# Presentation: 069280

## WHO-FIC Education Committee5 May 2006

- Training Certifiers of cause of death
- Roberto Becker

## Preparation

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

## 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

## The importance ofMortality statistics

## USES OF MORTALITY DATA1. 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**

## 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**

## USES OF MORTALITY DATA3. 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  **

## 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

## 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

## 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****                                    ...........................................................       ............... **

## 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 !

## 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

## 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

##               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

## Medical certification – Example 2

- 		Deaths due to gastroenteritis, Bahia, Brazil, 1984

## Medical certification – Example 2

- 		Deaths due to/_With_ gastroenteritis, Bahia, Brazil, 1984

## Medical certification – Example 2Attending physician  vs.  Coroner

- Coroner:
- I a) _Bronchopneumonia_  and  gastroenteritis
-   b)
- Attending physician:
- I a) Bronchopneumonia
-   b) _gastroenteritis_

## 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**

## 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.

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

## 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.

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

## 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.

**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

## 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.

## CASE    4

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

- I   a)   Tetralogy of Fallot			3 years
-     b)
-     c)
-     d)
- II

## 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).

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

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

## 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.

## 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

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

## 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.

## CASE 7

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

- I   a) Anoxia                                                       3 hours
-     b) Hemorrhagic abruptio placentae                2 days
-     c)
-     d)
- II

## 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 o’clock in the afternoon of the same day. Autopsy: Hemothorax (2 liters) and perforation of the upper lobe of the left lung.

- 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

## 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.

## CASE    9

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

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

## 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.

## CASE    10

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

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

## 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.

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

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

## 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.

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

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