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COMMUNITY MEDICINE

Causes of Adult Deaths by Verbal Autopsy in an


Urban Slum of Ludhiana
ALEXANDER SA*, SENGUPTA P†, BENJAMIN AI†

ABSTRACT
Twenty-three of the world’s 192 countries have high-quality death registration data and 75 have no cause-specific mortality
data at all. Verbal autopsy (VA), an alternative method for collecting mortality data, enables investigators to establish the cause
of death retrospectively. VA carries information on circumstances, events, signs, and symptoms of illness experienced by the
deceased before death. It can ascertain the leading causes of death, reduce the misclassification of causes, reduce the proportion
of adult (age 25 or older) deaths attributed to unspecified or unknown causes (from 54% to 23% in urban areas and from 41%
to 26% in rural areas). A study was undertaken in a urban slum of Ludhiana, to find the cause specific mortality of adult deaths
and get an insight into the mortality pattern of this sample population.
Keywords: Verbal autopsy, adult deaths, urban slum

T
wenty-three of the world’s 192 countries have probable underlying cause of death when it has not
high-quality death registration data and 75 have been reported, and yield a broad classification of the
no cause-specific mortality data at all.1 Verbal underlying causes in 90% of deaths before age 70.
autopsy (VA), an alternative method for collecting
This study was undertaken to find the cause specific
mortality data, enables investigators to establish
mortality of adult deaths and get an insight into the
the cause of death retrospectively.2 This method is
mortality pattern of this sample population.
used by the Registrar General of India’s Sample
Registration System, the country’s primary system for METHODS
collecting demographic data. VA carries information on
circumstances, events, signs, and symptoms of illness This cross-sectional study was conducted from June 1,
experienced by the deceased before death and hence 2011 to May 31, 2012. All the adult deaths (deaths in
the expensive process of sending professionally trained 15 years or older) in the 30,000 population of the urban
individuals for routine investigation of deaths is done field practice area of the Dept. of Community Medicine
away with. of a medical college in Ludhiana were studied. One
hundred thirty-five total deaths were reported from
Studies carried out in Tamil Nadu3,4 showed that VA
these areas in this 12-month period. There were 16
can ascertain the leading causes of death, reduce the
childhood deaths and 13 others who either met the
misclassification of causes, reduce the proportion of
exclusion criteria or did not give consent. Participating
adult (age 25 or older) deaths attributed to unspecified next of kin were interviewed with the help of a standard
or unknown causes (from 54% to 23% in urban areas VA tool, previously used and validated in a study in
and from 41% to 26% in rural areas), derive the Andhra Pradesh.5 Overall, the causes of death were
divided into three broad disease categories: Group I–
communicable diseases, maternal causes, conditions
*MBBS Student
†Professor (Community Medicine)
arising in the perinatal period, and nutritional
Dept. of Community Medicine deficiencies; Group II – noncommunicable diseases;
Christian Medical College, Ludhiana, Punjab and Group III – injuries).6 The causes of death were
Address for correspondence
Dr Paramita Sengupta then coded according to the International Statistical
Dept. of Community Medicine Classification of Diseases and Related Health Problems,
Christian Medical College, Ludhiana, Punjab
E-mail: drparamita2425@gmail.com
10th revision (ICD-10).7 Algorithms for selected adult
Source of Funding: This study was funded by the Indian Council of Medical causes of death as previously developed was used to
Research (STS-2012) – ID-2012-02674. come to a diagnosis of the probable cause of death.

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COMMUNITY MEDICINE

The data was then entered in Microsoft Excel and analyzed Group II conditions contributed to the majority of
in Epi-Info Version 6 software. Statistical analysis deaths (60.4%). Group I conditions contributed for
was done using simple proportions and percentages. 31.1% of the deaths and only 8.5% of the deaths were
Chi-square test was applied where appropriate. due to Group III conditions. There were no significant
gender differences in the deaths according to global
RESULTS burden of disease class (Table 1).

More than half of all deaths were in the geriatric age As per the available medical records, 37.7% of the deaths
group (59.4%), more in males (61.3%), with 89.6% of the had missing data and another 6.6% were not given a
respondents being present with the deceased at the time specific cause of death. In comparison, although there
of death. Majority (63.2%) of the deaths took place at was no missing data in the case of VA, 15.1% could not
home. be assigned a specific cause (p = 0.0000) and were coded
into R00-R99 of ICD-10 classification (Table 2).

Table 1. Categorization of Deaths According to DISCUSSION


Global Burden of Disease Class
There were total 135 deaths in the 1-year period from
Global Burden of No. of No. of Total No.
June 1, 2011 to May 31, 2012, with the crude death rate
Disease Class Males (%) Females (%) (%)
being 4.5/1,000 population8 of which 119 were in the
Group I 15 (23.1) 18 (43.9) 33 (31.1) age group of 15 years and above. VAs were done for
Group II 44 (67.7) 20 (48.8) 64 (60.4) 106 of the deaths in this age group (89.1%), hence, the
nonresponse rate was 10.9%. Yang et al9 reported a
Group III 6 (9.2) 3 (7.3) 9 (8.5) nonresponse rate of 6.5%, mostly in Beijing, Shanghai,
Total 65 (100.0) 41 (100.0) 106 (100.0) and Guangzhou.
The majority of the deaths were in the geriatric age group
χ2 = 5.10; df = 2; p = 0.078
(59.4%) and there were more deaths in males (61.3%)
as compared to females (38.7%). Similar findings were
Table 2. Causes of Deaths Identified Through VA in observed by Joshi,10 Kanungo et al,11 and Gajalakshmi
Comparison with Medical Record Data et al.3 In 89.6% of deaths, the death occurred in the
Cause of Death as Per ICD-10 VA MR presence of the respondent. This facilitates the correct
A00-B99: Certain infectious and 9 (8.5) 10 (9.4) reporting of the chain of events leading to death and
parasitic diseases hence a proper VA report. Nearly, two-thirds of the
C00-D48: Neoplasms 9 (8.5) 5 (4.7) deaths in the area took place at home (63.2%).
E00-E90: Endocrine, nutritional, 4 (3.8) 3 (2.8) It is estimated that nearly half the disease burden
and metabolic diseases in low- and middle-income countries is from
G00-G99: Disease of the 18 (17.0) 4 (3.8) noncommunicable diseases and more than 21% of
nervous system deaths in such countries are due to cardiovascular
I00-I99: Diseases of the 27 (25.5) 23 (21.7) diseases.12 In the present study also, noncommunicable
circulatory system diseases contributed to the majority of deaths (60.4%)
J00-J99: Disease of the 7 (6.6) 3 (2.8) that is similar to the findings of Kanungo et al11 who
respiratory system also found Group II conditions6 to be responsible for
K00-K93: Diseases of the 5 (4.7) 9 (8.5) 66% of the deaths, with cardiovascular conditions
digestive system
leading. Joshi10 also reported a preponderance of
N00-N99: Diseases of the 2 (1.9) 0 (0.0) chronic and noncommunicable causes of death in their
genitourinary system
study villages.
R00-R99: Symptoms, signs, and 16 (15.1) 7 (6.6)
abnormal clinical findings According to ICD-10, the most common cause of death
V01-Y98: External causes of 9 (8.5) 2 (1.9)
in this area was found to be diseases of the circulatory
morbidity and mortality system (25.5%), which was more common in males
Unknown (missing data) 0 (0.0) 40 (37.7)
than females. Joshi10 also reported a preponderance
of diseases of the circulatory system (32%), with more
Total 106 (100.0) 106 (100.0)
deaths in men. Out of these, it was not possible to

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COMMUNITY MEDICINE

assign a specific cause for 15.1% of deaths. These study can be incorporated in healthcare systems while
deaths were found to be due to some abnormal ascertaining the cause of death.
clinical or laboratory finding and were given codes
R00-R99. Chandramohan8 reported that 22% of their REFERENCES
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