VERBAL AUTOPSY (VA)KORAY HARUN MUNAWAR

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OUTLINE OF PRESENTATION• DEFINITION OF VERBAL AUTOPSY (VA)• INTRODUCTION AND DEVELOPMENT OF VA• THE USAGE OF VA• METHODS OF INTERPRETING VA DATA• IMPORTANCE OF VA• INSTANCES OF VA WAS USED• CONCLUSION• REFERENCE

DEFINITION OF VERBAL AUTOPSY(VA)• Verbal autopsy is a research method that helps

determine probable causes of death in cases where there is no medical record or formal medical attention given.

• Verbal autopsy (VA) is a method of determining individuals’ causes of death and cause-specific mortality fractions in populations without a complete vital registration system.

INTRODUCTION AND DEVELOPMENT OF VA

• The term verbal autopsy was first coined in research projects by the Department of International Health of Johns Hopkins School of Hygiene and Public Health which ran from 1965 to 1973 in Punjab, India.

• These two research projects were located in villages near Ludhiana, with headquarters in Narangwal village.

• These projects were aimed at assessing the relationships between nutrition, infection and child development, and

• the acceptance of family planning services by rural communities in response to maternal and early child care service packages

INTRODUCTION AND DEVELOPMENT OF VA

• Feeding centers and health care for under-5s, and on maternal and newborn health care services were created in various villages in the Narangwal district.

• Early In 1971, results from the nutrition villages showed no significant decrease in child mortality, and causes and circumstances of child deaths had remained largely unknown

• In response, an information system was established, wherein all child deaths in the villages had to be reported to the Narangwal Project Office by the resident health worker within five days

INTRODUCTION AND DEVELOPMENT OF VA

• One of the project physicians then went to the concerned family and through intense questioning of close relatives as to the signs and symptoms of the process leading to death.

• Review of the child’s health records supplemented by visits to the external health care provider if such was the case.

• These are all done to established possible reasons for, and a most likely cause of death.

• Recommendations from the causes of death obtained through verbal autopsy, were implemented. There was a significant reduction in child morbidities and mortalities

INTRODUCTION AND DEVELOPMENT OF VA

• In 1972, results from the two projects were presented to the project office in Narangwal

• The term Verbal Autopsy was used ‘in irony’ by a visiting medical dignitary who not only questioned the results but also the method, labelling it ‘’unscientific”.

• The term was retained by the then director of the two projects, Carl E. Taylor, chairman of the Department of International Health and he also chaired the conference.

• Seven years later (1980), the Ministry of Health of Egypt conducted an investigation into prevention of child mortality from developmentally disabled

INTRODUCTION AND DEVELOPMENT OF VA

• The verbal autopsy method as originally developed in Narangwal was slightly modified to the Egyptian setting. It was used to identify prevailing mortality patterns among preschoolers.

• Following implementation of different treatment schedules, child mortality rates dropped significantly by 40% in specific input villages over the period of study.

• The project site was re-visited six years following completion of the investigation confirming utility and effectiveness of the V.A. method, and applied intervention modalities respectively.

INTRODUCTION AND DEVELOPMENT OF VA

• As early as the 1950s forms of VA called lay reporting were employed in countries with low coverage of medical access.

• The World Health Organization (WHO) continued to encourage lay reporting in such settings and in 1975 an official lay reporting form was established.

THE USAGE OF VERBAL AUTOPSY• The past two decades have seen a proliferation of

interest, research and development in all aspects of the VA process, including data-collection systems where VA is applied

• Needs and demands for standardization of VA, led to the 2007 publication of the WHO VA standards, which many researchers have adopted.

THE USAGE OF VERBAL AUTOPSY• The standards included:1. Verbal autopsy questionnaires for three age

groups (under four weeks; four weeks to14 years; and 15 years and above);

2. Cause of death certification and coding resources consistent with the International Classification of Diseases and Related Health Problems, tenth revision (ICD-10); and

3. A cause-of-death list for verbal autopsy prepared according to the ICD-10

THE USAGE OF VERBAL AUTOPSY• However, the WHO 2007 instrument was modified

in several projects to accommodate the local needs.

• 2012, a new VA instrument was created as a modified version of the 2007 instrument.

• The 2012 instrument eliminated unreported causes and focus on useful questions.

• It was designed to facilitate VA use in routine vital registration systems to improve national cause-specific mortality data.

THE USAGE OF VERBAL AUTOPSY• The full set of questions and the resulting full

questionnaire of the 2012 instrument included1) Personal informationa) Information on the deceasedb) Vital registration2) Information on the respondent

THE USAGE OF VERBAL AUTOPSY3) Cause of death• a) Medical history• b) General signs and symptoms• c) Signs and symptoms associated with pregnancy• d) Neonatal and child history, signs and symptoms• e) History of injuries and accidents• f) Risk factors• g) Health service utilization

THE USAGE OF VERBAL AUTOPSY4) Background and context

5) Recommended optional open narrative text field

THE USAGE OF VERBAL AUTOPSY• Also, the following are indicated on the

questionnaire form; 1. A unique ID, control or reference number for the

VA questionnaire being completed;2. The date, place and time of the interview and

identity of the interviewer;3. Key characteristics of the respondent;4. The time, place and date of death;5. The name, sex and age of the deceased

THE USAGE OF VERBAL AUTOPSY• Interviewers should be trained on the

instrument and on conducting interviews with persons that may still be in mourning.

• Interviewers should be given enough time to carry out their task in VA.

THE USAGE OF VERBAL AUTOPSY• Interviewers involved in the application of the VA

should have the following minimum qualifications:1. Have completed at least secondary school and

have good working knowledge in the relevant local language(s)

2. Be acceptable to the local community; where possible, selected by the local community;

3. Have good training in conducting VA interviews;4. Know very well the content and uses of the VA

instrument

Methods of interpreting VA data• Three or more Physicians review of the

questionnaires, and the signs and symptoms and then classify the cause of death without any validation sample

• This approach can be expensive as it involves approximately three or more physicians, each taking 20–30 minutes to review symptoms and classify each death.

• Judgments by these doctors are highly sensitive to their socio-demographic location. So physicians need to come from local areas.

Methods of interpreting VA data• Another method of VA data analysis which is

currently and mostly in use is using computer algorithm.

• Database is created for all the causes and risk factors related to death are encrypted.

• When the data from the questionnaire is inputted into the computer, the data is analyzed and possible cause of death is displayed.

• It is more easier and less time consuming.

Importance of Verbal Autopsy• First, it has been primarily used as a research tool in

population studies, intervention research or epidemiological studies.

• Second, it has become a source of cause of death statistics to meet the demand for population cause-specific mortality data to be used in policy, planning, priority setting and benchmarking.

• Third, VA data are gaining acceptance as a source of cause of death statistics because vital registration coverage has not significantly improved in developing countries.

Importance of Verbal Autopsy• VA methods have been used in the following data

collection systems: clinical trials and large-scale epidemiological studies; demographic surveillance systems; national sample surveillance systems; and household surveys

INSTANCES VERBAL AUTOPSY WAS USED

• Noteworthy uses of the verbal autopsy method include the Million Death Study in India.

• China's national program to document causes of death in rural areas.

• And the Global Burden of Disease Study 2010

CONCLUSION• Verbal autopsy is a method used in determining

the cause specific mortality.• It is used mostly in developing countries where

vital registration is poor.• It has undergone modifications since it inception

and currently, the WHO 2012 verbal autopsy standard instrument is used.

REFERENCE1. Verbal Autopsy (VA) | Institute for Health

Metrics and• www.healthdata.org/verbal-autopsy2. Verbal Autopsy Methods with Multiple Causes of - Gary King• gking.harvard.edu/files/vamc.pdf3. What is Verbal Autopsy? www.cghr.org4. Verbal autopsy standards – WHOwww.who.int/healthinfo/statistics/verbal_autopsy