This document provides details about a lesson plan on verbal autopsy presented by Dr. P. Sujitha to 204 students. The plan includes an introduction to verbal autopsy, its history and uses, components of a verbal autopsy instrument, and the role of verbal autopsy in maternal death review. Verbal autopsy is used as a research tool to determine probable causes of death in places without reliable death registration or medical records. It involves interviewing family members about symptoms before death. The data collected is used by researchers, policymakers, and health programs.

1. VERBAL AUTOPSY
Dr.P.Sujitha, Post Graduate
Guide: Dr.R.Umadevi, Professor
Dr.N.B.Swetha,Assistant Professor
Department of Community medicine
1

2. LESSON PLAN
◦ Name of the lecturer: Dr. P. Sujitha
◦ Date: 19.08.2020 Time: 60 minutes
◦ No. of. Students: 204 Subject: Community Medicine
◦ Topic: VERBAL AUTOPSY
General objective: At the end of the session, the audience should
be able to describe the concept of verbal autopsy and its role in
death review
Specific learning objectives: At the end of the session, the
audience should be able to
1. Describe the concept of verbal autopsy
2. List the uses and users of verbal autopsy
3. Describe the components of Verbal autopsy instrument
4. Discuss the role of verbal autopsy in death review
2

3. S.No Content Method and Media Duration
1 INTRODUCTION Narration and LCD
projector
10 mins
2 HISTORY Narration and LCD
projector
5 mins
3 USES AND USERS OF VERBAL
AUTOPSY
Narration and LCD
projector
10 mins
4 VERBAL AUTOPSY INSTRUMENT Narration and LCD
projector
15 mins
5 ROLE OF VERBAL AUTOPSY IN
MATERNAL DEATH REVIEW
Narration and LCD
projector
10 mins
6 SUMMARY Discussion 10 mins
3

4. 4
Death at hospital Death at home

5. Introduction
5
Death registration
It is a mandatory document issued by registrar that declares
time, date and location of death and is entered in an official
register of deaths
Reported by any personnel with the concerned local
authorities, by filling up the forms prescribed by the Registrar.
Death certification
It is the official recording of persons death with cause of
death as stated by doctor or another responsible health
worker
This legal document is issued by medical professional
which states time, date, cause of death.

6. 21.1%
6
Office of Registrar General & Census Commissioner, India. Ministry of Home Affairs, Government of India

7. Need for mortality survey
◦ To have a count of all deaths
◦ To ascertain the cause of deaths
◦ These reliable data on causes of mortality lay
cornerstones for building solid evidence base for
health policy, planning, monitoring and evaluation.
7
AM Kadri. IAPSM’s Textbook of Community Medicine

8. 8
National Centre for Disease Information and Research,ICMR,e-Mortality

9. 9
Office of Registrar General & Census Commissioner, India. Ministry of Home Affairs, Government of India

10. Sample Registration
System
 SRS was initiated in mid 1960 to provide
reliable estimates of births and deaths and covers
the entire country
 SRS is the single most important source of data
on annual demographic indicators including deaths
in country.
10
Park K. Textbook of Preventive and Social medicine 25th edition.

11. Sample Registration
System
SRS is carried out by Office of Registrar General and Census
Commissioner under Ministry of Home Affairs, Govt. of India
Objectives of SRS are to provide
 Reliable estimates of birth rate, death rate at National level for
major States and at State level for Districts
 Data for other measures of fertility and mortality at higher
geographical levels
 Ideas about various heath programs like family welfare,
epidemic control, MCH etc
AM Kadri. IAPSM’s Textbook of Community Medicine 11

12. Sample Registration System
SRS is a dual record system
1. Continuous enumeration of births and deaths at National and
State level done by enumerator
2. Independent survey every 6 months by an investigator
supervisor at District level
◦ Both the data are matched
◦ Every unmatched or partially matched data is again verified by
visit to the respective household where the cause of death is
also recorded using verbal autopsy instrument
12
Park K. Textbook of Preventive and Social medicine 25th edition.

13. Verbal autopsy
Verbal autopsy is a research method that helps
determine probable causes of death in
populations without a complete vital registration
system and in cases where there is no medical
record or formal medical attention given.
13
AM Kadri. IAPSM’s Textbook of Community Medicine

14. Objective
Verbal autopsy helps to determine the cause of
death
 At community level
 Where there was no medical record
 No formal medical attention is given
 In developing countries where vital registration is
poor
14
AM Kadri. IAPSM’s Textbook of Community Medicine

15. Verbal autopsy
• Verbal autopsy used to ascertain the cause of a death based
on an interview with next of kin or other caregivers.
• The interview is done using a standardized questionnaire that
elicits information on :
 Signs, symptoms
 medical history
 circumstances preceding death.
15
AM Kadri. IAPSM’s Textbook of Community Medicine

16. Historical background
• In Europe, before the 19th century when modern
systems of death registration were implemented,
designated dead searchers visited the households
of deceased people to assess the nature of deaths.
16

17. • As an alternative, in the 1950s and 60s in Asia and
Africa, systematic interviews by physicians were
used to determine causes of death.
• As early as the 1950s lay reporting were employed
in countries with low coverage of medical access.
• In 1971, Two research projects were conducted in
Narangwal village in India were they named this
new technique “verbal autopsy”
17
The Narangwal nutrition study: a summary review. The American journal of clinical nutrition. 1978 Nov 1;31(11):2040-52.

18. • During 1970s, WHO continued to encourage lay reporting of
health information by people with no medical training, in such
settings and in 1975 an official lay reporting form was established.
• In 2007, needs and demands for standardization led to the 2007
publication of the WHO Verbal Autopsy standards.
• In 2012, WHO brought about standardised questionnaire to use
• Now verbal autopsy standard 2016 guidelines are in routine use
18
Verbal autopsy standards – WHO: www.who.int/healthinfo/statistics/verbal_autopsy

19. Verbal autopsy in India
 Until December 1998, cause of death data for rural areas
used to be collected under the Survey of Cause of Death
Rural scheme, from a sample of villages by lay diagnosis
and reporting system.
 From January 1999, a cause of death component was
merged with the SRS.
 After an initial pilot, in 2001 , the Government of India initiated a
process of doing verbal autopsy (VA) of about 45,000 deaths
(0.5% of all annual deaths) identified under SRS every year.
19

20. MILLION
DEATH
STUDY
(MDS)
20
Million Death Study (MDS):http://www.cghr.org/projects/million-death-study-project/

21. • One of the largest studies of premature mortality in the world.
• In collaboration with the ORGI, MDS monitored nearly 14 million people in
2.4 million nationally representative households in India between 1998-
2014
• Any deaths that occur in these households during this period were
assigned a probable cause, as determined by verbal autopsy.
• The results for the leading causes of death in India were provided to
governments, research agencies, and media so that they can take
action against preventable deaths.
21
Million Death Study (MDS):http://www.cghr.org/projects/million-death-study-project/

22. Uses of verbal autopsy
22
Verbal autopsy standards – WHO: www.who.int/healthinfo/statistics/verbal_autopsy
First, it has been primarily used as a research tool
Second, it has become a source of cause of death
statistics for population level cause-specific mortality
data to be used in policy, planning, priority setting.
Third, this data is used for monitoring progress and
evaluating the programme.

23. Users of verbal autopsy
Potential users of data generated through VA are
Researchers
Epidemiologists
Global-level decision-makers
National and sub-national decision-makers
Health system managers
23
Verbal autopsy standards – WHO: www.who.int/healthinfo/statistics/verbal_autopsy

24. Verbal autopsy instruments
Components of verbal autopsy instruments
1) Questionnaire
2) List of causes of death
3) Sets of diagnostic criteria for assigning causes of
death
24
Verbal autopsy standards – WHO: www.who.int/healthinfo/statistics/verbal_autopsy

25. Questionnaire
VA Forms
28 days or less
Fill Form 10A:
Neonatal deaths
29 days to 14
years
Fill Form 10B:
Child deaths
15 years or more
Fill Form 10C:
Adult deaths
Female 15-49
years
Fill Form 10D:
Maternal deaths
25
Verbal autopsy standards – WHO: www.who.int/healthinfo/statistics/verbal_autopsy

26. Questionnaire
The standard content will include-
◦ Unique ID or reference number for the VA questionnaire
◦ Date, place and time of the interview and identification of the
interviewer
◦ Key characteristics of the respondent
◦ Details of the deceased
The time, place and date of death
The name, sex and age of the deceased
The cause(s) of death and events leading to death according to the
respondent
26

27. Questionnaire
Sections of a standard Verbal Autopsy Questionnaire
◦ Sections 1 and 2 contain key identifying and socio-demographic
information.
◦ Section 3 provides essential information for assigning the cause of
death.
◦ Section 4 provides background information on deaths that occur in
non-enumerated populations.
◦ Section 5 includes an open narrative text field that allows for
comments and adding additional information
27
The 2014 WHO Verbal autopsy Instrument. Available athttp://www.who.int/healthinfo/statistics/verbalautopsystandards

28. 28
The 2014 WHO Verbal autopsy Instrument. Available athttp://www.who.int/healthinfo/statistics/verbalautopsystandards

29. CAUSE OF DEATH
WHO defines COD as
The disease which initiated the train of events leading
directly to death
OR
The circumstances of the accident or violence which
produced the fatal injury
29

30. Cause of death
Order the events in a chronological sequence.
The underlying cause of death is NOT:
The Mode of death: Eg: Respiratory/heart failure
OR
Contributory cause of death:
Eg: Diabetes before stroke
30

31. Cause of Death Assignment
◦ Cause-of-death registration in the context of verbal autopsy
aims to assign a single underlying cause of death.
◦ In order to collect reliable and useful statistical information,
each step must be performed in a standard fashion.
◦ As much as possible, try to code the underlying cause of death
& not the risk factor.
31

32. Diagnostic criteria
(algorithms):
Diagnostic criteria may also be called algorithms.
They describe which combination of symptoms,
duration and severity may lead to a specific
diagnosis.
32

33. Cause of Death
Example: Measles
Code for infectious disease as cause of death-VAs-
01.06 and ICD code-B05
33

34. ICD-10 codes for cause of
death list for VA 2016
• VAs-01 Infectious and parasitic diseases
• Non-communicable diseases
• VAs-02 Neoplasms
• VAs-03 Nutritional and endocrine disorders
• VAs-04 Diseases of the circulatory system
• VAs-05 Respiratory disorders
• VAs-06 Gastrointestinal disorders
• VAs-07 Renal disorders
• VAs-08 Mental and nervous system disorders
• VAs-09 Pregnancy-, childbirth and puerperium-related
• VAs-10 Neonatal causes of death
• VAs-11 Stillbirths
• VAs-12 External causes of death

35. 2016 cause of death list for verbal autopsy with
corresponding ICD-10 codes

36. • Earlier, two Physicians review of the questionnaires, andthe signs
and symptoms and then classify the cause of death without any
validation sample
• This approach was expensive and time consuming
• Another method of V
Adata analysis which is currentlyand
mostly in use is using computer algorithm.
• When the data from the questionnaire is inputted into the
computer, the data is analyzed and possible cause of deathis
displayed.
• It is more easier and less time consuming.
36

37. Sets of diagnostic criteria for
assigning causes of death.
Softwares’ are used for automated interpretation of VA
Currently, the two most commonly used programs are the
• InterVA method developed by the Umea University
(Sweden)
• Tariff method (SmartVA) developed by the Institute of
Health Metrics and Evaluation (USA).
37

38. Example
Adult female, aged 63
Narrative: Respondent thought person died of “unconscious”. This 63 year
old female had two years ago an attack on one side of the body in which
she could not move and her tongue was twisted also. She was seen by a
doctor at the hospital who gave her some blood thinner drugs and then
said all that could be done would be is to put her into a nursing home.
Reluctantly her son agreed. One month ago, she went unconscious and
then one day had a cough with high fever. She was drooling from her
mouth. Doctors gave her more intravenous medications, but she got worse
and died. She had no other past medical problems except for some blood
pressure in the past (she had not taken medications for a while).
38

39. Steps 1 and 2: Carefully read past medical history & narrative
AND highlight cardinal symptoms & negative evidence. Note
keywords. Consider diagnostic information provided:
Cardinal symptoms:
◦ “Got pneumonia while passed out” – Aspiration
Bronchopneumonia
◦ “unconsciousness” – prolonged coma
◦ “Paralysis on one side of the body” – preceding a stroke
Keywords include:
◦ “attack on one side”, “tongue twisted”, “blood pressure”,
“unconscious”
39

40. ◦ Step 3: Think of chronological sequence. Adhere to cardinal symptoms
& negative evidence. Do not imagine facts which are not in the record.
◦ Sequence of events:
“Got pneumonia while passed out”
“unconscious”
“Paralysis on one side of the body”
Step 4: Choose underlying cause of death. Select specific ICD code &
confirm against guidelines. Here Stroke/CVA (I64) is chosen.
40

41. Step 5: Reconsider ICD code using differential
diagnoses:
• Ischemic heart disease (I20- I25)
• Falls (W00-W19)
No history of chest discomfort possibly rules out
Ischemic heart disease and no history of falls
rules out the fall
41

42. Medical Certification of Cause
of death
42
Stroke/CVA
Pneumonia- Respiratory failure
Hypertension

43. 43

44. Methods
of
interpreting
V
A
data
44

45. Role of Verbal Autopsy in
Maternal Death Review - India
45

46. Role of verbal autopsy in
Maternal death review
NOTIFICATION
◦ Notification of maternal deaths within 24hours
◦ Notification includes all pregnancy related deaths
including suicides, accidents
◦ Use of semi structured VA format to conduct
community based audit and field based review of
each maternal death by PHC medical officer
46

47. Form 10D
Maternal
death
(Female aged
15-49 years)
47
Centre for Global Health Research

48. MDSR timelines
48
AM Kadri. IAPSM’s Textbook of Community Medicine

49. District VA meeting
 District collectors conduct the meeting once a month
 All maternal deaths occurred during the past one month are
reviewed
 All the service providers including the private service providers,
district health managers and relatives of the diseased
participate in VA meeting to discuss the findings
 The various delays, barriers in accessing care, delay in
providing care and quality of care are discussed
49
Guidelines for Maternal death Surveillance & Response

50. Later the service providers are sensitised about the various
delays and the quality of care
All the contributory factors for each maternal death are
analysed
The minutes of the meeting sent to commissioner MCH and
Welfare every month
Common factors are identified and informed to State level for
policy changes
50

51. 51
Guidelines for Maternal death Surveillance & Response

52. MINEr
VA
MINEr
VA
52

53. MINErVA-Mortality in India
established through Verbal Autopsy
◦ Online system inaugurated in Delhi AIIMS to provide
data on cause of death
◦ 19th November 2018 , online VA form coding platform
◦ Provide support for SRS
◦ Enables physicians to review the VA form and enter
the COD in the form of a standard international code
sitting at their office
53
MINErVA Coding Platform: http://minervacoding.aiims.edu/

54. Two online IT platforms
• A training platform
• which is in public domain meant for training of
physicians in ascertaining cause of death from
VAs
• A coding platform
• which is for network members to code
deaths identified under SRS based on the
VAforms.
54
MINErVA Coding Platform: http://minervacoding.aiims.edu/

55. • As of August 2019, Departments of Community
Medicine of 25 government and private medical
colleges from across the country are part of the
MINErVA network and have together enrolled 804
physician coders.
• The MINErVA Technical Advisory Group consists of
• Public health experts/ Clinicians
• Social scientists
• Statisticians
• Nominees from ORGI
• Ministry of Health and Family Welfare
• WHO
• Indian Council of Medical Research.
55
MINErVA Coding Platform: http://minervacoding.aiims.edu/

56. SWOT Analysis of VA
STRENGTHS
VA instrument facilitates the use of analytical
software for assigning the cause of death
The systematic application of VA instrument will
facilitate the application of VA in routine
surveillance systems and introduce more
consistency and cross comparability of mortality
data.
56

57. SWOT Analysis of VA
WEAKNESS
Adding or removing questions will impact the
comparability of data but also may compromise the
usability of analytical software for assigning cause of
death.
It may not be possible to use the existing analytical
software for assigning the newly added causes of death.
 Although it may not be an accurate method for
attributing causes of death at the individual level
57

58. SWOT Analysis of VA
OPPURTUNITIES
The application of VA instrument in routine use and
research with its standardized international set of
questions will facilitate the compilation of
databases that finally would provide the evidence
for stepwise improvement of verbal autopsy
questionnaire internationally, and become a basis for
continuous development of analytical methods.
58

59. SWOT Analysis of VA
THREATS
The quality of information on the diagnosis varies
depending on the skills of the interviewer and the
memory of the respondents.
59

60. Summary
 Verbal autopsy is a research method that helps to determine
probable causes of death
 Done using a standardized questionnaire
 Conducted as a component of SRS
 Separate forms for each group covering all age groups
 A cause-of-death list for verbal autopsy prepared according to
the ICD-10.
 Used as a research tool for policy making, planning, monitoring
and evaluation.
 Used as an essential substitute for medical certification of
cause of death.
60

61. Reference
 Park K. Textbook of Preventive and Social medicine 25th
edition.
 AM Kadri. IAPSM’s Textbook of Community Medicine
 The 2014 WHO Verbal autopsy Instrument. Available at
http://www.who.int/healthinfo/statistics/verbalautopsystandards
 Verbal autopsy standards – WHO:
www.who.int/healthinfo/statistics/verbal_autopsy
 Report On Medical Certification Of Cause Of Death 2017
https://censusindia.gov.in/2011-
Documents/mccd_Report1/MCCD_Report-2017.pdf
 MINErVA Coding Platform: http://minervacoding.aiims.edu/
61

62. Reference
 Guidelines for Maternal death Surveillance &
Response:https://nhm.gov.in/images/pdf/programmes/maternal-
health/guidelines/Guideline_for_MDSR.pdf
 Million Death Study (MDS):http://www.cghr.org/projects/million-death-
study-project/
 National Centre for Disease Information and Research,ICMR,e-
Mortality: https://ncdirindia.org/e-mor/
 Office of Registrar General & Census Commissioner, India. Ministry of
Home Affairs, Government of India: https://censusindia.gov.in/2011-
Common/orgi_divisions.html
 Kielmann AA, Taylor CE, Parker RL. The Narangwal nutrition study: a
summary review. The American journal of clinical nutrition. 1978 Nov
1;31(11):2040-52.https://pubmed.ncbi.nlm.nih.gov/102180/
62

63. 63