Deaths from rhesus haemolytic disease in England and Wales in 1982 and 1983.

Examination of death certificates and the clinical notes of the patients concerned showed that the number of deaths from rhesus (D) haemolytic disease in England and Wales was 44 and 34 during 1982 and 1983, respectively, a substantial decrease from the figure of 106 for 1977. Of the 78 women whose infants died in 1982 and 1983, 49 had not received anti-Rh immunoglobulin after previous pregnancies with Rh positive infants; most of these deaths would presumably have been prevented had postnatal anti-Rh immunoglobulin been given. In 13 women anti-D was detected during, or immediately after, a first pregnancy, and in 15 women rhesus immunisation developed despite administration of anti-Rh immunoglobulin postnatally. One or two apparent failures of treatment may have been due to underdosage, but it must be concluded that about one third of the deaths in 1982 and 1983 could have been prevented only by giving anti-Rh immunoglobulin antenatally as well as postnatally.     

The validity of cancer information on death certificates in Norway and the impact of death certificate initiated cases on cancer incidence and survival

BackgroundDeath certificates are an important source of information for cancer registries. The aim of this study was to validate the cancer information on death certificates, and to investigate the effect of including death certificate initiated (DCI) cases in the Cancer Registry of Norway when estimating cancer incidence and survival.MethodsAll deaths in Norway in the period 2011–2015 with cancer mentioned on the death certificates were linked to the cancer registry. Notifications not registered from other sources were labelled death certificate notifications (DCNs), and considered as either cancer or not, based on available information in the registry or from trace-back to another source.ResultsFrom the total of 65 091 cancers mentioned on death certificates in the period 2011–2015, 58,425 (89.8%) were already in the registry. Of the remaining 6 666 notifications, 2 636 (2 129 with cancer as underlying cause) were not regarded to be new cancers, which constitutes 4.0% of all cancers mentioned on death certificates and 39.5% of the DCNs. Inclusion of the DCI cases increased the incidence of all cancers combined by 2.6%, with largest differences for cancers with poorer prognosis and for older age groups. Without validation, including the 2 129 disregarded death certificates would over-estimate the incidence by 1.3%. Including DCI cases decreased the five-year relative survival estimate for all cancer sites combined with 0.5% points.ConclusionIn this study, almost 40% of the DCNs were regarded not to be a new cancer case, indicating unreliability of death certificate information for cancers that are not already registered from other sources. The majority of the DCNs where, however, registered as new cases that would have been missed without death certificates. Both including and excluding the DCI cases will potentially bias the survival estimates, but in different directions. This biases were shown to be small in the Cancer Registry of Norway.     

Death certification and epidemiological research. Medical Services Study Group of the Royal College of Physicians of London.

The cause of death shown on 191 death certificates was compared with the cause indicated by the hospital case notes, the consultants'' opinions, and the necropsy findings. All 191 deaths occurred among medical hospital patients aged under 50. In 39 cases there was a major discrepancy between the two sources over the cause of death and in another 54 ther was a minor but epidemiologically important difference. Death certificates are not primarily intended for epidemiological research, but researchers often rely on them. This and other studies have shown, however, that death certificates are often inaccurate records of the cause of death--even coroner''s certificates issued after a coroner''s necropsy. The accuracy of death certificates might be improved if coroners consulted clinicians more closely and if senior hospital staff completed hospital death certificates.     

Trends in mortality statistics in England and Wales with particular reference to AIDS from 1984 to April 1987

Death certification should be able to provide accurate data on the number of deaths due to AIDS as a basis for predicting future deaths from the syndrome. Trends in deaths from other causes may identify conditions that have not been recognised to be associated with HIV infection. Mortality statistics with reference to AIDS in England and Wales were completed from death certificates. Increases in deaths from selected causes likely to be associated with AIDS or HIV infection suggested that in some patients with HIV infection, AIDS was not stated on the death certificate or subsequently notified by the doctor who signed the certificate. From calculations of excess deaths between the beginning of 1985 and the end of April 1987, compared with 1984 at least 495 deaths possibly associated with HIV infection were estimated to have occurred among men aged 15-54 during that period. In 261 AIDS or HIV infection was stated on the original or amended death entry as the cause of death, and of these 198 were included in the estimated number of excess deaths.Accurate notification of the underlying cause of death and associated diseases is required for the precise monitoring of trends in mortality from AIDS and possible identification of unrecognised conditions associated with HIV infection.     

Impact of using multiple causes of death codes to compute site-specific, death certificate-based cancer mortality statistics in the United States

Background: Cancer mortality statistics, an important indicator for monitoring cancer burden, are traditionally restricted to instances when cancer is determined to be the underlying cause of death (UCD) based on information recorded on standard certificates of death. This study's objective was to determine the impact of using multiple causes of death codes to compute site-specific cancer mortality statistics. Methods: The state cancer registries of California, Colorado and Idaho provided linked cancer registry and death certificate data for individuals who died between 2002 and 2004, had at least one cancer listed on their death certificate and were diagnosed with cancer between 1993 and 2004. These linked data were used to calculate the site-specific proportion of cancers not selected as the UCD (non-UCD) among all cancer-related deaths (any mention on the death certificate). In addition, the retrospective concordance between the death certificate and the population-based cancer registry, measured as confirmations rates, was calculated for deaths with cancer as the UCD, as a non-UCD, and for any mention. Results: Overall, non-UCD deaths comprised 9.5 percent of total deaths; 11 of the 79 cancer sites had proportions greater than 3 standard deviations from 9.5 percent. The confirmation rates for UCD and for any mention did not differ significantly for any of the cancer sites. Conclusion and impact: The site-specific variation in proportions and rates suggests that for a few cancer sites, death rates might be computed for both UCD and any mention of the cancer site on the death certificate. Nevertheless, this study provides evidence that, in general, restricting to UCD deaths will not under report cancer mortality statistics.     

Mortality rates in subjects with fetal alcohol spectrum disorders and their siblings

BACKGROUND: Our objective was to estimate the mortality rate in subjects with fetal alcohol spectrum disorders (FASD) and their siblings whose FASD status was unknown. METHODS: We used the state FASD Registry to link subjects with FASD to a North Dakota birth certificate. We were able to link 304 of 486 cases (63%). We used the birth certificates to identify the mother and children born to the mother (siblings). We then searched for death certificates for both the FASD cases and their siblings. We then calculated the annual and age‐adjusted mortality rates for the siblings of the Registry cases and compared them with mortality rates from North Dakota. RESULTS: The FASD case mortality rate was 2.4%, with a 4.5% mortality rate for their sibings, accounting for 14% of all deaths when compared to the North Dakota residents matched by age and year of death. The sibling deaths accounted for 21.5% of all cause mortality matched by age and year of death. The age‐standardized mortality ratios were 4.9 for the FASD cases and 2.6 for their siblings whose FASD status was unknown. CONCLUSIONS: Mortality rates for FASD cases and their siblings were increased and represent a substantial proportion of all cause mortality in North Dakota. Prevention of FASD may be a useful strategy to decrease mortality. Birth Defects Research (Part A), 2008. © 2008 Wiley‐Liss, Inc.     

Adverse effect of plasma exchange on anti-D production in rhesus immunisation owing to removal of inhibitory factors.

Intensive plasma exchange was used to reduce the maternal anti-D concentration in case of severe rhesus haemolytic disease. Initially the concentration fell from 30 to 4 IU/ml, but after six exchanges it increased to 490 IU/ml despite continued exchanges, and intrauterine fetal death eventually ensued. The increase in the rate of maternal anti-D production coincided with, and may have resulted from, removal of plasma immuno-regulatory factors that inhibited in-vitro lymphocyte functions. These results that the role of plasma exchange in haemolytic disease of the newborn is more complex than simply removing the antibody and that further investigations are needed.     

Unrecognised HIV related deaths.

OBJECTIVES--To establish whether follow up of deaths from selected HIV related causes could increase the number of cases of HIV infection reported to the Public Health Laboratory Service Communicable Disease Surveillance Centre (CDSC), and to estimate the proportion of deaths among HIV positive men that occurred in men who were not known to be HIV positive at the time of death by the person who signed the death certificate. DESIGN--Follow up of draft death entries received by the Office of Population Censuses and Surveys on which one of 11 medical or external causes likely to be related to HIV was stated; letters were sent to the people who signed the certificates. The respondents were invited to report men known to have been HIV positive who were not already on the CDSC register. SETTING--England and Wales. SUBJECTS--Men aged 15-54 who died in February 1989 to July 1989 with one of the 11 selected HIV related diseases as cause of death on their death certificates. MAIN OUTCOME MEASURES--Number of men reported to the CDSC as a result of this follow up; estimate of excess deaths due to an HIV related cause; estimate of the proportion of excess deaths that occurred in those who were not known to be HIV positive at the time of death. RESULTS--Replies were received for 473 deaths (86%). Forty were for men known to have been HIV positive, 31 of whom had been reported to CDSC by the time they died; six were subsequently reported. The respondent did not know that the decreased was HIV positive for 20 (35%) of the 57 excess deaths in men for whom one of the medical causes was stated and 41 (93%) of the 44 excess deaths in men for whom one of the external causes was stated. CONCLUSION--Follow up of death registrations is not an efficient way of increasing the number of cases of HIV infection reported to CDSC. Between 35% and 60% of HIV positive people for whom certain causes are stated may be dying without HIV positivity having been diagnosed. There may be implications for those caring for people with these conditions and those who carry out postmortem examinations.     

Evaluation of cause of deaths' validity using outcome measures from a prospective, population based cohort study in Tehran, Iran

Objective

The aim of this study was to evaluate the validity of cause of death stated in death certificates in Tehran using outcome measures of the Tehran Lipid and Glucose Study (TLGS), an ongoing prospective cohort study.

Methods

The cohort was established in 1999 in a population of 15005 people, 3 years old and over, living in Tehran; 3551 individuals were added to this population three years later. As part of cohort''s outcome measures, deaths occurring in the cohort are investigated by a panel of medical specialists (Cohort Outcome Panel-COP) and underlying cause of death is determined for each death. The cause of death assigned in a deceased''s original death certificate was evaluated against the cause of death determined by COP and sensitivity and positive predictive values (PPV) were determined. In addition, determinants of assigning accurate underlying cause of death were determined using logistic regression model.

Result

A total of 231 death certificates were evaluated. The original death certificates over reported deaths due to neoplasms and underreported death due to circulatory system and transport accidents. Neoplasms with sensitivity of 0.91 and PPV of 0.71 were the most valid category. The disease of circulatory system showed moderate degree of validity with sensitivity of 0.67 and PPV of 0.78. The result of logistic regression indicated if the death certificate is issued by a general practitioner, there is 2.3 (95% CI 1.1, 5.1) times chance of being misclassified compared with when it is issued by a specialist. If the deceased is more than 60 years, the chance of misclassification would be 2.5 times (95% CI of 1.1, 5.9) compared with when the deceased is less than 60 years.     

Causes of Mortality for Indonesian Hajj Pilgrims: Comparison between Routine Death Certificate and Verbal Autopsy Findings

Background

Indonesia provides the largest single source of pilgrims for the Hajj (10%). In the last two decades, mortality rates for Indonesian pilgrims ranged between 200–380 deaths per 100,000 pilgrims over the 10-week Hajj period. Reasons for high mortality are not well understood. In 2008, verbal autopsy was introduced to complement routine death certificates to explore cause of death diagnoses. This study presents the patterns and causes of death for Indonesian pilgrims, and compares routine death certificates to verbal autopsy findings.

Methods

Public health surveillance was conducted by Indonesian public health authorities accompanying pilgrims to Saudi Arabia, with daily reporting of hospitalizations and deaths. Surveillance data from 2008 were analyzed for timing, geographic location and site of death. Percentages for each cause of death category from death certificates were compared to that from verbal autopsy.

Results

In 2008, 206,831 Indonesian undertook the Hajj. There were 446 deaths, equivalent to 1,968 deaths per 100,000 pilgrim years. Most pilgrims died in Mecca (68%) and Medinah (24%). There was no statistically discernible difference in the total mortality risk for the two pilgrimage routes (Mecca or Medinah first), but the number of deaths peaked earlier for those traveling to Mecca first (p=0.002). Most deaths were due to cardiovascular (66%) and respiratory (28%) diseases. A greater proportion of deaths were attributed to cardiovascular disease by death certificate compared to the verbal autopsy method (p<0.001). Significantly more deaths had ill-defined cause based on verbal autopsy method (p<0.001).

Conclusions

Despite pre-departure health screening and other medical services, Indonesian pilgrim mortality rates were very high. Correct classification of cause of death is critical for the development of risk mitigation strategies. Since verbal autopsy classified causes of death differently to death certificates, further studies are needed to assess the method’s utility in this setting.     

Perinatal death recording: time for a change?

The new perinatal death certificate proposed by the World Health Organisation was examined in relation to existing measures for recording perinatal death statistics and also with regard to new information gathered. Present procedures appear to underestimate the number of perinatal deaths by roughly 10%, though late registrations may lower this figure slightly. The use of a minimum birth weight as the criterion for inclusion in perinatal statistics removed much of the uncertainty associated with definitions of live birth and stillbirth. The new certificate led to duplication of some information already recorded through birth notification yet failed to provide information on some other factors generally considered relevant to perinatal mortality. The format proposed for recording cause of death provided a more logical presentation of events. Standardizing birth information recorded on all infants, modifying death certificates, and developing efficient record-linkage schemes would be more valuable than introducing the WHO certificate. Useful interpretation of the meaning of the characteristics of infants dying in the perinatal period awaits these timely changes.     

CYSTIC FIBROSIS

To determine the actual number of deaths from cystic fibrosis reported in 1957 in California, all death certificates mentioning any one of the various terms used to describe the condition were reviewed.As a cause of death, cystic fibrosis is infrequently mentioned on death certificates. In 1957, only 42 of a total of 124,082 death certificates mentioned cystic fibrosis. Half of the deaths occurred in persons less than 12 months of age. There was no significant difference by sex between deaths due to cystic fibrosis and deaths from all causes. All deaths occurred in the white population.     

Leatherwork: a possible hazard to reproduction.

A retrospective study was carried out aimed at eliciting the causes of perinatal death in Leicestershire between 1976 and 1982. Case notes were reviewed and the mothers interviewed in over 1000 cases. An analysis of maternal occupations showed that leatherworkers were at increased risk of having a perinatal death, particularly from congenital malformations and macerated stillbirths, even when compared with other manual workers in the same social class. The excess risk occurred in all towns of the county where leatherwork was undertaken. Further investigation is needed of the materials used in the leather industry in order to ensure that risks are minimised. Fecund women working in the industry should be informed of any residual risk if these findings are confirmed.     

Impact of HIV infection on mortality in young men in a London health authority.

OBJECTIVE--To determine the number of deaths attributable to HIV infection among men aged 15-64 in a geographically defined population in the United Kingdom. DESIGN--Retrospective review of death certificates and linkage with local and national HIV and AIDS surveillance data. SETTING--Riverside District Health Authority, London. MAIN OUTCOME MEASURES--Numbers of deaths attributed to HIV infection in male residents of Riverside aged 15-64 and 15-44 over a six month period. Proportion of attributed deaths were (i) identified from death certificates by the Office of Population Censuses and Surveys as being due to HIV infection and (ii) reported as cases of AIDS or HIV related deaths to the Public Health Laboratory Service Communicable Disease Surveillance Centre. RESULTS--34 of 213 (16%) deaths in men aged 15-64 and 27 of 69 (39%) deaths in men aged 15-44 were attributed to HIV infection. Six of 33 (18%) attributed deaths were identified by the Office of Population Censuses and Surveys and 32/34 (94%) were reported to the Communicable Disease Surveillance Centre. CONCLUSIONS--HIV infection was the leading cause of death in male residents of Riverside aged 15-44 and the third commonest cause of death in those aged 15-64. Most individuals dying of known HIV infection were reported to the Communicable Disease Surveillance Centre but identification of the true cause of death from the process of death certification was poor. Measures to improve the certification of HIV and AIDS or the use of AIDS surveillance information correctly to code the cause of death needs to be considered to ensure that the true impact of HIV infection is reflected in routine mortality statistics.     

Improving the accuracy of death certification

BACKGROUND: Population-based mortality statistics are derived from the information recorded on death certificates. This information is used for many important purposes, such as the development of public health programs and the allocation of health care resources. Although most physicians are confronted with the task of completing death certificates, many do not receive adequate training in this skill. Resulting inaccuracies in information undermine the quality of the data derived from death certificates. METHODS: An educational intervention was designed and implemented to improve internal medicine residents'' accuracy in death certificate completion. A total of 229 death certificates (146 completed before and 83 completed after the intervention) were audited for major and minor errors, and the rates of errors before and after the intervention were compared. RESULTS: Major errors were identified on 32.9% of the death certificates completed before the intervention, a rate comparable to previously reported rates for internal medicine services in teaching hospitals. Following the intervention the major error rate decreased to 15.7% (p = 0.01). The reduction in the major error rate was accounted for by significant reductions in the rate of listing of mechanism of death without a legitimate underlying cause of death (15.8% v. 4.8%) (p = 0.01) and the rate of improper sequencing of death certificate information (15.8% v. 6.0%) (p = 0.03). INTERPRETATION: Errors are common in the completion of death certificates in the inpatient teaching hospital setting. The accuracy of death certification can be improved with the implementation of a simple educational intervention.     

Maternal and Antenatal Risk Factors for Stillbirths and Neonatal Mortality in Rural Bangladesh: A Case-Control Study

Objective

To identify maternal and antenatal factors associated with stillbirths and neonatal deaths in rural Bangladesh.

Study Design

A prospective cohort study is being conducted to evaluate a maternal and child nutrition program in rural Bangladesh. Cases were all stillbirths and neonatal deaths that occurred in the cohort between March 7, 2011 and December 30, 2011. Verbal autopsies were used to determine cause of death. For each case, four controls were randomly selected from cohort members alive at age 3-months. Multivariable logistic regression was used to identify factors associated with these deaths.

Results

Overall, 112 adverse pregnancy outcomes (44 stillbirths, 19/1,000 births; 68 neonatal deaths, 29/1,000 live births) were reported. Of the stillbirths 25 (56.8%) were fresh. The main causes of neonatal death were birth asphyxia (35%), sepsis (28%) and preterm birth (19%). History of bleeding during pregnancy was the strongest risk factor for stillbirths (adjusted odds ratio 22.4 [95% confidence interval 2.5, 197.5]) and neonatal deaths (adjusted odds ratio 19.6 [95% confidence interval 2.1, 178.8]). Adequate maternal nutrition was associated with decreased risk of neonatal death (adjusted odds ratio 0.4 [95% confidence interval 0.2, 0.8]).

Conclusions

Identifying high-risk pregnancies during gestation and ensuring adequate antenatal and obstetric care needs to be a priority for any community-based maternal and child health program in similar settings.     

The influence of antenatal and maternal factors on stillbirths and neonatal deaths in New South Wales, Australia

This study identified the influences of maternal socio-demographic and antenatal factors on stillbirths and neonatal deaths in New South Wales, Australia. Bivariate and multivariate analyses were used to explore the association of selected antenatal and maternal characteristics with stillbirths and neonatal deaths. The findings of this study showed that stillbirths and neonatal deaths significantly varied by infant sex, maternal age, Aboriginality, maternal country of birth, socioeconomic status, parity, maternal smoking behaviour during pregnancy, maternal diabetes mellitus, maternal hypertension, antenatal care, plurality of birth, low birth weight, place of birth, delivery type, maternal deaths and small gestational age. First-born infants, twins and infants born to teenage mothers, Aboriginal mothers, those who smoked during the pregnancy and those of lower socioeconomic status were at increased risk of stillbirths and neonatal deaths. The most common causes of stillbirths were conditions originating in the perinatal period: intrauterine hypoxia and asphyxia. Congenital malformations, including deformities and chromosomal abnormalities, and disorders related to slow fetal growth, short gestation and low birth weight were the most common causes of neonatal deaths. The findings indicate that very low birth weight (less than 2,000 g) contributed 75.6% of the population-attributable risks to stillbirths and 59.4% to neonatal deaths. Low gestational age (less than 32 weeks) accounted for 77.7% of stillbirths and 87.9% of neonatal deaths. The findings of this study suggest that in order to reduce stillbirths and neonatal deaths, it is essential to include strategies to predict and prevent prematurity and low birth weight, and that there is a need to focus on anti-smoking campaigns during pregnancy, optimizing antenatal care and other healthcare programmes targeted at the socially disadvantaged populations identified in this study.     

Accuracy of industry and occupation on death certificates of electric utility workers: implications for epidemiologic studies of magnetic fields and cancer

A substantial epidemiologic literature has relied on occupation and industry information from death certificates to make inferences about the association of electric and magnetic field exposure with cancer, but the validity of the occupational data on death certificates is questionable. We compared occupation and industry information from death certificates to company work histories for 793 electric utility workers who died from brain cancer (n=143), leukemia (n=156), lung cancer (n=246, randomly sampled), and non-cancer causes (n=248, randomly sampled). Nearly 75% of death certificates correctly indicated utility industry employment and of those, 48% matched the longest held occupation derived from company work histories. Hence, only 36% matched on both industry and occupation. We computed odds ratios relating occupations involving magnetic field exposure to brain cancer and leukemia both for the occupation listed on the death certificate and for the longest-held occupation based on company records in order to examine the impact of exposure misclassification based on reliance on the death certificate information. For brain cancer, the odds ratio was 1.2 based on death certificates and 1.7 based on company work history, suggesting some attenuation due to misclassification. For leukemia, death certificate information yielded an odds ratio of 0.9, whereas company work histories yielded an odds ratio of 1.3. Although work histories are limited to the period of employment in a specific company, these data suggest that there is substantial misclassification in use of death certificate information on industry and occupation of utility workers, as found in other industries. The limited quality of occupation and industry information on death certificates argues against relying on such information to evaluate modest associations with mortality.     

Errors in birth registrations and coding of twins and higher order multiples.

Dizygotic compared with monozygotic conceptions are at decreased risk of fetal and infant death and serious morbidity in surviving infants. Different sex twin maternities must be dizygotic but miscoding and incorrect registration of sex and number of fetuses may lead to an incorrect assignment of zygosity. The aim of the study was to validate the coding and registration of number and sex of births in multiple pregnancies. Fetal and infant death registrations from all multiple maternities in England and Wales 1993-1998 were examined. There were 51,792 twin, 1627 triplet and 51 higher order multiple maternities that were registered. Among these there were 1926 fetal deaths, 58 of which were registered as being of indeterminate sex but were coded as male in 56 and female in 2 cases. A fetus papyraceous was registered as male in 19 and as female in 19 cases. Other fetal deaths weighing >/= 100g, with no mention of papyraceous on the death certificate, nevertheless, likely to be of indeterminate sex, were registered as male in 26 and as female in 23 cases. In 13 maternities, the number of infants registered at birth was less than the number mentioned on the registration certificate. It cannot be assumed that multiple births of different registered sex are dizygotic. As surviving infants from a monozygotic multiple birth are at much greater risk of infant death and serious morbidity than dizygotic multiple births, incorrect assignment of sex has important implications for parental counselling and may have medico-legal relevance when attributing negligence as the cause of morbidity in a survivor from a multiple pregnancy.