Dataset Information

Measuring mortality due to HIV-associated tuberculosis among adults in South Africa: Comparing verbal autopsy, minimally-invasive autopsy, and research data.

ABSTRACT:

Background

The World Health Organization (WHO) aims to reduce tuberculosis (TB) deaths by 95% by 2035; tracking progress requires accurate measurement of TB mortality. International Classification of Diseases (ICD) codes do not differentiate between HIV-associated TB and HIV more generally. Verbal autopsy (VA) is used to estimate cause of death (CoD) patterns but has mostly been validated against a suboptimal gold standard for HIV and TB. This study, conducted among HIV-positive adults, aimed to estimate the accuracy of VA in ascertaining TB and HIV CoD when compared to a reference standard derived from a variety of clinical sources including, in some, minimally-invasive autopsy (MIA).

Methods and findings

Decedents were enrolled into a trial of empirical TB treatment or a cohort exploring diagnostic algorithms for TB in South Africa. The WHO 2012 instrument was used; VA CoD were assigned using physician-certified VA (PCVA), InterVA-4, and SmartVA-Analyze. Reference CoD were assigned using MIA, research, and health facility data, as available. 259 VAs were completed: 147 (57%) decedents were female; median age was 39 (interquartile range [IQR] 33-47) years and CD4 count 51 (IQR 22-102) cells/?L. Compared to reference CoD that included MIA (n = 34), VA underestimated mortality due to HIV/AIDS (94% reference, 74% PCVA, 47% InterVA-4, and 41% SmartVA-Analyze; chance-corrected concordance [CCC] 0.71, 0.42, and 0.31, respectively) and HIV-associated TB (41% reference, 32% PCVA; CCC 0.23). For individual decedents, all VA methods agreed poorly with reference CoD that did not include MIA (n = 259; overall CCC 0.14, 0.06, and 0.15 for PCVA, InterVA-4, and SmartVA-Analyze); agreement was better at population level (cause-specific mortality fraction accuracy 0.78, 0.61, and 0.57, for the three methods, respectively).

Conclusions

Current VA methods underestimate mortality due to HIV-associated TB. ICD and VA methods need modifications that allow for more specific evaluation of HIV-related deaths and direct estimation of mortality due to HIV-associated TB.

SUBMITTER: Karat AS

PROVIDER: S-EPMC5363862 | biostudies-literature | 2017

REPOSITORIES: biostudies-literature

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Publications

Measuring mortality due to HIV-associated tuberculosis among adults in South Africa: Comparing verbal autopsy, minimally-invasive autopsy, and research data.

Karat Aaron S AS Tlali Mpho M Fielding Katherine L KL Charalambous Salome S Chihota Violet N VN Churchyard Gavin J GJ Hanifa Yasmeen Y Johnson Suzanne S McCarthy Kerrigan K Martinson Neil A NA Omar Tanvier T Kahn Kathleen K Chandramohan Daniel D Grant Alison D AD

PloS one 20170323 3

<h4>Background</h4>The World Health Organization (WHO) aims to reduce tuberculosis (TB) deaths by 95% by 2035; tracking progress requires accurate measurement of TB mortality. International Classification of Diseases (ICD) codes do not differentiate between HIV-associated TB and HIV more generally. Verbal autopsy (VA) is used to estimate cause of death (CoD) patterns but has mostly been validated against a suboptimal gold standard for HIV and TB. This study, conducted among HIV-positive adults, ...[more]

PMID: 28334030

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Project description:BackgroundThe South African national cause of death validation (NCODV 2017/18) project collected a national sample of verbal autopsies (VA) with cause of death (COD) assignment by physician-coded VA (PCVA) and computer-coded VA (CCVA).ObjectiveThe performance of three CCVA algorithms (InterVA-5, InSilicoVA and Tariff 2.0) in assigning a COD was compared with PCVA (reference standard).MethodsSeven performance metrics assessed individual and population level agreement of COD assignment by age, sex and place of death subgroups. Positive predictive value (PPV), sensitivity, overall agreement, kappa, and chance corrected concordance (CCC) assessed individual level agreement. Cause-specific mortality fraction (CSMF) accuracy and Spearman's rank correlation assessed population level agreement.ResultsA total of 5386 VA records were analysed. PCVA and CCVAs all identified HIV/AIDS as the leading COD. CCVA PPV and sensitivity, based on confidence intervals, were comparable except for HIV/AIDS, TB, maternal, diabetes mellitus, other cancers, and some injuries. CCVAs performed well for identifying perinatal deaths, road traffic accidents, suicide and homicide but poorly for pneumonia, other infectious diseases and renal failure. Overall agreement between CCVAs and PCVA for the top single cause (48.2-51.6) indicated comparable weak agreement between methods. Overall agreement, for the top three causes showed moderate agreement for InterVA (70.9) and InSilicoVA (73.8). Agreement based on kappa (-0.05-0.49)and CCC (0.06-0.43) was weak to none for all algorithms and groups. CCVAs had moderate to strong agreement for CSMF accuracy, with InterVA-5 highest for neonates (0.90), Tariff 2.0 highest for adults (0.89) and males (0.84), and InSilicoVA highest for females (0.88), elders (0.83) and out-of-facility deaths (0.85). Rank correlation indicated moderate agreement for adults (0.75-0.79).ConclusionsWhilst CCVAs identified HIV/AIDS as the leading COD, consistent with PCVA, there is scope for improving the algorithms for use in South Africa.

Project description:INTRODUCTION:There is a growing recognition of the importance of developing learning health systems which can engage all stakeholders in cycles of evidence generation, reflection, action and learning from action to deal with adaptive problems. There is however limited evaluative evidence of approaches to developing or strengthening such systems, particularly in low-income and middle-income settings. In this protocol, we aim to contribute to developing and sharing knowledge on models of building collaborative learning platforms through our evaluation of the Verbal Autopsy with Participatory Action Research (VAPAR) programme. METHODS AND ANALYSIS:The evaluation takes a participatory approach, focussed on joint learning on whether and how VAPAR contributes to its aims, and what can be learnt for this and similar settings. A realist-informed theory of change was developed by the research team as part of a broader collaboration with other stakeholders. The evaluation will draw on a wide variety of perspectives and data, including programme data and secondary data. This will be supplemented by in-depth interviews and workshops at the end of each cycle to probe the different domains, understand changes to the positions of different actors within the local health system and feedback into improved learning and action in the next cycle. Quantitative data such as verbal autopsy will be analysed for significant trends in health indicators for different population groups. However, the bulk of the data will be qualitative and will be analysed thematically. ETHICS AND DISSEMINATION:Ethics in participatory approaches include a careful focus on the power relationships within the group, such that all groups are given voice and influence, in addition to the usual considerations of informed participation. Within the programme, we will focus on reflexivity, relationship building, two-way learning and learning from failure to reduce power imbalances and mitigate against a blame culture. Local engagement and change will be prioritised in dissemination.

Project description:Background:Time-critical conditions (TCC) are estimated to cause substantial mortality in low and middle-income countries. However, quantification of deaths and identification of contributing factors to those deaths are challenging in settings with poor health records. Aim:To use verbal autopsy (VA) data from the Agincourt health and sociodemographic surveillance system in rural South Africa to quantify the burden of deaths from TCC and to evaluate the barriers in seeking, reaching and receiving quality care for TCC leading to death. Methodology:Deaths from 1993 to 2015 were analysed to identify causality from TCC. Deaths due to TCC were categorised as communicable, non-communicable, maternal, neonatal or injury-related. Proportion of deaths from TCC by age, sex, condition type and temporal trends was described. Deaths due to TCC from 2012 to 2015 were further examined by circumstances of mortality (CoM) indicators embedded in VA. Healthcare access, at illness onset and during the final day of life, as well as place of death, was extracted from free text summaries. Summaries were also analysed qualitatively using a Three Delays framework to identify barriers to healthcare. Results:Of 15?305 deaths, 5885 (38.45%) were due to TCC. Non-communicable diseases were the most prevalent cause of death from TCC (2961/5885 cases, 50.31%). CoM indicators highlighted delays in a quarter of deaths due to TCC, most frequently in seeking care. The most common pattern of healthcare access was to die outwith a facility, having sought no healthcare (409/1324 cases, 30.89%). Issues in receipt of quality care were identified by qualitative analysis. Conclusion:TCCs are responsible for a substantial burden of deaths in this rural South African population. Delays in seeking and receiving quality care were more prominent than those in reaching care, and thus further research and solution development should focus on healthcare-seeking behaviour and quality care provision.

Project description:ObjectivesCardiovascular diseases are the second leading cause of mortality behind HIV/AIDS in South Africa. This study investigates cardiovascular disease mortality trends in rural South Africa over 20+ years and the associated barriers to accessing care, using verbal autopsy data.DesignA mixed-methods approach was used, combining descriptive analysis of mortality rates over time, by condition, sex and age group, quantitative analysis of circumstances of mortality (CoM) indicators and free text narratives of the final illness, and qualitative analysis of free texts.SettingThis study was done using verbal autopsy data from the Health and Socio-Demographic Surveillance System site in Agincourt, rural South Africa.ParticipantsDeaths attributable to cardiovascular diseases (acute cardiac disease, stroke, renal failure and other unspecified cardiac disease) from 1993 to 2015 were extracted from verbal autopsy data.ResultsBetween 1993 and 2015, of 15 305 registered deaths over 1 851 449 person-years of follow-up, 1434 (9.4%) were attributable to cardiovascular disease, corresponding to a crude mortality rate of 0.77 per 1000 person-years. Cardiovascular disease mortality rate increased from 0.34 to 1.12 between 1993 and 2015. Stroke was the dominant cause of death, responsible for 41.0% (588/1434) of all cardiovascular deaths across all years. Cardiovascular disease mortality rate was significantly higher in women and increased with age. The main delays in access to care during the final illness were in seeking and receiving care. Qualitative free-text analysis highlighted delays not captured in the CoM, principally communication between the clinician and patient or family. Half of cases initially sought care outside a hospital setting (50.9%, 199/391).ConclusionsThe temporal increase in deaths due to cardiovascular disease highlights the need for greater prevention and management strategies for these conditions, particularly for the women. Strategies to improve seeking and receiving care during the final illness are needed.

Dataset Information

Measuring mortality due to HIV-associated tuberculosis among adults in South Africa: Comparing verbal autopsy, minimally-invasive autopsy, and research data.

Background

Methods and findings

Conclusions

Publications

Measuring mortality due to HIV-associated tuberculosis among adults in South Africa: Comparing verbal autopsy, minimally-invasive autopsy, and research data.

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