Verbal autopsy

Verbal autopsy
04-02-2020 Dr.Aman Bansal 1

Content
• Need for mortality data collection
• Methods to identify causes of
deaths
• Definition
• Objective
• Need
• Uses
• Users
• Historical background
• Need and demand of
standardization
• Components of 2007 WHO VA
questionnaire
• Automated interpretation of VA
• WHO 2016 VA Standards
• MDR
• CDR

Mortality surveillance
• It has two components –
1. To count all the deaths
2. To ascertain the cause of death
in all of them or a representative subsample

Registration of Deaths in India
SYSTEM BY TO
Civil registration system By next of kin
By hospitals
Registrar birth and
death
Panchayati raj system Gram sewak / gram
panchayat member
In villages

METHODS OF MORTALITY DATA COLLECTION
• Civil registration systems
• Population-based reporting systems
• Demographic surveys.
• Reproductive Age Mortality Studies (RAMOS)
• Census
• Annual survey
• Sample Registration System

Ascertaining cause of death
• Hospital deaths are certified by a doctor under MCCD.
• Limitations with the MCCD:
1. Coverage.
2. Majority of deaths in India do not take place at hospitals
• especially in rural and tribal areas.

Reporting under MCCD
• As per ORGI in 2015, only about 20% of the reported deaths
and 14% of all deaths were medically certified.

NEED FOR MORTALITY DATA COLLECTION
• Reliable data on the levels and causes of mortality are
cornerstones for building a solid evidence base for
• health policy
• planning
• monitoring and evaluation.

14 (3), 154-62 May-Jun 2001 PMID: 11467144
Cause of Death Reporting Systems in India: A Performance Analysis
P Mahapatra 1, P V Chalapati Rao

Abstract
Background: Reliable statistics on the causes of death in the population are essential for setting priorities in the health
sector. Most cause of death reporting systems in developed countries rely on medical certification of the cause of death
according to the International Classification of Death (ICD-10), and have achieved near-total coverage. Developing
countries such as India, where adequate medical facilities are not available, depend on lay reporting of the cause of
death in rural areas, using a sample registration system. The use of the cause of death statistics in India is questioned in
view of the poor coverage, and poor compliance with guidelines for cause of death reporting, coding and classification.
Methods: A brief description of the reporting system in India is followed by the characteristics of a usable cause of death
reporting system. We identified 9 criteria based on a review of the literature and our own assessment of the problem.
The performance of the cause of death reporting system for rural and urban areas of India was examined against each
of the 9 criteria. We offer a subjective rating on a three-category rating scale consisting of (i) satisfactory, (ii) tolerable,
and (iii) poor.
Results: The major factors affecting the use of the cause of death statistics in India are: (i) poor coverage; (ii) high
incidence of unclassifiable deaths; (iii) long delay and irregular publication of statistics; and (iv) lack of systematic
screening.
Conclusions: We recommend the following steps to improve the usability of cause of death statistics in India.
Introducing periodical reviews jointly by the Departments of Health and Municipal Administration to identify non-reporting
municipalities, sample units, and further identification of non-reporting health care institutions sustained over a period of,
say, five years will raise coverage substantially. The other measures include: (i) training programmes to build up cause of
death report writing skills among physicians; (ii) compilation and publication of cause of death statistics at the state level;
(iii) sponsored research on the cause of death reporting structure and its implications for policy-making; and (iv)
computerization of filling, tabulation and flow of cause of death statistics at the municipality and the state levels. To
reduce the unusually high level of unclassifiable deaths, the Registration of Births and Deaths Act should be amended to
ensure that hospitals and health care institutions maintain medical records. For accurate cause of death data from rural

Verbal Autopsy
• Verbal autopsy is a method 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.

MAIN OBJECTIVE
• Is to describe the causes of death at the community level
• Where civil registration and death certification systems are
weak
and
• Where most people die at home without having had contact with
the health system.

Need of Verbal Autopsy
• VA has become a primary source of information
 about causes of death in populations lacking vital
registration and medical certification.
• It has become an essential public health tool
 for obtaining a reasonable direct estimation of the cause
structure of mortality at population level,

Components of a standard VA instrument
• Questionnaire,
• List of causes of death
• Sets of diagnostic criteria for assigning causes of death.

USES
• First, it has been primarily used as a research tool
• longitudinal population studies
• intervention research
• epidemiological studies.
• Second, it has become a source of cause of death statistics
• to meet the demand for population-level cause specific
mortality data to be used in policy, planning, priority setting
and benchmarking.
• to be used for monitoring progress and evaluating what
works and what does not.

Application of VA
• Clinical trials and large-scale epidemiological studies
• Demographic surveillance systems
• National sample surveillance systems
• Household surveys

USERS
• Researchers
• Epidemiologists
• Global-level decision-makers
• National and sub-national decision-makers
• Health system managers

Limitation of VA
• Although it may not be an accurate method for attributing
causes of death at the individual level
• VA cannot ascertain all causes of death and, as many validation
studies have shown.

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.

• As an alternative, in the 1950s and 60s in Asia and Africa,
systematic interviews by physicians were used to determine
causes of death.
• Workers at the Narangwal project in India labelled this new
technique “verbal autopsy”

• The interest of WHO in VA (formerly “lay reporting”) of health
data was first demonstrated in a publication by Dr. Yves Biraud
in 1956.
• During the 1970s, WHO encouraged the use of lay reporting of
health information by people with no medical training, leading to
development in 1975 of lay reporting forms (WHO 1978).

• Since the late 1970s and early 80s when the following
questionnaires first emerged
• Reproductive Age Mortality Studies (RAMOS),
• MATLAB (Bangladesh)
• NIAKHAR (Senegal),

• The past two decades have seen a proliferation of interest,
research and development in all aspects of the VA process,
including
• VA data-collection systems,
• VA questionnaires’ content and format,
• Cause of death assignment process,
• Coding and tabulation of causes of death,
• Validation of VA instruments.

Needs and demands for standardization

WHO_2007 VA standards tools included
• Verbal autopsy questionnaires for three age groups
• under four weeks
• four weeks to 14 years
• 15 years and above
• Cause of death certification and coding resources consistent
with the ICD-10
• A cause-of-death list for VA mapped according to the ICD-10

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).

• To facilitate the application of the two commonly used and publicly
available automated methods for interpreting VA
• To allow comparison the causes of death data determined by these
methods comparative analysis of these commonly used automated
methods of VA interpretation,

• The 2016 version of the WHO verbal autopsy instrument is
suitable for routine use.
• Based on the 2012 instrument, experiences with the interim
2014 version
• questions have been added or edited to facilitate the use of
the publicly available analytical software

• The questions allow for responses with a simple yes or no
answer, multiple choice, or a duration in some instances.
• This approach makes the instrument usable with analytical
software that assigns causes of death

2016 WHO VA instrument
• It is intended to allow for simple and inexpensive identification
of causes of death in places where no other routine system is in
place and will serve the needs of countries’ civil registration and
vital statistics (CRVS) systems.
• Independently, this instrument can also be used in research and
disease specific programmes
• Intended for strengthening national vital statistics systems

• The systematic application of the 2016 WHO VA instrument will
facilitate the application of VA in routine surveillance of vital events
and introduce more consistency and crosscomparability of VA-derived
mortality data.
• The application of the 2016 Instrument in routine use and research
with its standardized international set of questions will facilitate the
compilation of larger databases that finally would provide the
evidence for stepwise improvement of VA questionnaires
internationally, and become a basis for continuous development of
analytical methods.

VA 2016 Implementation Kit
• A set of sample questionnaires
• Training curricula and template agendas for training of
interviewers, master trainers and interviewers

Sections of the 2016 WHO VA instrument

• 1. Preset HIV-Malaria mortality and season
• 2. Information on the respondent and background about
interview;
• 3. Information about the deceased and vital registration;
• Information on the deceased
• Civil registration numbers.
• 4. History of injury/accidents;

• 5. Health history;
• Duration of illness
• Medical history associated with final illness
• General signs and symptoms associated with final illness
• Signs and symptoms associated with pregnancy and women
• Neonatal and child history, signs and symptoms
• Health service utilization
• Background and context
• Death certificate with cause of death.
• 6. Open narrative (text field).
• Check list of additional items to record in the narrative open
space.

Sample questionnaires are provided for three age groups
• Under four weeks
• 4 weeks-11 years,
• 12 years and above.

• To develop an adequate instrument for application in large-
scale surveillance, the VA instrument needs to have a system
that synergizes with other national mechanisms that are already
in place.
• A permanent team that conducts Verbal autopsies on a
representative sample of deaths is likely the most feasible way.

VA interviewer
• Typically it would take at least five VA interviews to become confident
in doing VA interviews.
• The name of the interviewer and date, time and duration of the
interview should also be retained in the database

Appendix 1: 2016 cause of death list for verbal
autopsy with corresponding ICD-10 codes
(identical with 2014)

• 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

The WHO Verbal Autopsy (VA) Reference Group
• It was established at the first meeting of the WHO Reference
Group on Global Health Statistics, 9–10 December 2013.
• Chaired by Daniel Chandramohan of the London School of
Hygiene and Tropical Medicine,
• The group brought together experts in this field to support WHO
in the development of WHO VA standards.
• The working group was re-constituted as a WHO VA Reference
Group (VARG), which convened for the first time in Seoul,
South Korea at the annual meeting of the WHO Family of
International Classifications (WHO-FIC) Network in October
2018.

VARG supports and advises WHO regarding
• Development and maintenance of WHO VA standards and respective VA instrument with
evidence from the field;
• Standards and recommendations for VA training and implementation;
• Advancement of methods and tools for assigning causes of death from VA interviews;
• Use of the causes of death data determined by VA;
• Use of the VA causes of death data as a complement to medically certified cause of death
data;
• Quality assessment and assurance of VA data;
• Methods for comparing and evaluating VA results, including causes of death distribution
estimated by different VA instruments.

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.

MILLION
DEATH
STUDY
(MDS)

• One of the largest studies of premature mortality in the world.
• In collaboration with the Registrar General of India, the MDS will
monitor 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
will be assigned a probable cause, as determined by a method
called verbal autopsy.
• The results for the leading causes of death in India will be
provided to governments, research agencies, and media as
they become available so that they can take action against
preventable deaths.

• Full-time, non-medical field workers were trained
• to record written narratives from families or other reliable informants in
the local language describing the events that preceded the death.
• In addition, answers to standard questions about key symptoms were
also recorded.
• These records were then scanned and randomly sent to two of 130 trained
physicians,
• who independently assigned a probable underlying cause of death to
each case.
• In cases where the physicians did not agree on the cause of death, the
conflicting physicians were given the other physician’s notes, and cases
were anonymously reviewed again.
• Further disagreements were resolved by the opinion of a third, senior
physician.

Concerns with VA under MDS
• India’s mortality data being managed by an international agency.
• This is in keeping with a global concern about data privacy and
protection and a movement toward safeguarding national data.
• Other concerns with the existing system are the 5–6 years delay in the
release of reports and the shrinking number of deaths within the
existing sampling units due to declining mortality rates.
• This impacts the ability and precision of the system to generate
state-level estimates and estimation of maternal mortality

Mortality in India Established through
Verbal Autopsies
MINErVA

MINErVA
MINErVA

• 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.

Two online IT platforms
• A training platform (http:// causeofdeathindia.com)
• which is in public domain meant for training of physicians in
ascertaining cause of death from Vas and
• A coding platform (http://minervacoding.aiims.edu)
• which is for network members to code deaths identified
under SRS based on the VA forms.

• The MINErVA network will work to strengthen the mortality
surveillance system in India by
• Ensuring timeliness of data collection and availability
• Improving the quality of VA
• Its coding by leveraging information technology in the
process of data collection and coding.
• This development also means that the system has moved from
a “study” to a “surveillance” mode.

USE OF VERBAL AUTOPSY BY HEALTH WORKERS IN U5 CHILDREN

CRITICAL APPRAISAL
• India has committed itself to SDG’s
• SDGs have specific targets for deaths in specific age groups (infant
and neonatal), pregnancy-related deaths, and deaths due to specific
diseases such as NCDs, tuberculosis, or malaria.
• Having a robust mortality surveillance system is not a luxury but an
essential prerequisite for any country that is interested in improving
the health of its citizens.

CRITICAL APPRAISAL
• However, the Ministry of Health presently does not have an adequate
stake in the current mortality surveillance system despite being its
prime user.
• An effective mechanism needs to be put in place for better
harmonization between the Ministries of Health and Home Affairs.
• In the long term, we should integrate civil registration with the
primary health-care system and conduct VAs on all nonhospital
deaths.
• This has a great transformative potential in making mortality
indicators useful for monitoring the health of the nation.

• THANK YOU

Verbal autopsy

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