The distribution and effects of child mortality risk factors in Ethiopia: A comparison of estimates from DSS and DHS

Objectives: To conduct a comparative analysis of the distribution and effects of under-five mortality correlates using Demographic and Health Survey (DHS) and Demographic Surveillance System (DSS) data from Ethiopia, and to investigate the methodological bias in DHS-based childhood mortality rates due to the impossibility of including children whose mothers were deceased. Methods: Using all-cause under-5 mortality as an outcome variable, the distribution and effects of risk factors weremodeled using survival analysis. All live births in rural Ethiopia in the 5-year period before the 2005 DSS+ survey and between 01/01/2000 and 31/12/2004 in the DSS in the Butajira Rural Health Program (in the Southern Nations, Nationalities, and People's (SNNP) region of Ethiopia) were included. Results: Overall, similar estimates of hazard rate ratios were derived from both DHS and DSS data and the child mortality risk profile is similar between each data source, with multiple births and living in less populous households being significant risk factors for under-five mortality. Nevertheless, some notable differences were observed. The DSS data was more sensitive to local variations in population composition and health status, whilst the more dispersed DHS approach tended to average out local variation across the country. Excluding children whose mothers were deceased from the DSS analysis had no important effect on risk profiles or estimates of survival functions at age 5 years. DHS survival functions were somewhat lower than DSS estimates (BRHP=0.87, DHS rural Ethiopia=0.67, DHS SNNP=0.66). Conclusion: Despite differing methodologies, cross-sectional DHS and longitudinal DSS data produce estimates of the distribution and effects of under-five mortality risk factors that are broadly similar. The differing methodological characteristics of DHS and DSS mean that when combined, these two data sources have the potential to provide a comprehensive picture of national population composition and health status as well as the extent of local variation –both of which are important for health monitoring and planning

Essential evidence for guiding health system priorities and policies: anticipating epidemiological transition in Africa

KIMBACKGROUND: Despite indications that infection-related mortality in sub-Saharan Africa may be decreasing and the burden of non-communicable diseases increasing, the overwhelming reality is that health information systems across most of sub-Saharan Africa remain too weak to track epidemiological transition in a meaningful and effective way. PROPOSALS: We propose a minimum dataset as the basis of a functional health information system in countries where health information is lacking. This would involve continuous monitoring of cause-specific mortality through routine civil registration, regular documentation of exposure to leading risk factors, and monitoring effective coverage of key preventive and curative interventions in the health sector. Consideration must be given as to how these minimum data requirements can be effectively integrated within national health information systems, what methods and tools are needed, and ensuring that ethical and political issues are addressed. A more strategic approach to health information systems in sub-Saharan African countries, along these lines, is essential if epidemiological changes are to be tracked effectively for the benefit of local health planners and policy makers. CONCLUSION: African countries have a unique opportunity to capitalize on modern information and communications technology in order to achieve this. Methodological standards need to be established and political momentum fostered so that the African continent's health status can be reliably tracked. This will greatly strengthen the evidence base for health policies and facilitate the effective delivery of services

Performance of the Tariff Method: validation of a simple additive algorithm for analysis of verbal autopsies

<p>Abstract</p> <p>Background</p> <p>Verbal autopsies provide valuable information for studying mortality patterns in populations that lack reliable vital registration data. Methods for transforming verbal autopsy results into meaningful information for health workers and policymakers, however, are often costly or complicated to use. We present a simple additive algorithm, the Tariff Method (termed Tariff), which can be used for assigning individual cause of death and for determining cause-specific mortality fractions (CSMFs) from verbal autopsy data.</p> <p>Methods</p> <p>Tariff calculates a score, or "tariff," for each cause, for each sign/symptom, across a pool of validated verbal autopsy data. The tariffs are summed for a given response pattern in a verbal autopsy, and this sum (score) provides the basis for predicting the cause of death in a dataset. We implemented this algorithm and evaluated the method's predictive ability, both in terms of chance-corrected concordance at the individual cause assignment level and in terms of CSMF accuracy at the population level. The analysis was conducted separately for adult, child, and neonatal verbal autopsies across 500 pairs of train-test validation verbal autopsy data.</p> <p>Results</p> <p>Tariff is capable of outperforming physician-certified verbal autopsy in most cases. In terms of chance-corrected concordance, the method achieves 44.5% in adults, 39% in children, and 23.9% in neonates. CSMF accuracy was 0.745 in adults, 0.709 in children, and 0.679 in neonates.</p> <p>Conclusions</p> <p>Verbal autopsies can be an efficient means of obtaining cause of death data, and Tariff provides an intuitive, reliable method for generating individual cause assignment and CSMFs. The method is transparent and flexible and can be readily implemented by users without training in statistics or computer science.</p

Cause-specific mortality at INDEPTH Health and Demographic Surveillance System Sites in Africa and Asia: concluding synthesis.

PKThis synthesis brings together findings on cause-specific mortality documented by means of verbal autopsies applied to over 110,000 deaths across Africa and Asia, within INDEPTH Network sites. Methods: Developments in computerised methods to assign causes of death on the basis of data from verbal autopsy (VA) interviews have made possible these standardised analyses of over 110,000 deaths from 22 African and Asian Health and Demographic Surveillance System sites in the INDEPTH Network. In addition to previous validations of the InterVA-4 probabilistic model, these wide-ranging analyses provide further evidence of the applicability of this approach to assigning the cause of death. Plausible comparisons with existing knowledge of disease patterns, as well as substantial correlations with out-of-model parameters such as time period, country, and other independent data sources were observed. Findings: Substantial variations in mortality between sites, and in some cases within countries, were observed. A number of the mortality burdens revealed clearly constitute grounds for public health actions. At an overall level, these included high maternal and neonatal mortality rates. More specific examples were childhood drowning in Bangladesh and homicide among adult males in eastern and southern Africa. Mortality from non-communicable diseases, particularly in younger adulthood, is an emerging cause for concern. INDEPTH’s approach of documenting all deaths in particular populations, and successfully assigning causes to the majority, is important for formulating health policies. Future directions: The pooled dataset underlying these analyses is available at the INDEPTH Data Repository for further analysis. INDEPTH will continue to fill cause-specific mortality knowledge gaps across Africa and Asia, which will also serve as a baseline for post-2015 development goals. The more widespread use of similar VA methods within routine civil registration systems is likely to become an important medium-term strategy in many countries

Intraoperative contrast-enhanced sonography of bowel blood flow: preliminary experience

The potential to predict, and therefore avoid, anastomotic failure has eluded generations of colon and rectal surgeons to date. A reliable, reproducible method of assessing bowel blood flow therefore would be of enormous potential clinical relevance. To our knowledge, intraoperative contrast-enhanced sonography of the bowel has not been performed previously. We present our study assessing the feasibility of using contrast-enhanced sonography to study bowel perfusion intraoperatively. We studied 8 patients (4 male and 4 female) with an age range of 52 to 81 years who underwent colorectal surgery (right hemicolectomies, n = 3; Hartmann procedure, n = 1; anterior resections, n = 2; and bowel resections with ileocolic anastomoses, n = 2). A 5-mL bolus of a sulfur hexafluoride contrast agent solution was injected before and after vascular ligation with simultaneous noncompression ultrasound scanning directly over the large bowel. The patients were followed clinically to assess for leaks. Contrast-enhanced sonographic time-intensity curves were generated for the time to peak and maximum amplitude. Moderate interobserver agreement was shown for the time to peak (κ = 0.50) and maximum amplitude (κ = 0.42), and moderate intraobserver agreement was shown for the time to peak (κ= 0.53) and maximum amplitude (κ= 0.53). No significant differences were shown between the time to peak (P = .28) and maximum amplitude (P = .49) for the preligation and postligation scans. To our knowledge, intraoperative contrast-enhanced sonography of the bowel has not been performed previously. We have shown the technique to be feasible with good intraobserver and interobserver agreement. Further work is ongoing to optimize the technique and assess its use in predicting anastomotic breakdown.published_or_final_versio

Vulnerability to episodes of extreme weather: Butajira, Ethiopia, 1998–1999

BACKGROUND: During 1999-2000, great parts of Ethiopia experienced a period of famine which was recognised internationally. The aim of this paper is to characterise the epidemiology of mortality of the period, making use of individual, longitudinal population-based data from the Butajira demographic surveillance site and rainfall data from a local site. METHODS: Vital statistics and household data were routinely collected in a cluster sample of 10 sub-communities in the Butajira district in central Ethiopia. These were supplemented by rainfall and agricultural data from the national reporting systems. RESULTS: Rainfall was high in 1998 and well below average in 1999 and 2000. In 1998, heavy rains continued from April into October, in 1999 the small rains failed and the big rains lasted into the harvesting period. For the years 1998-1999, the mortality rate was 24.5 per 1,000 person-years, compared with 10.2 in the remainder of the period 1997-2001. Mortality peaks reflect epidemics of malaria and diarrhoeal disease. During these peaks, mortality was significantly higher among the poorer. CONCLUSIONS: The analyses reveal a serious humanitarian crisis with the Butajira population during 1998-1999, which met the CDC guideline crisis definition of more than one death per 10,000 per day. No substantial humanitarian relief efforts were triggered, though from the results it seems likely that the poorest in the farming communities are as vulnerable as the pastoralists in the North and East of Ethiopia. Food insecurity and reliance on subsistence agriculture continue to be major issues in this and similar rural communities. Epidemics of traditional infectious diseases can still be devastating, given opportunities in nutritionally challenged populations with little access to health care

Measurement of serum haptoglobin as an indicator of the efficacy of malaria intervention trials

Serum haptoglobin levels were measured by an enzyme-linked immunosorbent assay in Gambian children who participated in 3 malaria intervention trials with untreated or impregnated bed nets. In one study, in which a significant effect on clinical malaria was observed, the mean serum haptoglobin level was significantly higher in the intervention than in the control group. In the other 2 studies, in which no significant protection was observed, mean haptoglobin levels were similar in intervention and control groups. Measurement of serum haptoglobin may provide a useful indirect measure of the effectiveness of malaria control programme

Determinants of the risk of dying of HIV/AIDS in a rural South African community over the period of the decentralised roll-out of antiretroviral therapy: a longitudinal study.

Antiretroviral treatment (ART) has significantly reduced HIV mortality in South Africa. The benefits have not been experienced by all groups. Here we investigate the factors associated with these inequities. This study was located in a rural South African setting and used data collected from 2007 to 2010, the period when decentralised ART became available. Approximately one-third of the population were of Mozambican origin. There was a pattern of repeated circular migration between urban areas and this community. Survival analysis models were developed to identify demographic, socioeconomic, and spatial risk factors for HIV mortality. Among the study population of 105,149 individuals, there were 2,890 deaths. The HIV/TB mortality rate decreased by 27% between 2007-2008 and 2009-2010. For other causes of death, the reduction was 10%. Bivariate analysis found that the HIV/TB mortality risk was lower for: those living within 5 km of the Bhubezi Community Health Centre; women; young adults; in-migrants with a longer period of residence; permanent residents; and members of households owning motorised transport, holding higher socioeconomic positions, and with higher levels of education. Multivariate modelling showed, in addition, that those with South Africa as their country of origin had an increased risk of HIV/TB mortality compared to those with Mozambican origins. For males, those of South African origin, and recent in-migrants, the risk of death associated with HIV/TB was significantly greater than that due to other causes. In this community, a combination of factors was associated with an increased risk of dying of HIV/TB over the period of the roll-out of ART. There is evidence for the presence of barriers to successful treatment for particular sub-groups in the population, which must be addressed if the recent improvements in population-level mortality are to be maintained

The Unequal World of Health Data

Peter Byass argues that less data are available on the health of the poor than of the rich, and discusses several alternative strategies to improve the representativeness of health data