinformation,andsomechangesinterminology;

The majority of questions removed were sub‐indicators specifying duration,severityanddevelopmentformofsignsandsymptoms;

From the review of the outcomes of the Tariff item reduction exercise it wasverified that some of the duration‐related indicators are needed to qualifycertainindicators,eveniftheyarenotveryrelevantbythemselves;

The proposed background social questionswere found to be too complex andunreliable. Itwas agreed that further investigation and assessment of these isrequiredbeforeagreeingonacoresetofbackgroundsocialquestions;

As a next step, indicators need to be phrased into answerable questions, andhaveclearexplanationsfortheinterviewersandtranslators.

Thedetailedoutcomes of the group reviews and the discussionsduring the feedbacksession were consolidated in a two day workshop with a sub group of participantsfollowing the main meeting. Rationales for retaining, removing or editing a specificindicatorare included inAnnex5, togetherwith theexistenceof that indicator in therelevantsoftwareassistingdiagnosinginstruments,InterVAandPHMRC.

4 Leitao, JC., Chandramohan, D., Byass, P., Jakob, R. Revising and simplifying the WHO verbal autopsy instrument for routine cause-of-death monitoring. 2011.

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The revised instrument has a total of 221 items (questions) that are subdivided in 4sectionswithatotalof93causeofdeathrelatedstemquestionsthathavetobeaskedand87sub‐questions (31sub‐sub‐questionsand104th levelquestions). Asa result,themaximumnumber of questions to be answered by a respondent ranges between101foraneonataldeathand130forawomanatreproductiveage.

Implementation and  IT  Issues: Applying probabilistic model of VA for Surveillance and Response Dr. Sennen Hounton addressed the opportunities and challenges associatedwith theimplementationofprobabilisticVAmodel,throughIT,inroutinesurveillancecontexts.Inroutinesurveillancecontexts,informationneedstobetimelylinkedtoactionandtoaresponse thatwill involve disseminationmechanisms, an assured use of surveillancedataandanevaluationofthesurveillancesystem.ThelattercanoriginatearevisionofthecorecomponentsandoperationmechanismsoftheVAsysteminplace.Thus,useofVA in routine surveillance context implies monitoring, accountability, planning andprogramming.Dr.Hountonpinpointedsomeofthebarriersandfacilitatorsthatneedtobeconsideredwhen implementing probabilistic VAmodels via IT. In regards to the interviewer thefollowingissueswerehighlighted:

Training; Supervision; Sensitivity; Recruitment; Salaries;and Supportmaterials.

Someaspectsoftheprocessdependonthelocalcultureandcontextsuchasthe:

Notificationofdeaths; Mourningperiods; Dissolutionofhouseholdsfollowingadeath;and PossiblestigmasurroundingsomedeathssuchasHIV/AIDSandsuicide.

Todevelop an adequate instrument for application in large‐scale surveillance, theVAinstrument needs to be tested, piloted and have a system in place that is synergizedwiththenationalhealthsystem.ThepresentationconcludedwiththeexampleofapilotstudyconductedinMaliforthesurveillance ofmaternalmortality. Other countries for piloting of the VA instrumentincludeBenin,BurkinaFaso,Mali,SierraLeoneandMadagascar.ParticipantswerealsoinformedthatthenextstepwillinvolvethepilotofInterVA.Discussion

Dependingonthecountry,districthealthofficersandsurveillanceofficersmaybe available for VA. CHWswere considered to have a highworkload from the

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national health system, and employing them as interviewers can overburdenthem.InthespecificcaseofGhana,nursesweresuggestedasagoodalternativefortheadministrationofVA;

The optimal workload for VA interviewers was discussed. The minimal levelproposedwas theconductionof1‐2VAper interviewerpermonth inorder toretainagoodtraininglevel;

ThebackboneoftheimplementationoftheroutineVAinstrumentshouldbethelocalbirthanddeathregistrationsystem;

AsanincentiveforVAinterviewers,theirnamescouldbeincludedonreportsorstudies’forpublicationsusingdatacollected.

Closure Themeetingaccomplisheditsobjectivesandparticipantsappreciatedtheoutcomesofthemeeting. The experiences and evidence shared on the use of VA instruments incommunitysettingswereefficientlyusedtoreviewtheWHOVAinstrument.TheWHOVACoDandindicatorswerereviewedandasimplifiedCoDlistandVAindicatorsweredeveloped with consensus achieved among participants on their adequacy andsuitability for application in routine surveillance contexts. Dr. Boerma thanked thecommitmentandcontributionofalltheparticipants.Themeetingclosedwithadiscussionandformulationofrecommendationsforthenextsteps for the simplified VA instrument’s development, validation, utilization andimplementation.

The agreed set ofVA indicatorswouldbeoncemore reviewed for consistencyafterbeingconsolidatedfollowingtheworkshopafterthismeeting;

The agreed VA indicators should be converted into clearly defined andstraightforward questions, with short descriptions informing translators andinterviewers;and

Thailand,Bangladesh,GhanaandthePhilippineswereproposedassitesforthevalidationofthenewagreedsimplifiedVAinstrument.

 

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Annex 1: List of participants 

ReviewoftheWHOVerbalAutopsy(VA)InstrumentsWorldHealthOrganization(WHO),Geneva,Switzerland

19‐20December2011;

ListofParticipants

DrCarlaAbou‐Zahr6chemindesFins1218GenevaSwitzlernadcarla.abouzahr@gmail.comDrKanittaBundhamcharoenThailandMinistryofPublicHealthInternationalHealthPolicyProgramNonthaburiThailandTel.:+6625902383Mob.:+66814008158kanitta@ihpp.thaigov.netDrPeterByass+!ProfessorofGlobalHealthDirectorUmeaCentreforGlobalHealthUmeaSwedenTel:+46907853345peter.byass@epiph.umu.seDrDanielChandramohan+!DiseaseControlandVectorBiologyLondonSchoolofHygiene&TropicalMedicineKeppelStreetLondonWCIE7HTUKDaniel.Chandramohan@lshtm.ac.ukDrChanpenChoprapawonSeniorAdvisor,HealthInformationSectionHealthPolicyandStrategicBureauOfficeofthePermanentSecretaryMinistryofPublicHealthNonthaburiThailand

Tel:+66818273634cchopra2004@gmail.comDrDondeSavigny*DirectorEpidemiology,PublicHealthandHealthSystemsSwissTropicalandPublicHealthInstituteSocinstr.574051BaselTel:+41612848160D.deSavigny@unibas.chDrEdwardFottrell+UCLCentreforInternationalHealthandDevelopmentInstituteofChildHealth30GuilfordStreetLondonWC1N1EHUKTel:+44(0)2079052203&UmeåCentreforGlobalHealthResearchUmeåUniversity90185UmeåSwedenTel:+46907851079e.fottrell@ucl.ac.ukProfessorElizabethFrançaPublicHealthandResearchGroupinEpidemiology&HealthEvaluationFacultyofMedicineFederalUniversityofMinasGeraisAv.AlfredoBalena,190BeloHorizonte,30130‐100BrazilMob:+553198223248efranca@medicina.ufmg.br

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DrFrederikFrøenDepartmentDirectorDeptofGenesandEnvironmentDivisionofEpidemiologyNorwegianInstituteofPublicHealthP.O.Box4404‐Nydalen0403OsloNorwayTel:+4721078194Mob:+4792493435E‐mail:frederik.froen@fhi.noProfessorGihanGewaifelFacultyofMedicineUniversityofAlexandriaAlexandriaEgyptEmail:ggewaifel@yahoo.comDrBernardoHernandez!InstituteforHealthMetricsandEvaluation(IHME)UniversityofWashingtonUSADrAbrahamHodgson+!DirectorofResearchGhanaHealthServiceAccraGhanaTel:+233244577665Abraham.hodgson@ghsmail.orgDrSennenHounton+PopulationExpertUNFPAHeadquartersNewYorkUSATel:+12122972706Mob:+16464284214hounton@unfpa.orgDrKathleenKahn+!HealthandPopulationDivision,SchoolofPublicHealthUniversityoftheWitwatersrandJohannesburgSouthAfricakathleen.kahn@wits.ac.za

DrAnandKrishnan+CentreforCommunityMedicineAllIndiaInstituteofMedicalSciencesAnsariNagarNewDelhi110029IndiaTel:+911126594253kanandiyer@yahoo.comDrVishwajeetKumarCenterforMaternal,NeonatalandChildHealthHabitatforGlobalHealthShivgarhUttarPradeshIndiavishwajeet.kumar@shivgarh.orgDrJordanaLeitao!19HighburyQuadrantLondonN52THUKleitaojordana@gmail.comDrAlanLopezHead,SchoolofPopulationHealthProfessorofGlobalHealthTheUniversityofQueenslandLevel2,PublicHealthBuildingHerstonRoad,Herston,Qld4006AustraliaPhone:+61733655590Mobile:0400115231a.lopez@sph.uq.edu.auProfessorRafaelLozano*ProfessorofGlobalHealthInstituteforHealthMetricsandEvaluation(IHME)UniversityofWashingtonUSArlozano@uw.eduDrHonoratiMasanjaIfakaraHealthInstituteP.O.Box78373DaresSalaamTanzaniaTel:+255222774756Mob:+255784605046hmasanja@ihi.or.tzDrLeneMikkelsenUniversityofQueensland

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BrisbaneQLD4072Australial.mikkelsen@sph.uq.edu.auDrCarlosNavarro‐ColoradoInternationalEmergencyandRefugeeHealthBranchCentersforDiseaseControlandPrevention(CDC)Jgx4@cdc.govDrMohammadHafizRasooly*TechnicalAdvisorAfghanPublicHealthInstitute(APHI)MinistryofPublicHealthKabulAfghanistandochafez@yahoo.comProfessorIanRiley!ProfessorofMedicalStatisticsandPopulationHealthTheUniversityofQueenslandHerstonRoadHerstonQLD4006Australiai.riley@sph.uq.edu.auDrOsmanSankohExecutiveDirector,INDEPTHNetworkInt.INDEPTHNetworkSecretariat11MensahWoodStreetEastLegon,AccraP.O.BoxKD213Kanda,AccraGhanaosman.sankoh@indepth‐network.orgDrPaulSpiegel*UNHCRChief,PublicHealthandHIVSection,DPSM,UNHCR94RuedeMontbrillant1211GenevaSwitzerlandTel:+41227398289www.unhcr.org/health

WHORegionsAFRO,DrDeregeKebedeAFRO,DrWilliamSoumbeyAlleyAMRO,DrFatimaMarinhoEMRO,DrMohamedAli*EURO,DrEnriqueLoyola*SEARO,DrJyotsnaChikersalWPRO,DrJunGao*HQDrGiuseppeAnnunziata*,ERMDrRajivBahl,RHR*DrKidistBartolomeus*,VIPDrTiesBoerma,HSIDrDorisChou,RHRDrLuluMuhe+,CAHDrRobertJakob+!,HISDrMatthewsMathai,CAHDrBedirhanUstun,HSIHMN:DrMarcAmexo+

*Unabletoattend+Workshop21‐22December!CoDsmallreviewgroup

Annex 2: Agenda 

ReviewoftheWHOVerbalAutopsyInstrumentsWHO and HMN, in collaboration with INDEPH and UQ

19‐20 December, Geneva

Salle G

AgendaDay1,19DecemberSession1

Settingthestage Moderator:JaneThomason

9:00‐9:30 Welcome,introductionsandobjectives

AlanLopez(UQ),OsmanSankoh(INDEPTH),TiesBoerma(WHO)

Session2

GeneralprogressVA Moderator:CarlaAbou‐Zahr

9:30‐10:00 MoVE‐IT MarkAmexo(HMN)10:00‐10:30 WHOVerbalautopsyinstrument

usesDanielChandramohan,JordanaLeitao(LSHTM)

10:30‐11:00 Coffeebreak11:00‐11:30 Inter‐VAneedsand

INDEPTH/ALPHAmeetingoutcomes

PeterByass(Univ.Umea)

11:30‐12:00 GC13causeofdeathwork AlanLopez(UQ)12:00‐12:30 Discussion12:30‐13:30 LunchbreakSession3

VAItemreduction Moderator:AlanLopez

13:30‐13:45 Thailandexperience KanittaBundhamcharoen(ThailandMoH)

13:45‐14:00 VAtoolexperiencewithafocusonmaternal,neonatalandchildhealth

VishvajeetKumar(Centreofmaternal,neonatalandchildhealth,UttarPradesh)

14:15‐14:30 Brazilexperience ElizabethFrança(UniversityMinasGerais)

14:30‐14:45 Afghanistanexperienceinnationalsurvey

HafezRasooly(InstituteofPublicHealth)

14:45‐15:00 ItemreductionfromINDEPTHsites

OsmanSankohandPeterByass

15:00‐15:15 MeasuringreductioninperformanceforVAusingitemreductionmethods

RafaelLozano(IHME)

15:15‐15:30 Discussion15:30‐16:00 Coffeebreak

33

16:00‐16:30 Presentationofthesummaryofproposededitstothesimplifiedtool

Chandramohan/Byass/Jakob

16:30‐17:30 Discussion

Day2,20DecemberSession4

Reviewingroups Moderator:OsmanSankoh

9:00‐9:30 Summaryoffirstday‐ keyissues,discussion

CarlaAbou‐Zahr

9:30‐10:30 Introductiontothegroups&groupwork

RobertJakob

10:30‐1:30 Coffeebreak11:00‐12:00 Groupworkcontinued12:00‐12:30 Groupreportsanddiscussion12:30‐14:00 LunchbreakSession5

VAItemreduction Moderator:TiesBoerma

14:00‐14:30 Presentationoftheeditedtool Chandramohan/Byass/Jakob14:30‐15:00 Discussion15:00‐15:30 ImplementationandITissues DondeSavigny(Swiss

TropicalInstitute)SennenHounton(UNFPA)

15:30 NextstepsandclosureDay3and4WorkshopReviewoftheinputfromthereviewgroupsandconsolidationoftheresultsAssessmentofnewcausesagainstindicatorsandprobabilities

Annex 3: Review process and outcomes of the WHO verbal autopsy cause of death list. 

2007WHOVACoDList ReducedWHOVACoDList Action FinalreviewedsimplifiedWHOVACoDList

InfectiousandparasiticdiseasesInfluenza/Influenza Acuterespiratoryinfection

CombinedAcuterespiratoryinfectionincludingpneumonia

Acutelowerrespiratoryinfections(includingpneumoniaandacutebronchitis)

Pneumonia

Sepsis Retained SepsisHIV/AIDS HIV/AIDSrelateddeath Retained HIV/AIDSrelateddeath

Intestinalinfectiousdiseases(includingdiarrhoealdiseases)

BloodydiarrhoeaCombined Diarrhoealdiseases

Non‐bloodydiarrhoea Otherdigestivedisease Dropped Malaria Malaria Retained MalariaMeasles Measles Retained MeaslesMeningitis Meningitis Retained MeningitisandEncephalitisTetanus(excludingtetanusneonatorum)

Tetanus Retained Tetanus

Tuberculosis Pulmonarytuberculosis Terminologychange Pulmonarytuberculosis

TyphoidandParatyphoid TyphoidandParatyphoid Dropped Pertussis(whoopingcough) Pertussis Retained Pertussis

37

2007WHOVACoDList ReducedWHOVACoDList Action FinalreviewedsimplifiedWHOVACoDList

Arthropod‐borneviralfeversandviralhaemorrhagicfevers Added Haemorrhagicfever

Viralhepatitis Viralhepatitis Dropped Leishmaniasis Leishmaniasis Dropped Otherspecifiedinfectiousandparasiticdiseases Otheracuteinfection

CombinedOtherandunspecifiedinfectiousdisease

Infectiousdiseases,unspecified Otherchronicinfection

AddedOtherandunspecifiednon‐communicabledisease

Neoplasms

Malignantneoplasmoflip,oralcavityandpharynx Oralneoplasms Retained Oralneoplasms

Malignantneoplasmofoesophagus

Digestiveneoplasms Retained Digestiveneoplasms

MalignantneoplasmofstomachMalignantneoplasmofsmallandlargeintestineMalignantneoplasmofliverandhepaticductMalignantneoplasmofrectumandanusMalignantneoplasmoftrachea,bronchusandlung

Respiratoryneoplasms Retained Respiratoryneoplasms

Malignantneoplasmofbreast Breastneoplasms Retained Breastneoplasms

38

2007WHOVACoDList ReducedWHOVACoDList Action FinalreviewedsimplifiedWHOVACoDList

Malignantneoplasmofcervix

Neoplasmsofreproductivetract Subdivided

FemalereproductiveneoplasmsMalignantneoplasmofuterus(excludingcervix)MalignantneoplasmofovariesMalignantneoplasmofprostate MalereproductiveneoplasmsMalignantmelanomaofskin

Malignantneoplasmoflymphoid,haematopoieticandrelatedtissue

Otherspecifiedneoplasms Neoplasmofuncertainorunknownbehaviour,unspecified

Neoplasms,unspecified Terminologychange

Otherandunspecifiedneoplasms

NutritionalandendocrinedisordersNutritionalanaemia Severeanaemia Retained Severeanaemia

Severemalnutrition Severeacutemalnutrition Terminologychange Severemalnutrition

Diabetesmellitus DiabetesTerminologychange Diabetesmellitus

Otherspecifiedendocrinedisorders

Endocrinedisorders,unspecified Othernutritionalandendocrinedisorders

Diseasesofthecirculatorysystem

39

2007WHOVACoDList ReducedWHOVACoDList Action FinalreviewedsimplifiedWHOVACoDList

Otherspecifieddiseasesofcirculatorysystem Acutecardiacdisease Retained Acutecardiacdisease

Ischaemicheartdisease

HaemoglobinopathyTerminologychange Sicklecellwithcrisis

Cerebrovasculardisease Cerebrovasculardisease Terminologychange Stroke

Chronicrheumaticheartdiseases Chroniccardiacdisease Change Otherandunspecifiedcardiovasculardiseases

Congestiveheartfailure Hypertensivediseases Diseasesofcirculatorysystem,unspecified

Respiratorydisorders

Otherspecifieddiseasesoftherespiratorysystem

Non‐communicableacuterespiratorydisease

Dropped

Respiratorydisorder,unspecified Non‐communicablechronicrespiratorydisease Dropped

Chronicobstructivelungdisease Added COPD

Asthma Added AsthmaRespiratoryfailure,notelsewhereclassified

Gastrointestinaldisorders

40

2007WHOVACoDList ReducedWHOVACoDList Action FinalreviewedsimplifiedWHOVACoDList

Gastricandduodenalulcer

AcuteabdominalconditionTerminologychange Acuteabdomen

ParalyticileusandintestinalobstructionwithoutherniaPeritonitisHerniasAcuteabdomen

Chronicliverdisease ChronicliverdisorderTerminologychange

Livercirrhosis

Otherdiseasesofintestine

Diseaseofintestine,unspecified

RenaldisordersRenalfailure

DiseaseofthekidneyTerminologychange

RenalfailureOtherspecifiedrenaldisorders Disordersofkidneyandureter,unspecified

MentalandnervoussystemdisordersSpecifiedmentaldisorders Mentaldisorder Dropped Mentaldisorders,unspecified Otherspecifieddisordersofthenervoussystem

Diseaseofnervoussystem Dropped

Nervoussystemdisorders,nototherwiseclassified

Alzheimerdisease

41

2007WHOVACoDList ReducedWHOVACoDList Action FinalreviewedsimplifiedWHOVACoDList

Epilepsy Epilepsy/Acuteseizures Terminologychange Epilepsy

Pregnancy‐,childbirthandpuerperium‐relateddisordersEctopicpregnancy Ectopicpregnancy Retained EctopicpregnancySpontaneousabortion Abortion‐relateddeath Retained Abortion‐relateddeathMedicalabortion Otherandunspecifiedabortion Hypertensivedisordersofpregnancy

Pregnancy‐inducedhypertension Retained Pregnancy‐inducedhypertension

Antepartumhaemorrhage Obstetrichaemorrhage Retained ObstetrichaemorrhagePostpartumhaemorrhage Intrapartumhaemorrhage Obstructedlabour Obstructedlabour Retained ObstructedlabourPuerperalsepsis Pregnancy‐relatedsepsis Retained Pregnancy‐relatedsepsis Anaemiaofpregnancy Retained Anaemiaofpregnancy Ruptureduterus Retained RuptureduterusOtherspecifieddirectmaternalcauses

Otherdirectmaternalcauses,unspecified

Maternityrelateddeath,unspecified

Terminologychange

Otherandunspecifiedmaternalcause

PerinatalcausesofdeathTetanusneonatorum Neonataltetanus Retained NeonataltetanusPrematurity(includingrespiratorydistress)

Prematurity Retained Prematurity

42

2007WHOVACoDList ReducedWHOVACoDList Action FinalreviewedsimplifiedWHOVACoDList

Lowbirthweight Birthtrauma Perinatalasphyxia Retained PerinatalasphyxiaBirthasphyxiaandperinatalrespiratorydisorders

Neonatalpneumonia Neonatalpneumonia Retained NeonatalpneumoniaCongenitalviraldiseases Bacterialsepsisofnewborn NeonatalSepsis Retained NeonatalSepsisCongenitalmalformationsofthenervoussystem Congenitalmalformation Retained Congenitalmalformation

Congenitalmalformation,otherandunspecified

Stillbirths Otherspecifieddisordersrelatedtoperinatalperiod

Otherdiseasesrelatedtotheperinatalperiod,unspecified

Perinatalcauseofdeath,unspecified

Terminologychange

Otherandunspecifiedperinatalcauseofdeath

Stillbirths Stillbirths Added Freshstillbirths Added Maceratedstillbirths

ExternalcausesofdeathPedestrianinjuredintrafficaccident Roadtrafficaccident Retained Roadtrafficaccident

Othertransportaccident Othertransportaccident Retained OthertransportaccidentAccidentalfall Accidentalfall Retained Accidentalfall

43

2007WHOVACoDList ReducedWHOVACoDList Action FinalreviewedsimplifiedWHOVACoDList

Accidentaldrowningandsubmersion

Accidentaldrowningandsubmersion

RetainedAccidentaldrowningandsubmersion

Accidentalexposuretosmoke,fireandflames

Accidentalexposuretosmoke,fireandflames

Retained Accidentalexposuretosmoke,fireandflames

Contactwithvenomousanimalsandplants

Contactwithvenomousanimalsandplants Retained Contactwithvenomousanimals

andplantsExposuretoforceofnature Exposuretoforceofnature Retained Exposuretoforceofnature

Accidentalpoisoningandexposuretonoxioussubstance

Accidentalpoisoningandexposuretonoxioussubstance

Retained Accidentalpoisoningandexposuretonoxioussubstance

Lackoffoodand/orwater Intentionalself‐harm Intentionalself‐harm Retained Intentionalself‐harmAssault Assault Retained AssaultLegalintervention Accident,unspecified Otherspecifiedevent,undeterminedintent

Otherspecifiedevent,undeterminedintent

Combined

Unspecifiedevent,undeterminedintent

Unspecifiedevent,undeterminedintent

Otherandunspecifiedexternalcause

Annex 4: Mapping of CoD between WHO, InterVA and PHMRC VA instruments, reduced  

2007WHOVACoD InterVACoD ReducedWHOVACoD Globalburdenofdisease PHMRCVACoD

InfectiousandParasiticDiseases

Acutelowerrespiratoryinfections(includingpneumoniaandacutebronchitis)

Pneumonia/Sepsis

Acuterespiratoryinfectionincludingpneumonia

Lowerrespiratoryinfections Pneumonia

Sepsis Sepsis

Acuterespiratorydiseasenotpneumonia

Influenza/Influenza

HIV/AIDS HIV/AIDSrelateddeath HIV/AIDSrelateddeath HIV/AIDS AIDS

Intestinalinfectiousdiseases(includingdiarrhoealdiseases)

Bloodydiarrhoea BloodydiarrhoeaDiarrhoealdiseases

Diarrhoea/DysenteryNon‐bloodydiarrhoea Non‐bloodydiarrhoea

Otherdigestivedisease Otherdigestivedisease Otherdigestivediseases

Malaria Malaria Malaria Malaria MalariaMeasles Measles Measles Measles Measles

Meningitis Meningitis Meningitis Meningitis Meningitis

45

2007WHOVACoD InterVACoD ReducedWHOVACoD Globalburdenofdisease PHMRCVACoD

Encephalitis

Otherspecifiedinfectiousandparasiticdiseases

Otheracuteinfection Otheracuteinfection Otherinfectiousdiseases

Infectiousdiseases,unspecified Otherchronicinfection Otherchronicinfection

Tetanus(excludingtetanusneonatorum) Tetanus Tetanus

Tuberculosis Tuberculosis(pulmonary) Pulmonarytuberculosis Tuberculosis Tuberculosis

TyphoidandParatyphoid TyphoidandParatyphoid

Pertussis(whoopingcough) Pertussis Whoopingcough

Arthropod‐borneviralfeversandviralhaemorrhagicfevers Haemorrhagicfever

Viralhepatitis Viralhepatitis

Leishmaniasis Leishmaniasis

Neoplasms

46

2007WHOVACoD InterVACoD ReducedWHOVACoD Globalburdenofdisease PHMRCVACoD

Malignantneoplasmoflip,oralcavityandpharynx

Malignancy/Cancer

Oralneoplasms Mouthandoropharynxcancers

Malignantneoplasmofoesophagus

Digestiveneoplasms

Oesophagealcancer;stomachcancer

Malignantneoplasmofstomach StomachcancerMalignantneoplasmofsmallandlargeintestine

Malignantneoplasmofliverandhepaticduct

Malignantneoplasmofrectumandanus Colonandrectumcancers Colorectalcancer

Malignantneoplasmoftrachea,bronchusandlung Respiratoryneoplasms

Trachea,bronchus,lungcancers Lungcancer

Malignantneoplasmofbreast Breastneoplasms Breastcancer BreastcancerMalignantneoplasmofcervix

Neoplasmsofreproductivetract

Cervicalcancer;Prostatecancer

Malignantneoplasmofuterus(excludingcervix)

Malignantneoplasmofovaries Malignantneoplasmofprostate ProstatecancerMalignantmelanomaofskin Malignantneoplasmoflymphoid,haematopoieticandrelatedtissue

Leukaemia/lymphomas

Otherspecifiedneoplasms

47

2007WHOVACoD InterVACoD ReducedWHOVACoD Globalburdenofdisease PHMRCVACoD

Neoplasmofuncertainorunknownbehaviour,unspecified Neoplasms,unspecified Othercancers

Othernon‐communicablediseasesandcancers

NutritionalandEndocrineDisordersNutritionalanaemia Severeanaemia Kwashiorkor Severemalnutrition Malnutrition Severeacutemalnutrition Protein‐energymalnutrition Diabetesmellitus Diabetes Diabetes Diabetesmellitus DiabetesOtherspecifiedendocrinedisorders

Endocrinedisorders,unspecified

Othernutritionalandendocrinedisorders

DiseasesoftheCirculatorySystemChronicrheumaticheartdiseases

Chroniccardiacdeath/Cardiovasculardisease

Chroniccardiacdisease

Othercardiovasculardiseases

Congestiveheartfailure Hypertensivediseases HypertensiveheartdiseaseDiseasesofcirculatorysystem,unspecified

Acutecardiacdeath/cardiovasculardisease

Otherspecifieddiseasesofcirculatorysystem

Ischaemicheartdisease Acutecardiacdisease Ischaemicheartdisease Acutemyocardial

48

2007WHOVACoD InterVACoD ReducedWHOVACoD Globalburdenofdisease PHMRCVACoD

infarction

Haemoglobinopathy Haemoglobinopathy

Cerebrovasculardisease Stroke Cerebrovasculardisease Cerebrovasculardisease StrokeRespiratoryDisorders

Otherspecifieddiseasesoftherespiratorysystem

Acuterespiratorydiseasenotpneumonia/Respiratorydisease

Non‐communicableacuterespiratorydisease

Respiratorydisorder,unspecified

Chronicrespiratorydisease/Respiratorydisease

Non‐communicablechronicrespiratorydisease

Asthma;COPDChronicobstructivelungdisease

Respiratorydisease

Chronicobstructivepulmonarydisease

Asthma Respiratoryfailure,notelsewhereclassified

GastrointestinalDisordersGastricandduodenalulcer

Acuteabdominalcondition

Paralyticileusandintestinalobstructionwithouthernia

Peritonitis Hernias Acuteabdomen Chronicliverdisease Liverdisease Chronicliverdisorder Cirrhosisoftheliver CirrhosisOtherdiseasesofintestine Diseaseofintestine,unspecified

RenalDisorders

49

2007WHOVACoD InterVACoD ReducedWHOVACoD Globalburdenofdisease PHMRCVACoD

Kidneyorurinarydisease/Kidneydisease

Diseaseofthekidney

Nephritisandnephrosis

RenalfailureRenalfailure Otherspecifiedrenaldisorders Disordersofkidneyandureter,unspecified

MentalandNervousSystemDisordersSpecifiedmentaldisorders

Mentaldisorder

Mentaldisorders,unspecified Otherspecifieddisordersofthenervoussystem

Diseaseofnervoussystem Diseaseofnervoussystem

Nervoussystemdisorders,nototherwiseclassified

Alzheimerdisease Epilepsy Epilepsy/Acuteseizures Epilepsy

Pregnancy‐,ChildbirthandPuerperium‐relatedDisorders

Maternityrelateddeath Maternityrelateddeath,unspecified

Maternal

Ectopicpregnancy Ectopicpregnancy Ectopicpregnancy Spontaneousabortion Abortion‐relateddeath

Abortion‐relateddeath

Medicalabortion Otherandunspecifiedabortion Hypertensivedisordersofpregnancy

Pregnancy‐inducedhypertension

Pregnancy‐inducedhypertension

AntepartumhaemorrhageObstetrichaemorrhage Obstetrichaemorrhage

Postpartumhaemorrhage

50

2007WHOVACoD InterVACoD ReducedWHOVACoD Globalburdenofdisease PHMRCVACoD

Intrapartumhaemorrhage Obstructedlabour Obstructedlabour Obstructedlabour Puerperalsepsis Pregnancy‐relatedsepsis Pregnancy‐relatedsepsis Anaemiaofpregnancy Anaemiaofpregnancy Ruptureduterus Ruptureduterus Otherspecifieddirectmaternalcauses

Otherdirectmaternalcauses,unspecified Othermaternalcause

Non‐pregnancyrelatedinfection

PerinatalCausesofDeathTetanusneonatorum Tetanus Neonataltetanus

Prematurity(includingrespiratorydistress)

Pre‐term/smallbaby Prematurity

Prematurityandlowbirthweight

Pretermdeliverywithoutrespiratorydistresssyndrome/pretermdelivery(withoutRDS)andbirthasphyxia/pretermdelivery(withorwithoutRDS)andsepsis/pretermdelivery(withoutRDS)andsepsisandbirthasphyxia

Lowbirthweight

Birthtrauma Perinatalasphyxia Perinatalasphyxia Birthasphyxiaandbirth Birthasphyxia

51

2007WHOVACoD InterVACoD ReducedWHOVACoD Globalburdenofdisease PHMRCVACoD

Birthasphyxiaandperinatalrespiratorydisorders

trauma

Neonatalpneumonia Neonatalpneumonia Neonatalinfectionsandother PneumoniaCongenitalviraldiseases

Bacterialsepsisofnewborn NeonatalSepsis Sepsiswithlocalbacterialinfection

Congenitalmalformationsofthenervoussystem Congenitalmalformation Congenitalmalformation Congenitalanomalies

Congenitalmalformation

Congenitalmalformation,otherandunspecified

Stillbirths Otherspecifieddisordersrelatedtoperinatalperiod

Otherdiseasesrelatedtotheperinatalperiod,unspecified Perinatalcauseofdeath,

unspecified

Stillbirths

Stillbirths Stillbirth

ExternalCausesofDeathPedestrianinjuredintrafficaccident Transport‐related

accident/InjuryRoadtrafficaccident Roadtrafficaccidents Roadtraffic

Othertransportaccident Othertransportaccident

Accidentalfall Otherfatalaccident/Injury

Accidentalfall Falls

Accidentaldrowningandsubmersion Accidentaldrowning Accidentaldrowningand

submersion Drowning

52

2007WHOVACoD InterVACoD ReducedWHOVACoD Globalburdenofdisease PHMRCVACoD

Accidentalexposuretosmoke,fireandflames Otherfatalaccident Accidentalexposureto

smoke,fireandflames Fires Fires

Contactwithvenomousanimalsandplants Accidentalpoisoning

Contactwithvenomousanimalsandplants

Biteofvenomousanimal

Exposuretoforceofnature Injury Exposuretoforceofnature

Accidentalpoisoningandexposuretonoxioussubstance Accidentalpoisoning

Accidentalpoisoningandexposuretonoxioussubstance

Poisonings

Lackoffoodand/orwater Intentionalself‐harm Suicide Intentionalself‐harm Self‐inflictedinjuries SuicideAssault Homicide Assault,homicide,war Violence Homicide ViolentdeathLegalintervention

Accident,unspecified Otherfatalaccident/Injury Accident,unspecified

Otherspecifiedevent,undeterminedintent

Unspecifiedevent,undeterminedintent

Injury Unspecifiedevent,undeterminedintent

Otherinjuries

Otherdefinedcauseofchilddeaths

Annex  5  List  of  indicators  –  see WHO  VA  instrument  list  of  indicators,  and  criteria  for  exclusion  and inclusion online at http://www.who.int/healthinfo/statistics/verbalautopsystandards