WHO-FIC Education Committee 5 May 2006

1
WHO-FIC Education Committee5 May 2006

• Training Certifiers of cause of death
• Roberto Becker

2
Preparation

• Workshop format
• Who extends invitations
• Time
• Duration
• Content / adaptations
• Local examples

3
Content

• Uses of mortality data
• Role of the certifier
• Work done with the information
• International form for medical certification
• How to certify
• Special issues
• Examples
• Standard definitions
• Exercises

4
The importance ofMortality statistics
5
USES OF MORTALITY DATA1. HEALTH SITUATION
ANALYSIS

• WHO (SEX, AGE), WHEN, WHERE, WHAT CAUSE(S)
• HOW LONG AND HOW THE PEOPLE LIVE
• HEALTH (INDIRECT) INDICATORS
• CRUDE MORTALITY RATE
• LIFE EXPECTANCY / IMPACT OF THE CAUSES
• INFANT MORTALITY RATE
• MATERNAL MORTALITY RATE/RATIO
• YEARS OF POTENTIAL LIFE LOST
• SPECIFIC RATES (CAUSE, SEX, AGE)
• MORTALITY DATA MAIN INSTRUMENT TO IDENTIFY
• PUBLIC HEALTH PROBLEMS
• GROUPS AT RISK
• NEEDS OF MEDICAL AND PUBLIC HEALTH RESEARCH
• LEADING CAUSES OF DEATH - PRIORITIES

6
USES OF MORTALITY DATA 2. EPIDEMIOLOGICAL
SURVEILLANCE

• MAIN OR FIRST SOURCE OF DATA FOR SOME DISEASES OR
  CONDITIONS
• HIV/AIDS
• YELLOW FEVER
• RABIES
• ACCIDENTS AND POISONING
• VIOLENCE
• USE AT LOCAL LEVELS
• LIST OF DIAGNOSTIC TERMS (PARALYSIS,
  IMMUNODEFICIENCY)
• INVESTIGATION
• CONFIRMATION OR CHANGE CHECKING WITH STATISTICS
• SPECIFIC ACTIONS
• GROUPS OF POPULATION
• WOMEN (MATERNAL MORTALITY)
• CHILDHOOD
• ADOLESCENCE
• ELDERLY

7
USES OF MORTALITY DATA3. EVALUATION /
INVESTIGATION

• QUALITY AND RESULTS OF HEALTH CARE
• MATERNAL MORTALITY
• CASE FATALITY RATE
• SURVIVAL
• HEALTH PROGRAMS, SPECIFIC DISEASES / CONDITIONS
• VACCINE PREVENTABLE
• TUBERCULOSIS
• DIABETES
• CHOLERA
• HYPERTENSION
• ISCHEMIC HEART DISEASES
• NEOPLASMS
• ACCIDENTS AND VIOLENCE
• TECHNOLOGY
• CASE FATALITY RATE (ACUTE DISEASES)
• SURVIVAL (CHRONIC DISEASES)
• NEOPLASMS
• HIV/AIDS
• RISK FACTORS / MULTIPLE CAUSES / LINKED CAUSES

8
Medical Certification of Mortality

• Legal
• To certify the occurrence of a death
• To define the nature natural causes or not
• Civil Registration / vital statistics
• Statistical
• Demographic aspects sex, age, ethnic group,
  residence, socioeconomic data
• Epidemiology / public health
• Cause(s)
• Data for specific groups infant and maternal
  deaths
• 1925 Health Organization of League of Nations
  proposed a model for medical certification
• 1948 ICD-6 Adopted as international form
• 1950 Worldwide use

9
Work done with the information

• Selection of underlying cause
• Definition of Underlying cause
• Coding diagnostic terms
• General Principle, Sequences, Rules
• Validation and consistency
• Cause by sex by age
• Corrections
• Processing
• Analysis
• Decision making
• Dissemination

10
INTERNATIONAL FORM OF MEDICAL CERTIFICATE OF
CAUSE OF DEATH

• 
  Cause of death
  approximate interval
• I
• Disease or condition directly (a)
  ..................................................
  ............ ................
• leading to death
  due to (or as a consequence of)
• Antecedent causes
  (b) .............................................
  ................ ................
• Morbid conditions, if any
  due to (or as a consequence of)
• giving rise to the above cause
• stating the underlying
  (c) .............................................
  ................ ...............
• condition last
  due to (or as a consequence of)
• 
  
• 
  (d) ...............................
  ..............................
  ...............
• II
  
• Other significant conditions
• contributing to the death, but
  ..................................................
  .......... ...............
• not related to the disease or
• condition causing it
  ............................................
  ............... ...............

11
Medical certification

• Full information required, not only causes of
  death
• Sequence
• a due to b due to c due to d
• Part I / Part II
• Diagnoses per line
• Use of Abbreviations
• ARI, MI, etc.
• Handwriting !

12
Special issues

• Avoided diagnoses
• Suicide
• AIDS
• Tuberculosis
• Drug/alcohol abuse
• Manipulation of information (e. g. homicides,
  dengue)
• Injuries and poisoning
• Cardiac arrest ? infarction ?
• Incomplete and imprecise information
• Information on pregnancy
• Pneumonia (etiology / hypostatic / terminal)
• Infarction (acute or old / of the myocardium)
• Endocarditis (acute or chronic / valve /
  rheumatic ?)
• Senility / signs symptoms
• ARI

13
Medical certification Example 1

• Female, 37 years
• Admitted to an emergency room with generalized
  edema, exertional dyspnea and ascites
• Blood pressure 150 / 100, increased cardiac
  dullness with 80 beats per minute,
• Liver 5 fingers below the costal border
• For a few years was being treated for chronic
  glomerulonephritis
• With the treatment her health situation improved
  a little, with blood pressure oscillating between
  150-180 / 100-120
• After one month her health situation
  deteriorated, dying in one week with pulmonary
  acute edema

14
Medical certification Example 1
Original certificate
I a) Hypertension b) Pulmonary
edema c) d) II
Old nephritis

• Correct certificate
• I a) Acute pulmonary edema
  terminal
• b) Hypertensive cardiopathy years
• c) Chronic glomerulonephritis years
• d)
• II

15
Medical certification Example 2

• Deaths due to gastroenteritis, Bahia, Brazil,
  1984

16
Medical certification Example 2

• Deaths due to/With gastroenteritis, Bahia,
  Brazil, 1984

17
Medical certification Example 2Attending
physician vs. Coroner

• Coroner
• I a) Bronchopneumonia and gastroenteritis
• b)
• Attending physician
• I a) Bronchopneumonia
• b) gastroenteritis

18
STANDARDIZATION OF CONCEPTS AND DEFINITIONS

• LIVE BIRTHS
• FETAL DEATH
• ABORTION
• STILLBIRTH
• PERINATAL PERIOD (28/22 WEEKS - 7 DAYS)
• PERINATAL MORTALITY
• NEONATAL PERIOD
• EARLY
• LATE
• CONDITIONS ORIGINATING IN THE PERINATAL PERIOD
• INFANT MORTALITY
• NEONATAL
• LATE OR POST NEONATAL
• MATERNAL MORTALITY
• RATE / RATIO
• LATE MATERNAL DEATH
• PREGNANCY RELATED DEATH

19
CASE 1

• Female, 30 years
• A month before the admission she had several
  hematemesis episodes and, since then,
  deterioration of her general condition, extreme
  pallor and frequent melena. On the day of the
  hospitalization (18/11), new hematemesis. At the
  physical examination Blood pressure 80/ 60
  mm/Hg, pulse 128/ min, good hydration, pale
  mucous membranes (), spleen at 1 finger,
  smooth, and hard liver at 1 finger. In view of
  the fact that the patient came from a
  schistosomiasis endemic area, the clinical
  diagnosis was rupture of esophageal varices due
  to portal hypertension due to liver fibrosis
  schistosomiasis. This diagnosis was confirmed
  subsequently by liver biopsy. In addition the
  species of the helminth was established as
  "mansoni". The tamponade of the varices was not
  satisfactory. Operated (19/11) splenectomy and
  ligature of the cardiotuberositarious veins. The
  hematemesis persisted and the patient died in
  irreversible shock on 22/11. Necropsy was not
  done.

20

• CASE 1
• I a) Rupture of esophageal varices
  1 month
• b) Liver fibrosis
  years
• c) Schistosomiasis mansoni
  years
• d)
• II

21
CASE 2

• Female, 66 years
• Has had rheumatic fever for 30 years, with mitral
  stenosis as a complication. Five years ago began
  presenting congestive cardiac failure with
  compensation after treatment. The condition
  recently worsened, the cardiac failure becoming
  irreversible and the patient died. Four years ago
  it was confirmed that she had hypertension, with
  measurements that ranged between 160-190 /
  100-120.

22

• CASE 2
• I a) Congestive cardiac failure
  5 years
• b) Mitral stenosis
  30 years
• c) Rheumatic fever
  30 years
• d)
• II Hypertension

23
CASE 3

• Male, 72 years
• Ten months ago the patient was operated on for
  cancer in the upper part of the stomach (verified
  histopathologically). He subsequently presented
  pulmonary metastases and his clinical condition
  deteriorated progressively. One week before death
  he presented bronchopneumonia. The patient was
  hypertensive for many years and 3 months before
  death had a stroke, remaining hemiplegic.

24

• CASE 3
• I a) Bronchopneumonia
  7 days
• b) Pulmonary metastases
  months
• c) Stomach cancer, upper part
  10 months
• d)
• II Hypertension
  years
• Stroke
  3 months

25
CASE 4

• Female, 3 years
• Girl with Tetralogy of Fallot, doing relatively
  well, in preparation to being submitted to
  surgery. One morning she was found dead by her
  mother.

26

• CASE 4
• I a) Tetralogy of Fallot 3 years
• b)
• c)
• d)
• II

27
CASE 5

• Male, 42 years
• The mason was working on a scaffolding, at the
  twelfth floor when accidentally fell to the
  ground, dying instantaneously. The Coroner
  reported multiple injuries (skull, hip and
  limbs).

28

• CASE 5
• I a) Multiple injury of head, hip, and limbs
  
• b) Accidental fall from scaffolding while
  working
• c)
• d)
• II

29
CASE 6

• Female, 50 years
• Two years ago the patient found nodes in the left
  breast. At the medical examination presented
  great increase of the breast, retracted nipple,
  and palpable axillary nodes. She was taken to
  surgery in the month of April with diagnosis of
  malignant neoplasm of the breast with nodal
  metastases, with confirmation by surgery and by
  biopsy. She stayed well for four months, when her
  general health condition began to deteriorate,
  presenting increased volume of a nodular liver,
  jaundice and ascites. Two days before dying she
  entered in hepatic coma, well documented
  clinically and by laboratory. The patient died in
  December of the same year and an autopsy was not
  performed.

30

• CASE 6
• I a) Hepatic coma
  2 days
• b) Liver metastases
  months
• c) Malignant neoplasm of central part of the
  breast 2 yrs
• d)
• II

31
CASE 7

• Male, 3 hours
• Child born of spontaneous delivery in poor
  condition (Apgar score of 2). The pregnancy was
  normal up to the eighth month, when the mother
  started to present vaginal hemorrhage, not
  seeking assistance during the first 24 hours. She
  was then taken to the hospital where was she
  admitted with pre-shock. The diagnosis made was
  hemorrhagic abruptio placentae. The baby was born
  cyanotic with signs of anoxia, dying in three
  hours.

32

• CASE 7
• I a) Anoxia
  3 hours
• b) Hemorrhagic abruptio placentae
  2 days
• c)
• d)
• II

33
CASE 8

• Male, 55 years
• Two years before his death, the patient had an
  acute myocardial infarction, confirmed by
  electrocardiogram. From then on he began to
  present affective type mental disorders, with
  frequent episodes of depression and weeping.
• In the morning of the day of the death, at
  home, he shot himself in the chest with a
  handgun. Taken to the hospital, he died at two
  oclock in the afternoon of the same day.
  Autopsy Hemothorax (2 liters) and perforation of
  the upper lobe of the left lung.

34

• CASE 8
• I a) Hemothorax
  hours
• b) Perforation of upper lobe of the left lung
  hours
• c) Suicide by handgun shot at home
  hours
• d)
• II Acute myocardial infarction
  2 years
• Recurrent depressive disorders

35
CASE 9

• Female, 71 years
• The patient, with a diagnosis of adenocarcinoma
  of uterine body (verified by biopsy), had a
  panhysterectomy, followed by chemotherapy and
  blood transfusions. The patient had an old
  hypertension (220/ 140) that was being controlled
  with hypotensors and hyponatremic diet. One year
  and a half after the surgery she had symptoms of
  unconsciousness, with deviation of the mouth
  toward the left, right hemiplegia with patellar
  hyperreflexia and Babinski. She was treated as
  having had a stroke, with partial recovery. On
  the day of the death, two weeks after the
  beginning of this last episode, she presented
  deep coma with total areflexia, dying after a few
  hours, without recovering. The examination of the
  cerebral spinal liquid revealed hemorrhage.

36

• CASE 9
• I a) Coma
  hours
• b) Hemiplegia
  2 weeks
• c) Stroke 2 weeks
• d) Hypertension years
• II Adenocarcinoma of uterine body 2 years

37
CASE 10

• Female, 32 years
• The patient was admitted in shock on the
  emergency service. She was found at the end of
  the eighth month of pregnancy and she had had
  only two prenatal visits (fourth and fifth
  months). This was the fourth pregnancy and the
  previous ones were normal, with healthy live
  births. The blood pressure could not be measured,
  and the pulse was fine and tachycardic (140
  p/min). Intense anemia of mucous membranes.
  According to family information, she had had
  genital hemorrhage for more than one week, at the
  beginning with little intensity, but increasing
  progressively. For two days she was in the bed
  and today, upon getting up has fainted. The
  family then brought her to the emergency room.
  Diagnoses Acute anemia from hemorrhage due to
  placenta previa. Dead fetus. The mother was
  submitted to a caesarean, the death occurring
  just after the surgery.

38

• CASE 10
• I a) Acute anemia
• b) Uterine hemorrhage 1 week
• c) Placenta previa
  1 week
• d)
• II Caesarean Section
• Pregnancy of 8 months

39
CASE 11

• Male, 26 years
• Three years ago was diagnosed as carrier of HIV,
  not having any clinical manifestation until ten
  months ago, when he began to present fever,
  intense weight loss and a great deal of cough.
  The diagnosis of AIDS was made and also of
  tuberculosis of lung. He evolved very poorly, did
  not respond to the treatment, developed a
  bronchopneumonia, dying in four days.

40

• CASE 11
• I a) Bronchopneumonia 4 days
• b) Tuberculosis of lung
  10 months
• c) Acquired Immunodeficiency Syndrome 10
  months
• d)
• II Weight loss

41
CASE 12

• Female, 64 years
• The lady was exiting a small minibus, taking
  advantage of the red traffic light, and was hit
  by a motorcycle, which passed over her abdomen.
  She was removed alive to an emergency service. At
  the physical examination she presented signs of
  rupture of the spleen. A splenectomy was done.
  The patient lost 1.9 liters of blood and died
  before the end of the surgery.

42

• CASE 12
• I a) Acute hemorrhage
• b) Rupture of the spleen
• c) Hit by a motorcycle while exiting a
  minibus
• d)
• II Splenectomy