Causes of death

The finding that tuberculosis is the leading overall cause of death is consistent with prior autopsy studies of HIV patients from sub-Saharan Africa and India in the pre-ART era. In a 2010 meta-analysis of all autopsy studies of HIV patients from sub- Saharan Africa over the last two decades, tuberculosis was considered a cause of death in 32–45% of 593 autopsied adults. [11,13,18,20,31] In a series of 236 HIV-positive, ART-naı¨ve patients from Mumbai, tuberculosis was implicated in 63% of deaths. [17] Our finding that every case of tuberculosis was disseminated beyond the lungs supports the finding by Martinson et al. that in their largely HIV infected, ART-naı¨ve subjects, 97% of those with tuberculosis had evidence of disseminated disease during complete autopsy. [12] Our data on the importance of tuberculosis also support the conclusions of prior studies of cause- specific mortality of HIV patients on ART in low-income settings which used non-pathologic evidence from chart reviews and verbal autopsies. Tuberculosis is consistently among the leading causes of death in these studies, implicated in 16–18% of deaths in studies from Haiti, Senegal and Uganda and in 19–44% of deaths from two South African cohorts.[8,9,32–35] The higher number of deaths attributed to tuberculosis in our study is likely explained by the contribution of post-mortem investigations which revealed that a third of microbiologically and/or histologically-proven tubercu- losis infections were clinically unsuspected at the time of death.

Objective: The aim of this study is to identify the causes for discarding corneas at the Eye Bank of the Federal District in Brasilia, Brazil, and describe the social and demographic variables and Causa Mortis of cornea donors from 2014 to 2017. Methods: We conducted an exploratory and social-epidemiologic descriptive study regarding cornea donation. The data base information was obtained from the corneal donor’s medical records analysis. All of the potential donors’ records (cause of death, cause of cornea discard, month of donation, age, gender, and time of death, corneal enucleation and preservation), from 2014 to 2017 were included in the study. Results: We looked at 1,574 corneal donor notifications. Demographic characteristics displayed significant differences in gender distribution (male, 74.8% and female, 25.2%), and the average donor age was 40 ± 15.9 years. 25% of the causes of death were from cardiovascular disease followed by 19.6% from sharp or blunt instrument injury, 14.2% resulted from multiple traumas. We described 3,074 donated corneas from the DF Eye Bank, where 2.6% has not been uptaken. Of those 3,074 corneal tissues, nearly 60% (n=1,836) have been transplanted and 40% (n=1,238) were discarded. Regarding the causes of discard, 68% (n=841) were due to positive or indeterminate serological blood tests and 39% (n=486) because of matureness (expired medium guaranteed period of corneal preservation). Conclusions: Specific issues such as violent causes of death, gender disproportion and total time of corneal processing can be better managed to reduce procurement times, and availability, of corneal tissue for transplantation.

Objective: The study accompanied 131 crack-cocaine users over a 5-year period, and examined mortality patterns, as well as the causes of death among them. Method: All patients admitted to a detoxification unit in Sao Paulo between 1992 and 1994 were interviewed during two follow-up periods: 1995-1996 and 1998-1999. Results: After 5 years, 124 patients were localized (95%). By the study endpoint (1999), 23 patients (17.6%) had died. Homicide was the most prevalent cause of death (n = 13). Almost one third of the deaths were due to the HIV infection, especially among those with a history of intravenous drug use. Less than 10% died from overdose. Conclusions: The study suggests that the mortality risk among crack cocaine users is greater than that seen in the general population, being homicide and AIDS the most common causes of death among such individuals. Keywords: Crack cocaine; Longitudinal studies; Mortality rate; Cause of death; Substance related disorders

Inequity in health and social welfare were reflected in our findings as it revealed substantial differences in causes of death between undocumented migrants and Swedish residents. This may partly be due to the fact that undocu- mented migrants in Sweden have poor access to health care. Further, undocumented migrants in Sweden lack entitlement to enter the regular housing and labor market. Their housing and working conditions are therefore precarious. They are often forced to pay unreasonably high rents. Unable to afford the rent themselves, they often live in overcrowded conditions and sometimes lodge together with other marginalized groups, such as alco- holics, drug addicts, and drug pushers. Their employment opportunities are commonly of short duration, underpaid, and insecure (2, 6, 29). Undocumented migrants have a high risk of being exposed to violence (2). However, as they are in hiding from the authorities, they have no possibility of notifying the police if they have been subjected to violence (29). As living and working conditions are linked to aspects of life-quality, such as health, these factors could be possible explanations for the high number of external causes, including suicides, accidents, and assault, among undocumented migrants in Sweden. In order to improve equity in health, access to health care for all, together with actions to address the social determinants of health are needed (30).

Background: The monitoring of the underlying causes of death in people living with HIV/AIDS is important so that actions to reduce morbidity and mortality can be taken. Objective: To describe the temporal trends of underlying causes of death among people living with HIV/AIDS between 2000 and 2007 in Brazil and to identify factors associated with it. Methods: The Mortality Information System data for deaths occurred in Brazil between 2000 and 2007 that contained reference to HIV/ AIDS in any of the death certifi cate fi elds was analyzed. Temporal trends of the underlying cause of death were studied. Differences in the underlying cause of death according to gender, age, region of residence, level of education, certifying offi cer, race and year of death were verifi ed. Results: Between 2000 and 2007 the percentage of deaths not related to HIV/AIDS among people living with HIV/ AIDS increased from 2.5% to 7.0%. People with higher level of formal education, living in the South- East region of Brazil and aged under 13 or over 60 years old were more likely to have their underlying cause of death reported as not related to HIV/AIDS. Conclusion: The results suggest the importance of implementing actions aimed at improving the quality of life of PLWHA, and which could include behavioral changes, such as smoking and alcoholism cessation, early screening to detect neoplasms and the monitoring of chronic conditions, such as diabetes. That is to say, the need exists to integrate the actions of HIV/AIDS programs with other public health programs.

To assess different methods for determining cause of death from verbal autopsy (VA) ques- tionnaire data, the intra-rater reliability of Physician-Certified Verbal Autopsy (PCVA) and the accuracy of PCVA, expert-derived (non-hierarchical) and data-driven (hierarchal) algo- rithms were assessed for determining common causes of death in Ugandan children. A ver- bal autopsy validation study was conducted from 2008-2009 in three different sites in Uganda. The dataset included 104 neonatal deaths (0-27 days) and 615 childhood deaths (1-59 months) with the cause(s) of death classified by PCVA and physician review of hospi- tal medical records (the ‘reference standard’). Of the original 719 questionnaires, 141 (20%) were selected for a second review by the same physicians; the repeat cause(s) of death were compared to the original,and agreement assessed using the Kappa statistic.Physician reviewers’ refined non-hierarchical algorithms for common causes of death from existing expert algorithms, from which, hierarchal algorithms were developed. The accuracy of PCVA, non-hierarchical, and hierarchical algorithms for determining cause(s) of death from all 719 VA questionnaires was determined using the reference standard. Overall, intra-rater repeatability was high (83% agreement, Kappa 0.79 [95% CI 0.76-0.82]). PCVA performed well, with high specificity for determining cause of neonatal (>67%), and childhood (>83%) deaths, resulting in fairly accurate cause-specific mortality fraction (CSMF) estimates. For most causes of death in children, non-hierarchical algorithms had higher sensitivity, but cor- respondingly lower specificity, than PCVA and hierarchical algorithms, resulting in inaccu- rate CSMF estimates. Hierarchical algorithms were specific for most causes of death, and CSMF estimates were comparable to the reference standard and PCVA. Inter-rater reliabil- ity of PCVA was high, and overall PCVA performed well. Hierarchical algorithms performed better than non-hierarchical algorithms due to higher specificity and more accurate CSMF estimates. Use of PCVA to determine cause of death from VA questionnaire data is reason- able while automated data-driven algorithms are improved.

The percentages of crude annual mortality among males due to each of the specific causes examined in the study area, by age.. Barbados ranked sec- ond for both males [r]

The 452 horses evaluated during the seven years period, corresponded to a mean of a little less than 64 animals necropsied per year. There were more males than females in the observed population. Considering the data analysis, there is largest number of deaths in males compared to females. This result should be observed with parsimony, considering that we can not use it as an indicator of popu- lation, based on speciic characteristics of the population. Methodological differences restrict the comparisons of our results with those from the surveillance systems and moni- toring of the oficial veterinary service of the United King- dom (DEFRA) and the U.S. (APHIS), as well as with the re- sults published by Stover and Murray (2008). Additionally, another limitation of our study is that we haven’t had full access to the hospital medical records, which prevented the comparison of the data evaluated with the total number of animals treated in the same period. Nevertheless, this limi- tation can serve as warnings to the veterinary institutions have a greater control population of patients, through re- cords and building databases. If implemented, this could be used as a basis for comparison in future studies.

AbstrAct: Objective: To assess the quality of mortality information by analyzing the frequency of garbage codes (GC) registered as underlying cause-of-death in Belo Horizonte, Minas Gerais, Brazil. Methods: Data of deaths of residents from 2011 to 2013 were selected. GC causes were classiied as proposed by the Global Burden of Disease Study (GBD) 2015. They were grouped into GCs from ICD-10 Chapter XVIII and GCs excluding codes of Chapter XVIII. Proportions of GC were calculated by sex, age, and place of occurrence. Results: In Belo Horizonte, 30.5% of the total of 44,123 deaths were GC. Higher proportion of these codes was observed in children (1 to 4 years) and in people aged over 60 years. The following leading GCs observed were: other ill-deined and unspeciied causes of death (code R99), unspeciied pneumonia ( J18.9), unspeciied stroke (hemorrhagic or ischemic) (I64), and unspeciied septicemia (A41.9). The proportions of GC were 28.7% and 36.9% in deaths that occurred in hospitals and at home, respectively. An important diference occurred in the GC group from Chapter XVIII of ICD-10: 1.7% occurred in hospitals and 16.9% at home. Conclusion: The high proportions of GC in mortality statistics in Belo Horizonte demonstrated its importance for assessing the quality of information on causes of death.

The results indicate a reduction in the overall levels of deaths registered as ill-defined in Brazil. From 1991 to 2010, the number of mesoregions with more than 20% of deaths registered as ill-de- fined reduced significantly across the country. Most of these areas were located in the Northern and Northeastern parts of the country. Most im- portantly, the pace of decline in the percentage of ill-defined causes of death is significant. Ta- ble 1 shows that in some areas the percentage of ill-defined causes declined from 72% of total causes to less than 30% over the period of analy- sis. The percentage of ill-defined death records is still high for international standards, but recent investments led to a clear improvement in data quality. In recent years, one can observe clusters of ill-defined death causes in the less developed Northern and Northeastern regions and better data quality in the South and Southeast regions.

Introduction: The morbidity and mortality profi le in a given region refl ects its quality of life and provides tools for improving public health policies in that region. Methods: A cross-sectional epidemiological study was performed using secondary mortality data collected from the Monte Negro municipality of the Brazilian Western Amazon from 2000 to 2011. These data were compared with data from similar municipalities in other Brazilian macro-regions. Data were obtained through the Departamento de Informática do Sistema Único de Saúde (DATASUS) information system. Results: The number of deaths reported over the study period was 606. The most common cause of death was external causes of morbidity and mortality [International Classifi cation of Diseases (ICD)-10 chapter 20], followed by diseases of the circulatory system (ICD-10 chapter 9). Among the causes of death according to age group, infectious and parasitic diseases were the most common for 2- to 9-year-old children; external causes of disease were the most prevalent for 10- to 59-year-old people; and circulatory diseases prevailed in individuals over 60 years of age. Eleven percent of deaths were due to unknown causes. Conclusions: These results point to a fragility in the public policies for prevention and awareness of this problem. Infectious and parasitic diseases contribute only 4.5% of deaths, but had the third highest Disability-Adjusted Life Year score (1,190 days). Improving support to the Estratégia Saúde da Família (Family Health Strategy) program and implementing a death verifi cation service would signifi cantly aid in reducing the occurrence of non-transmissible chronic diseases and clarifying unknown causes of death.

The causes of death that frequently were associated to the deaths related to VL–HIV/AIDS co-infection are presented in Table 3. There was a clear predominance of affections related to the natural history of these diseases, especially complications or conditions directly arising from HIV/AIDS. The infectious and para- sitic (Chapter I: Certain infectious and parasitic diseases [A00- B99]) (58.8%, 160/272) and respiratory (Chapter X: Diseases of the respiratory system [J00-J99]) (51.1%, 139/272) 17 diseases/ disorders were the causes of death that most often associated with deaths related to VL–HIV/AIDS co-infection. Sepsis was men- tioned in more than 36.8% (100/272) of death certificates, and respiratory failure, pneumonia and multiple organ failure in over 20% (Table 3). Among AIDS-related opportunistic infections, tuberculosis, toxoplasmosis, pneumocystosis, cryptococcosis, and intestinal infectious diseases are registered. Liver diseases and blood abnormalities (coagulation disorders, anemia, and hemorrhage) were complications resulting from infection by VL. Renal failure, symptoms and signs involving the circulatory and respiratory systems, metabolic and electrolyte disorders, shock and other respiratory diseases were also important causes/condi- tions associated with deaths related to VL–HIV/AIDS co-infection (Table 3).

With the exception of perinatal diseases, congenital malfor- mations, and external causes, there was a similar percentage increase for risk of death for almost all causes when using RC-Total and RC-Non-external, unlike the proposed new criterion based on RC-IDCD, which corrected the different causes of death with different weights. By this criterion, endocrine diseases, particularly diabetes, diseases of the circulatory system and, particularly, maternal causes and mental disorders, had greater representation than they did using the other two criteria. In contrast, neoplasms, infec- tious diseases, and genitourinary diseases showed smaller relative increases. External causes were not addressed in the redistribution process using RC-Non-external and only had a small increase among the redistributed causes due to correction for unknown age and sex. RC-IDCD con- sidered a relatively smaller weight for them among the IDCD when compared to RC-Total (Table 4).

The systematic categorization of disorders, provided by the World Health Organization in the "International Statistical Classification of Diseases, Injuries and Causes of Death"[r]

the fi rst year of life in the metropolitan region of Belo Horizonte, Southeastern, between 1984 and 1998, using data from SIM and the Instituto Brasileiro de Geografi a e Estatística. During the study period, infant mortality decreased from 48.5 to 22.1 deaths per 1,000 LB. Among neonatal deaths, perinatal conditions were the main group of avoidable causes (mostly, perinatal malnutri- tion, prematurity, hypoxia and asphyxia), followed by cardiovascular and respiratory problems. The triad of diarrhea, pneumonia and malnutrition were the main avoidable causes of death during the postneonatal period. Comparison of the results from these studies to our study is limited by time (one decade or longer) and by geographical distance, as well as by the distinct methodology used to identify cause and classifi cation of avoidable death. Nonetheless, the three studies indicate that avoidable infant deaths have been an important public health problem in Brazil over the

In accordance with the ICD-10 coding rules, each cause of death recorded on the death certif- icates was independently translated into ICD-10 codes by a coder from the DEIS and a certified nosological coding instructor from the United States. The analysis considered the frequency of non translation of causes of death into ICD cod- ing by both coders. Demographic information about the deceased (age, sex, marital status, ed- ucation level, region of residence, place of death) and the type of medical certifier (physician, pa- thologist, other doctors) was recorded.

Objective: to describe and analyze youth (15-29 years of age) mortality trends in Brazil between 2000 and 2012. Methods: this was a descriptive and time series study conducted with Mortality Information System data; Prais-Winsten linear regression was used to analyze mortality rate trends. Results: 958,224 deaths were registered in the period, 79.6% were male; the overall corrected mortality rates were 1.6 and 1.5 per 1,000 inhabitants in 2000 and 2012, respectively; overall mortality rates showed stationary trends in the period (-0.34%; 95%CI -1.05;0.37); increasing trends among men were observed in the Northeast (3.08%; 95%CI 2.56;3.61) and Southern (0.88%; 95%CI 0.09;1.66) regions; in 2012, external causes accounted for 71.4% of deaths, 79.2% among men and 38.5% among women. Conclusion: youth mortality rates were high and stable during the study period; external causes were presented as the main causes of death, in both sexes.

Objective: To describe and analyze the causes of death in a pediatric secondary-care hospital (run by Médecins sans Frontières), in Monrovia, Liberia, 6 years post-civil war, to determine the quality of care and mortality in a setting with limited resources. Methods: Data were retrospectively collected from March 2009 to October 2009. Patient charts and laboratory records were reviewed to verify cause of death. Additionally, charts of patients aged over 1 month with an infectious cause of death were analyzed for decompensated septic shock, or fluid-refractory septic shock. Results: Of 8,254 admitted pediatric patients, 531 died, with a mortality rate of 6.4%. Ninety percent of deaths occurred in children <5 years old. Most deaths occurred within 24 hours of admission. The main cause of death (76%) was infectious disease. Seventy-eight (23.6%) patients >1 month old with infectious disease met the criteria for septic shock, and 28 (8.6%) for decompensated or fluid-refractory septic shock. Conclusion: Since the end of Liberia’s devastating civil war, Island Hospital has improved care and mortality outcomes, despite operating with limited resources. Based on the available data, mortality in Island Hospital appears to be lower than that of other Liberian and African institutions and similar to other hospitals run by Médecins sans Frontières across Africa. This can be explained by the financial and logistic support of Médecins sans Frontières. The highest mortality burden is related to infectious diseases and neonatal conditions. The mortality of sepsis varied among different infections. This suggests that further mortality reduction can be obtained by tackling sepsis management and improving neonatal care.

In effect, as the easily controllable causes, generally occurring in younger groups, are overcome, the causes of death characteristic of older age groups remain high [r]

Cysticercosis-related mortality has not been studied in Brazil. Deaths recorded in the State of São Paulo from 1985 to 2004 in which cysticer- cosis was mentioned on any line or in any part of the death certificate were studied. Causes of death were processed using the Multiple Cause Tabulator. Over this 20-year period, cysticercosis was identified in 1,570 deaths: as the underly- ing cause in 1,131 and as an associated cause of death in 439. Standardized mortality rates with cysticercosis as the underlying cause showed a downward trend and were higher among men and older individuals. Intracranial hyperten- sion, cerebral edema, hydrocephalus, inflamma- tory diseases of the central nervous system, and cerebrovascular diseases were the main associ- ated causes in deaths due to cysticercosis. AIDS was the principal underlying cause of death in which cysticercosis was an associated cause. The counties (municipalities) with the most cysticer- cosis-related deaths were São Paulo, Campinas, Ribeirão Preto, and Santo André. Wide variation was observed between counties regarding the value ascribed to cysticercosis as the underlying cause of death. This leads to underestimation of the disease’s importance in planning health in- terventions.