MITS: an interim step towards improved cause of death data
Authors: Peter Byass
Journal: The Lancet Global Health (2020)

In the Lancet Global Health, Allan Taylor and colleagues1Taylor AW Blau DM Bassat Q et al.Initial findings from a novel population-based child mortality surveillance approach: a descriptive study.Lancet Glob Health. 2020; 8: e909-e919Google Scholar present the first population-based study of minimally invasive tissue sampling (MITS) as a mid-spectrum approach for the determination of cause of death, positioned in robustness between clinical diagnostic autopsies and medical certification or verbal autopsy. In this descriptive study, the authors included data obtained in the first 2 years after the implementation of the Child Health and Mortality Prevention Surveillance (CHAMPS) Network in Asia and Africa. The findings from 933 childhood deaths across five countries (Mozambique, South Africa, Kenya, Mali, and Bangladesh) provide proof of principle for the scale-up of MITS. Although this study was not designed to be statistically generalisable in terms of mortality patterns, it provides insight regarding cause-specific childhood mortality and underlying pathophysiology. The ranked causes of death, which were pooled across disparate samples obtained from five considerably different countries, represent the overall potential of MITS rather than generalisable epidemiological findings. The CHAMPS Network has been successful in the completion of high-quality biomedical science despite challenging circumstances and logistical issues associated with shipping MITS samples to the Centers for Disease Control and Prevention (Atlanta, GA, USA) for further analysis. The authors did not indicate the costs involved per case, which might not have been a major issue in this internationally funded research study, but represents an important factor when considering the global potential of MITS. A previous study has estimated that costs for minimally invasive autopsies exceed €1000 per case.2Wagensveld IM Hunink MGM Wielopolski PA et al.Hospital implementation of minimally invasive autopsy: a prospective cohort study of clinical performance and costs.PLoS One. 2019; 14e0219291Crossref Scopus (5) Google Scholar Considering such costs, widespread implementation of MITS by national authorities in African and Asian countries is unlikely, particularly when compared with the relatively small costs of incorporating verbal autopsy into civil registration procedures. Thus, understanding how MITS findings from studies such as CHAMPS, which has so far analysed data for a relatively limited numbers of deaths, can be best used to leverage greater understanding of global mortality patterns is crucial. WHO estimates that only around half of deaths worldwide are registered with a reliable cause, with most unregistered deaths occurring in Africa and Asia.3WHOCompleteness of cause-of-death data, 2007–2016. World Health Organization, Geneva, Geneva2018http://gamapserver.who.int/mapLibrary/Files/Maps/Global_CivilRegistrationDeaths_2007_2016.pngDate accessed: April 23, 2020Google Scholar Thus, connections must be made between the millions of deaths that occur without a registered cause and the insights provided by the application of expensive MITS methods to a small proportion of deaths. The CHAMPS Network applied the 2016 WHO verbal autopsy instrument4Nichols E Byass P Chandramohan D et al.The WHO 2016 verbal autopsy instrument: an international standard suitable for automated analysis by InterVA, InSilicoVA and Tariff 2.0.PLoS Med. 2018; 15e1002486Crossref PubMed Scopus (40) Google Scholar to the deaths that the MITS approach had been applied to. Thus, the next logical step would be to process the CHAMPS verbal autopsy data using available automated verbal autopsy cause of death models, and to compare modelled causes of death with MITS findings. Observed differences might highlight possible improvements to the knowledge base that drive standard verbal autopsy models. Thus far, the CHAMPS Network has focused on deaths in children, however, extending the MITS concept to older children and adults could also be worthy of consideration, to provide additional knowledge for automated cause of death models. A number of the UN Sustainable Development Goal (SDG) targets are associated with adult mortality, for example SDG 3.4, which aims to reduce premature mortality from non-communicable diseases by a third by 2030.5UNSustainable development goal 3.https://sustainabledevelopment.un.org/sdg3Date accessed: April 23, 2020Google Scholar Unless substantial improvements are made to improve the reliability of methods and systems used for monitoring all-age cause-specific mortality across Africa and Asia, the accuracy with which SDG 3.4 and other targets will be evaluable globally in 2030 is unclear. Some adult MITS data could be useful, in addition to childhood data, to inform and improve verbal autopsy models for this purpose. Furthermore, as COVID-19 potentially spreads into populations where testing and clinical data are likely to be limited, MITS procedures could be similarly informative. MITS should be considered an innovative and informative component of the global quest for more complete cause-specific mortality data, and as a resource for enhancing other tools for measuring mortality. The MITS approach might also be useful for cases in which aetiology-specific cause of death determination is crucial, such as in vaccine trials. Generally, however, MITS alone is unlikely to become a widely applicable solution to fill global gaps in the routine assessment of individual cause of death. I declare no competing interests. Initial findings from a novel population-based child mortality surveillance approach: a descriptive studyCause of death determination using MITS enabled detailed characterisation of contributing conditions. Global estimates of child mortality aetiologies, which are currently based on a single syndromic cause for each death, will be strengthened by findings from CHAMPS. This approach adds specificity and provides a more complete overview of the chain of events leading to death, highlighting multiple potential interventions to prevent under-5 mortality and stillbirths. Full-Text PDF Open Access