Burial Surveillance in Addis Ababa: Providing Aids Related Mortality Data for Monitoring Program Impact

Gebrekidan, Tekebash Araya (2012) Burial Surveillance in Addis Ababa: Providing Aids Related Mortality Data for Monitoring Program Impact. PhD thesis, Addis Ababa University.

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Background: The Addis Ababa Mortality Surveillance Program was established in 2001 in Addis Ababa, the capital of Ethiopia as part of the Master of Public Health (MPH) work of TA, the Principal Investigator. In the last three decades, HIV/AIDS emerged as major health problems of adults, especially in developing countries. Reliable cause-specific mortality data were crucial resources for health monitoring, service planning and prioritization for the prevention and treatment of the HIV/AIDS epidemic. Objective: The major objective of this study was to monitor the impact of HIV/AIDS on adult mortality and the mitigating effect of ART on adult HIV/AIDS-mortality in the population of Addis Ababa. Methods: To address the aforementioned objective, various research methods were triangulated. As baseline data, prospective surveillance of burials was instituted in February 8, 2001 at all cemeteries in Addis Ababa, the capital of Ethiopia; and all deaths were registered continuously. Trained cemetery-based clerks registered the socio-demographic profile including address and lay reports of cause of death of the deceased from close relatives or friends performing the pre-requisites for burial. Pairs of trained interviewers conducted verbal autopsy interviews on random samples of burial records. By tracing the residential house of the deceased, a next of kin of the deceased was interviewed on the symptoms and events during the illness preceding the death using a standard verbal autopsy questionnaire. An independent panel of physician reviews and InterVA model were used interchangeably on the completed verbal autopsy information and probable underlying causes of death were assigned. A reference standard (gold standard) was constructed using prospective surveillance of patients in Zewditu Memorial Hospital in Addis Ababa, whereby patients were approached for an HIV-test (2003- 2004). Patients with known HIV-serostatus who either died in the hospital or elsewhere after discharge were linked with the burial surveillance. One hundred and ninety three adult hospital cases were matched with the burial records for which verbal autopsy interviews were conducted and the 167 had complete verbal autopsy information (response rate=86%). An independent panel of physicians reviewed the 167 casesand assigned probable underlying causes of deaths. The same data was also compared with the InterVA model to interpret the verbal autopsy interviews. A range of analyses were used to obtain cause-specific mortality fractions: Firstly, by dichotomizing the reference standard and the physician verbal autopsy diagnoses into AIDSand Non-AIDS, sensitivity and specificity were computed to validate the physician verbal autopsy diagnosis with the reference standard in diagnosing HIV and AIDS-related deaths. Secondly, using the Cohen’s Kappa Statistic (1) the agreement between two independent physician verbal autopsy reviewers in diagnosing HIV and AIDS-related causes of deaths was evaluated. Thirdly, the level of HIV-related mortality reduction after the introduction of large scale antiretroviral therapy was also determined using burial surveillance data in combination with the verbal autopsy physician diagnoses. The period before 2005 was defined as the preART era and that from 2005-2009 as the ART era. HIV-related specific mortality fractions were computed by age, sex and year of burial to examine the mortality trends before and during the ART era. Fourthly, sensitivity, specificity and CSMFs were computed using the interpreted verbal autopsy information by the InterVA model as indicators of the diagnostic accuracy of the InterVA model Results: The major findings obtained in this study revealed that triangulating burial surveillance with the verbal autopsy method and surveillance on hospital-based patients constitutes a unique data source for studying population-level cause-specific mortality patterns and in particular for adult HIV-and AIDS-specific mortality; and the effectiveness of ART on HIV/AIDS-related mortality. By reviewing verbal autopsy information, physicians accurately identified AIDS-related deaths with an acceptable level of sensitivity and specificity of 0.88 (95% CI: 0.80–0.93) and 0.77 (95% CI: 0.64–0.87), respectively, with high level of agreement between the first two physicians with K ranging from the early years 0.60 - 0.80. A significant reduction in HIV/AIDS-specific mortality was observed in the adult population after the introduction of ART: HIV/AIDS- related deaths in 2009 were 33% fewer than in 2001; and the proportion of HIV-related deaths was reduced from 44% in the pre-ART to 20% in the ART era. The InterVA model yielded sensitivity and specificity of 0.82 (95% CI: 0.74–0.89) and 0.76 (95% CI: 0.64–0.86), respectively, in diagnosing HIV/AIDS. The model also estimatedAIDS-specific mortality fraction at 61.7% (95% CI: 54–69%), that was close to 64.7% (95% CI: 57–72%) in the reference standard. Conclusions and Recommendations: In a setting where vital registration is absent and hospital statistics are incomplete, the methods used in this study served as a partial substitute for a full-fledged vital registration system. The accurateness and agreement of the panel of physicians in diagnosing HIV/AIDS-related deaths based on verbal autopsy information was demonstrated. Burial data combined with information from verbal autopsy interviews showed a significant reduction in HIV/AIDS-related deaths during the provision of free ART. The InterVA model performed well in diagnosis to be an easy to use and cheap alternative to physician review for assessing HIV/AIDS-related mortality. Expansion of burial surveillance coupled with verbal autopsy and hospital surveillance is recommended in similar settings, where vital registration is non-existent, to track large-scale population level interventions. Verbal autopsy diagnoses provided by physicians are reliable and thus a single verbal autopsy coder is practical for programmatic purposes in countries where there is critical shortage of doctors. Utilization of the InterVA model should be considered in times researchers sought cost-reduction.

Item Type: Thesis (PhD)
Uncontrolled Keywords: HIV/AIDS; mortality; surveillance; prospective burial surveillance; verbal autopsy; hospital patients; HIV-serostatus; methods; data; cause of death; ART; physician verbal autopsy; review; physician accuracy; InterVA model; urban population, adult mortality, significant reduction
Subjects: R Medicine > RA Public aspects of medicine > RA0421 Public health. Hygiene. Preventive Medicine
Divisions: Africana
Depositing User: Emmanuel Ndorimana
Date Deposited: 25 Jul 2018 14:23
Last Modified: 25 Jul 2018 14:23
URI: http://thesisbank.jhia.ac.ke/id/eprint/8155

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