MITS-INCLEN- 3 sites

RESEARCH PROPOSAL

1. Title of the Research Project

Applying minimally invasive tissue sampling (MITS) to document the causes of
death across different age groups (in children, adolescents and adults) and
stillbirths at three sites in India

Name of Principal Investigator and Co-Investigator(s)

Principal Investigator
Dr Manoja Kumar Das
Director Projects
The INCLEN Trust International
F1/5, Okhla Industrial Area, Phase 1, New Delhi-110020, INDIA
Email: manoj@inclentrust.org
Phone: (O) +91-11-47730000; (M) +91-9810203768
Co-Investigators
The INCLEN Trust International, New Delhi
Dr Abhishek Agarwal
Senior Program Officer, Public Health
The INCLEN Trust International
F1/5, Okhla Industrial Area, Phase 1, New Delhi-110020, INDIA
Email: abhishek.agarwal@inclentrust.org
Phone: (O) +91-11-47730000; (M) +91-9582366630
Dr Vaishali Deshmukh
Senior Program Officer, Social Science
The INCLEN Trust International
F1/5, Okhla Industrial Area, Phase 1, New Delhi-110020, INDIA
Email: vaishali@inclentrust.org
Phone: (O) +91-11-47730000; (M) +91-9868525220

North Eastern Indira Gandhi Regional Institute of Health and Medical

Sciences (NEIGRHMS), Shillong, Meghalaya
Dr Prasanta Kumar Bhattacharya
Professor & HOD, Department of General Medicine
North Eastern Indira Gandhi Regional Institute of Health and Medical
Sciences, Shillong, Meghalaya
Email: pkbdr78@gmail.com
Phone: 9435030138
Dr Himesh Barman
Associate Professor & HOD, Department of Pediatrics
North Eastern Indira Gandhi Regional Institute of Health and Medical
Sciences, Shillong, Meghalaya
Email: himeshbarman@gmail.com
Phone: 8974054513
Dr Iadarlang Tiwesoh
Assistant Professor, Department of General Medicine
North Eastern Indira Gandhi Regional Institute of Health and Medical

1
MITS-INCLEN- 3 sites

Sciences, Shillong, Meghalaya

Email: itiewsoh@gmail.com
Phone: 9402131982
Dr Annie B. Khyriem
Additional Professor & HOD, Department of Microbiology
North Eastern Indira Gandhi Regional Institute of Health and Medical
Sciences, Shillong, Meghalaya
Email: dranniebk20@gmail.com
Phone: 9862230415
Dr Y Khonglag
Additional Professor, Department of Pathology
North Eastern Indira Gandhi Regional Institute of Health and Medical
Sciences, Shillong, Meghalaya
Email: khonglahy@gmail.com
Phone: 9436336490

All India Institute of Medical Sciences, Patna, Bihar

Dr Chandramani Singh
Professor & HOD, Department of Community & Family Medicine
All India Institute of Medical Sciences, Patna, Bihar
Email: drcmsingh@aiimspatna.org, drcmsingh@yahoo.co.in
Phone: 7004988381, 9931733280
Dr Lokesh Tiwari
Additional Professor and HOD, Department of Pediatrics
All India Institute of Medical Sciences Patna, Bihar
Email: lokeshdoc@yahoo.com
Phone: 9631638095
Dr Divendu Bhushan
Assistant Professor, Department of General Medicine
All India Institute of Medical Sciences, Patna, Bihar
Email: drdivendubhushan@aiimspatna.org
Phone: 9661216010
Dr Bhaskar Thakuria
Additional Professor & HOD, Department of Microbiology
All India Institute of Medical Sciences, Patna, Bihar
Email: drbhaskart@aiimspatna.org; bhaskarthakuria1@rediffmail.com
Phone: 9410531002
Dr Shreekant Bharti
Assistant Professor, Department of Pathology
All India Institute of Medical Sciences, Patna, Bihar
Email: drskbpath@gmail.com ; drshreekantb@aiimspatna.org
Phone: 9598138986

Shri Ram Murthi institute of Medical Sciences (SRMS IMS), Bareilly, UP

Dr Atul Kumar
Associate Professor of Pediatrics
Shri Ram Murthi Institute of ,Medical Sciences (SRMS IMS), Bareilly, Uttar

2
MITS-INCLEN- 3 sites

Pradesh
E-mail: atulkemu@email.com
Phone: 9558071577
Dr Smita Gupta
Professor & HOD, Department of Medicine
Shri Ram Murthi lnstitute of ,Medical Sciences (SRMS IMS), Bareilly, Uttar
Pradesh
Email: smgu2001@yahoo.com
Phone:94587 02667, 9411914063
Dr Rahul Goyal
Professor & HOD, Department of Microbiology
Shri Ram Murthi lnstitute of ,Medical Sciences (SRMS IMS), Bareilly, Uttar
Pradesh
Email: dr_goyalrahul@yahoo.co.in
Phone No.: 9458702210, 9927019732
Dr Hema Pant
Professor, Department of Pathology
Shri Ram Murthi lnstitute of ,Medical Sciences (SRMS IMS), Bareilly, Uttar
Pradesh
Email: panthema18@gmail.com
Phone No.: 9458702200

2. Objectives
The objectives of the project are:
1. To better characterize the causes of death across different age groups including
under-five children, children (above 5 years) and adolescents and adults and the
stillbirths at three hospitals linked to the population sites in India;
2. To document the agreement between the causes of death and stillbirth
established by regular clinical and laboratory methods and MITS for the deaths
and stillbirths conducted at these three hospitals linked to the population sites in
India; and
3. To build the capacity of the teams from the participating sites to conduct MITS
and microbiology-, molecular diagnostics-, and pathology-based mortality
surveillance for improved categorization and classification of causes of death and
stillbirth.

3. Summary of the proposed research (upto 150 words) indicating overall aims of the
research, importance of the objectives and application of the work in the context
of national priorities of medical research.
The causes of death (CoD) in children and adults and stillbirths in India from different
regions/states remain under-characterized. While complete diagnostic autopsy is
challenging, minimally invasive tissue sampling (MITS) is an alternate with
comparable efficacy for determining CoD.
We shall conduct MITS (n=300) among children, adolescents, adults and stillbirths at
three sites (Bareilly, Uttar Pradesh; East Khasi Hills, Meghalaya; Patna, Bihar) for
identification of CoD. The ongoing community surveillance at the sites shall be
leveraged. The deaths happening at the study site hospitals shall be approached for

3
MITS-INCLEN- 3 sites

conduct of MITS. For the deaths happening at the community level, the family
members of the deceased patients/individuals shall be approached and persuaded
for MITS (to be done at hospitals). For the patients agreeing for MITS, multiple
samples including body fluids, tissue biopsies and swabs shall be taken and
processed for microbiological, molecular diagnosis and pathological testing at the
study site hospital laboratories. Verbal autopsy shall be done for the deaths. Based
on the clinical, investigators, molecular diagnosis and pathology tests findings, the
cause(s) of death shall be determined. The findings and CoD shall be communicated
to the family and counselled for appropriate action/care. CoDs from MITS shall be
compared with clinical diagnoses and verbal autopsy findings.

4. Present knowledge and relevant bibliography including full titles of articles relating
to the problem.
Despite significant reduction in the child health mortality, globally more than 5.0
million children under age 5, including 2.4 million newborns, along with 2.2 million
children and youth aged 5 to 24 years, 43% of whom are adolescents – died in 2020
(United Nations Inter-Agency Group for Child Mortality Estimation (UN IGME),
Report, 2021). India is a major contributor to the under-five and neonatal deaths
globally. As per the recent data (Sample Registration System Bulletin of Registrar
General of India), the Infant Mortality Rate (IMR) has reduced from 37 per 1000 live
births in 2015 to 30 per 1,000 live births in 2019 at national level. There was wide
variations in IMR across the states with Uttar Pradesh at 41, Bihar at 29 and
Meghalaya at 33 per 1000 live births (1). India is also the largest contributor to the
global stillbirth burden. In 2019, it is estimated that 2.0 million stillbirths occurred
globally. During 2019, it was estimated that 340,622 stillbirths occurred in India (2).
Most of these infant and early childhood deaths are caused by preventable diseases
and conditions that could be avoided through cost-effective and basic quality-
delivered interventions (3). The National Health Policy (2017) of India targets
reducing under-five mortality to 23 and neonatal mortality to ‘single digit’ per 1000
live births by 2025 (4). To meet these targets and accelerate the reduction in under-
five mortality, it is essential to identify the causes of death. In India, like several
other low-middle-income countries (LMICs), 21.7-52.6% of the children die without
any contact with a skilled healthcare professional (5). A sizable proportion of those
who reach a care provider do not have adequate documentation to identify cause of
death (CoD) (5)(6). Many children are buried soon after death without any
investigation into the CoD. Even among those who die at health facilities, the CoD is
often difficult to assess, particularly in the case of coexisting illnesses; in addition,
the quality and completeness of death certification in facilities is often quite low
(7)(8)(9).
According to UN-IGME estimates, the stillbirth rate in India has declined from 29.6 in
2000 to 13.9 in 2019 per 1000 livebirths. With 0.34 million stillbirths in 2019, India
still tops the chart globally (total 1.9 million stillbirths in 2019). The decline has been
relatively slower than the neonatal, child and maternal mortalities. Largely, the
causes of many stillbirths are unknown as discerning the actual cause of stillbirths is
a challenge.
Similarly, a sizable proportion of adults die at home or while being taken to hospital
or soon after hospitalization without appropriate investigation. While the non-

4
MITS-INCLEN- 3 sites

communicable diseases dominate the causes of death in adults, the infectious causes
also either considered as triggers for the terminal event or co-existing conditions.
There is limited experience of the exact cause of death in several of these outside
hospital deaths and infectious triggers or underlying pathologies. The symptom
based diagnosis assignment has several challenges, as many of the conditions have
similar presentation (10).
Complete diagnostic autopsies (CDA), the most comprehensive means to definitively
determine CoD, are difficult and not routinely implemented due to sociocultural and
religious beliefs, technical, financial and infrastructure limitations
(11)(12)(13)(14)(15). Thus most of the causes of death in LMIC settings are based on
verbal autopsy (VA), which have several limitations (16)(17)(18)(19). With non-
specific signs or symptoms, identifying the exact CoD for neonatal deaths is difficult
with the VA method, and it is not useful for stillbirths. The challenges in existing
methods of ascertaining CoD in children often result in uncertainties in national and
global disease estimations. The uncertainty about the true CoD compromises
effective planning, resource allocation and thereby the effectiveness of the public
health policies and programs. In view of the limitations in VA methodology and the
impracticality of CDA in LMICs, there is a need for alternative means to determine
CoD. Post-mortem minimally invasive autopsy or minimally invasive tissue sampling
(MITS), which involves targeted tissue samples from organs for histopathologic and
microbiological examinations, offers one approach to improving CoD determination
in LMIC settings (20)(21)(22). MITS is quicker, less invasive, more acceptable to
families, and less expensive than CDA and studies have shown that CoD results from
MITS are comparable to those from CDA (23)(24)(25). However, the perceptions and
acceptance of families, communities and healthcare professionals around
conducting MITS may vary according to the socio-cultural and religious contexts.
The Child Health and Mortality Prevention Surveillance (CHAMPS) Network
supported by the Bill & Melinda Gates Foundation has established field sites to
collect robust, standardized, and definitive data on CoD in several LMIC (26).
CHAMPS project/network aims to determine CoD for all under-five deaths (including
stillbirths), capturing both infectious and non-infectious etiologies. CHAMPS uses
information from MITS, VAs, and any available clinical information on each death to
attribute CoD as precisely as possible. The CHAMPS network includes sites in Africa
(Mali, South Africa, Mozambique, Kenya, Ethiopia and Sierra Leone) and three in
South Asia (Bangladesh, Pakistan and India). In India a pilot project was implemented
at Safdarjung Hospital, New Delhi led by Indian Council of Medical Research, for
documenting the feasibility and acceptability of MITS, capacity building, and
standardizing sample collection and laboratory procedures. Subsequently, three
more sites in India are being supported by CHAMPS network to undertake the MITS
related activities.
While MITS method has been applied mostly for the CoD determination of under-
five children and stillbirths, no information of MITS use in older children (including
adolescents) and adults are available from Indian context. This project is an effort to
contribute to the national effort of reducing the under-five, neonatal mortality and
also expand the MITS application for deaths in older children, adolescents and adults
to improve the diagnosis and CoD identification.

5
MITS-INCLEN- 3 sites

References
1. Ministry of Health and Family Welfare. Status of IMR and MMR in India [Internet].
New Delhi, India; 2022 Feb. Available from:
https://pib.gov.in/PressReleaseIframePage.aspx?PRID=1796436
2. United Nations, Inter-agency Group for Child Mortality Estimation (UN IGME) and its
Core Stillbirth Estimation Group (CSEG). A Neglected Tragedy. The global burden of
stillbirths- Report of the UN Inter-agency Group for Child Mortality Estimation, 2020
[Internet]. New York: Unicef; 2020 [cited 2021 Oct 31]. Available from:
https://www.unicef.org/media/84851/file/UN-IGME-the-global-burden-of-
stillbirths-2020.pdf
3. United Nations Inter-agency Group for Child Mortality Estimation (UN. Levels &
Trends in Child Mortality: Report 2018, Estimates developed by the United Nations
Inter-agency Group for Child Mortality Estimation. [Internet]. United Nations
Children’s Fund, New York.; 2018 [cited 2018 Sep 25]. Available from:
http://www.childmortality.org/files_v22/download/UN%20IGME%20Child%20Mort
ality%20Report%202018.pdf
4. Ministry of Health and Family Welfare. National Health Policy 2017 [Internet].
Government of India; 2017 [cited 2018 Sep 25]. Available from:
https://mohfw.gov.in/sites/default/files/9147562941489753121.pdf
5. Deshmukh V, Lahariya C, Krishnamurthy S, Das M, Pandey R, Arora N. Taken to
health care provider or not, under-five children die of preventable causes: Findings
from cross-sectional survey and social autopsy in Rural India. Indian J Community
Med. 2016;41(2):108.
6. Mathers CD, Fat DM, Inoue M, Rao C, Lopez AD. Counting the dead and what they
died from: an assessment of the global status of cause of death data. Bull World
Health Organ. 2005 Mar;83(3):171–7.
7. Gupta N, Bharti B, Singhi S, Kumar P, Thakur JS. Errors in Filling WHO Death
Certificate in Children: Lessons from 1251 Death Certificates. J Trop Pediatr. 2014
Feb 1;60(1):74–8.
8. Hernández B, Ramírez-Villalobos D, Romero M, Gómez S, Atkinson C, Lozano R.
Assessing quality of medical death certification: Concordance between gold
standard diagnosis and underlying cause of death in selected Mexican hospitals.
Popul Health Metr [Internet]. 2011 Dec [cited 2018 Dec 20];9(1). Available from:
http://pophealthmetrics.biomedcentral.com/articles/10.1186/1478-7954-9-38
9. Hazard RH, Chowdhury HR, Adair T, Ansar A, Quaiyum Rahman AM, Alam S, et al.
The quality of medical death certification of cause of death in hospitals in rural
Bangladesh: impact of introducing the International Form of Medical Certificate of
Cause of Death. BMC Health Serv Res. 2017 Oct 2;17(1):688.
10. Gomes M, Begum R, Sati P, Dikshit R, Gupta PC, Kumar R, et al. Nationwide Mortality
Studies To Quantify Causes Of Death: Relevant Lessons From India’s Million Death
Study. Health Aff (Millwood). 2017 Nov;36(11):1887–95.
11. Lewis C, Hill M, Arthurs O, Hutchinson C, Chitty L, Sebire N. Factors affecting uptake
of postmortem examination in the prenatal, perinatal and paediatric setting. BJOG
Int J Obstet Gynaecol. 2018 Jan;125(2):172–81.
12. Lishimpi K, Chintu C, Lucas S, Mudenda V, Kaluwaji J, Story A, et al. Necropsies in
African children: consent dilemmas for parents and guardians. Arch Dis Child. 2001
Jun;84(6):463–7.

6
MITS-INCLEN- 3 sites

13. Ugiagbe EE, Osifo OD. Postmortem examinations on deceased neonates: a rarely
utilized procedure in an African referral center. Pediatr Dev Pathol Off J Soc Pediatr
Pathol Paediatr Pathol Soc. 2012 Feb;15(1):1–4.
14. Fligner CL, Murray J, Roberts DJ. Synergism of verbal autopsy and diagnostic
pathology autopsy for improved accuracy of mortality data. Popul Health Metr
[Internet]. 2011 Dec [cited 2018 Nov 23];9(1). Available from:
http://pophealthmetrics.biomedcentral.com/articles/10.1186/1478-7954-9-25
15. Turner GDH, Bunthi C, Wonodi CB, Morpeth SC, Molyneux CS, Zaki SR, et al. The Role
of Postmortem Studies in Pneumonia Etiology Research. Clin Infect Dis. 2012 Apr
1;54(suppl_2):S165–71.
16. Soleman N, Chandramohan D, Shibuya K. Verbal autopsy: current practices and
challenges. Bull World Health Organ. 2006 Mar;84(3):239–45.
17. Serina P, Riley I, Hernandez B, Flaxman AD, Praveen D, Tallo V, et al. The paradox of
verbal autopsy in cause of death assignment: symptom question unreliability but
predictive accuracy. Popul Health Metr. 2016;14:41.
18. King G, Lu Y. Verbal Autopsy Methods with Multiple Causes of Death. Stat Sci. 2008
Feb;23(1):78–91.
19. Thomas LM, D’Ambruoso L, Balabanova D. Verbal autopsy in health policy and
systems: a literature review. BMJ Glob Health. 2018 May;3(2):e000639.
20. Bassat Q, Ordi J, Vila J, Ismail MR, Carrilho C, Lacerda M, et al. Development of a
post-mortem procedure to reduce the uncertainty regarding causes of death in
developing countries. Lancet Glob Health. 2013 Sep;1(3):e125-126.
21. Castillo P, Ussene E, Ismail MR, Jordao D, Lovane L, Carrilho C, et al. Pathological
Methods Applied to the Investigation of Causes of Death in Developing Countries:
Minimally Invasive Autopsy Approach. Cappello F, editor. PLOS ONE. 2015 Jun
30;10(6):e0132057.
22. Gillio-Meina C, Zielke HR, Fraser DD. Translational Research in Pediatrics IV: Solid
Tissue Collection and Processing. Pediatrics. 2016 Jan;137(1):e20150490.
23. Weustink AC, Hunink MGM, van Dijke CF, Renken NS, Krestin GP, Oosterhuis JW.
Minimally invasive autopsy: an alternative to conventional autopsy? Radiology. 2009
Mar;250(3):897–904.
24. Byass P. Minimally Invasive Autopsy: A New Paradigm for Understanding Global
Health? PLOS Med. 2016 Nov 22;13(11):e1002173.
25. Ben-Sasi K, Chitty LS, Franck LS, Thayyil S, Judge-Kronis L, Taylor AM, et al.
Acceptability of a minimally invasive perinatal/paediatric autopsy: healthcare
professionals’ views and implications for practice: Acceptability of less invasive
autopsy. Prenat Diagn. 2013 Mar;n/a-n/a.
26. CHAMPS Network. Child Health and Mortality Prevention Surveillance (CHAMPS).
Building and Sharing Knowledge to Save Lives [Internet]. CHAMPS; 2018 [cited 2018
Sep 25]. Available from: https://champshealth.org/

7
MITS-INCLEN- 3 sites

5. Preliminary work already done by the Investigator on this problem e.g. selection of
subjects, standardization of methods, and giving results, if any.
The Principal Investigator was involved in the MITS pilot project (led and coordinated
by Indian Council of Medical Research) at Safdarjung Hospital for determination of
the causes of death in under-five children (including neonates) and stillbirths. The PI
led the sociobehavioural research component and participated in the cause of death
assignment.
The Principal Investigator led the sociobehavioural research component for potential
conduct of MITS at Gorakhpur Uttar Pradesh (supported by Indian Council of Medical
Research).
The Principal Investigator is involved in the INCLEN demographic development
environmental surveillance sites (DDESS) operation at Bareilly (Uttar Pradesh) and
Mawphlang (East Khasi Hills, Meghalaya) and project linkage with the All India
Institute of Medical Sciences, Patna, which shall enable smooth operation of the
proposed project. The AIIMS, Patna team is working in the community area for
projects and teaching.

8. Detailed research plan.

The study has two components: (a) formative research to capture the community
perceptions and practices related to death and potential factors that may influence
the MITS acceptance; and (b) conduct of MITS and laboratory investigations to
identify the cause(s) of deaths.
8.1. Study design: This will be a prospective study involving community surveillance
for deaths in the target age groups. The formative research component will adopt
qualitative design involving grounded theory approach.
8.2. Study sites: The MITS shall be conducted at the three hospitals linked to the
population sites. The three sites proposed for MITS are the demographic surveillance
sites/population health training sites across different geographies in India, linked to
the medical colleges. Two of these are demographic development environmental
surveillance site (DDESS) has been established by INCLEN in Bareilly (Uttar Pradesh)
and East Khasi Hills (Meghalaya) districts. The third area in Patna (Bihar) is the
community field practice area of All
India Institute of Medical Sciences,
Patna. The information about the
population covered at these three
sites are mentioned below.
• Somaarth DDESS, Bareilly and
Shri Ram Murti Samarak
Institute of Medical Sciences,
Bareilly (Uttar Pradesh): This
demographic development
environmental surveillance site
(DDESS) has been established
by INCLEN in Bareilly district.
The rural site is located 14 kms
from Bareilly city and 250 Kms
from Delhi. The DDESS site

8
MITS-INCLEN- 3 sites

covers 44 villages from 3 Blocks across 73.13 Sq Km area. The population covered
by the site is 81,235 from 33,489 households. The annual death rate for the
population in this area is 6.7 deaths/1000 population and the infant mortality
rate is 41 infant deaths/ 1000 live births. The annual birth rate for the area is
25.9 per 1000 population.
We propose to conduct the MITS at the hospital, Shri Ram Murti Samarak
Institute of Medical Sciences (SRMSIMS), Bareilly. INCLEN has been partnering
with the SRMSIMS, Bareilly for the research activities linked to this DDESS.
SRMSIMS is an 800 bedded medial college with super-specialty facilities. It serves
as the referral hospital for the 2-3 districts in Uttar Pradesh. Several population
based and hospital linked projects have been conducted by INCLEN at this DDESS
site.
• Somaarth DDESS, East Khasi Hills and North Eastern Indira Gandhi Regional
Institute of Health and Medical Sciences, Shillong (Meghalaya): This tribal
demographic
development
environmental
surveillance site
(DDESS) has been
established by
INCLEN in
Mawphlang, East
Khasi Hills district.
The site is located
25 Kms from
Shillong. The DDESS site covers 207 villages from 4 Blocks across 301 Sq Km area.
The population covered by the site is 71,491 from 40,489 households. The annual
death rate for the population in this area is 6.1 deaths/1000 population and the
infant mortality rate is 39 infant deaths/ 1000 live births. The annual birth rate
for the area is 22.8 per 1000 population.
We propose to conduct the MITS at the hospital, North Eastern Indira Gandhi
Regional Institute of Health and Medical Sciences (NEIGRHMS), Shillong. INCLEN
has been partnering with the NEIGRHMS, Shillong for the research activities
linked to this DDESS. NEIGRHMS is an institute of national importance and 531
bedded medial college with super-specialty facilities. It serves as the referral
hospital for the state of Meghalaya. Several population based and hospital linked
projects are in progress by INCLEN at this DDESS site.
• Urban Health Training Centre
(UHTC) area, Khagaul and All India
Institute of Medical Sciences
(AIIMS), Patna: This urban
population health training site is
located in Patna urban area, near
the AIIMS, Patna. The UHTC is a
Primary Health Centre under the
administrative control of the
Community and Family Medicine

9
MITS-INCLEN- 3 sites

Department, AIIMS, Patna. The UHTC/PHC covers a population of 44,364 from

7,951 household located within one administrative urban ward of Patna. The
annual death rate for the population in this area is 5.8 deaths/1000 population
and infant mortality rate is 35 infant deaths/ 1000 live births. The annual birth
rate for the area is 26.4 per 1000 population.
We propose to conduct the MITS at the hospital, AIIMS, Patna. The AIIMS, Patna
is an institute of national importance with 960 beds with super-specialty
facilities. It serves as the referral center for the whole state. In view of the
proximity and referral center status, the majority of the population from the area
reach AIIMS, Patna. AIIMA-Patna team conducted clinical trials for the COVID
vaccine in past and currently undertaking projects in this area. INCLEN team has
been working with the AIIMS, Patna team on research projects.
The departments of Pediatrics and General Medicine from these institutes shall
conduct the MITS with support from Departments of Microbiology and Pathology.
The INCLEN Trust International team shall lead the formative research, provide
overall coordination between the participating institutes, quality assurance and data
management and analysis.

8.3. Population target groups: The MITS shall target the deaths across three different
age groups- neonates and under-five children; children aged >5 years and adolescents
and adults.
 Inclusion and exclusion criteria: The MITS shall include the deceased individuals
(and their family members) from these three areas as per the following inclusion and
exclusion criteria.
o Inclusion criteria:
 Deceased individual belongs to the targeted age groups
 Death occurred at home or hospital
 Stillbirth occurs at home or hospital
 Deceased individual belongs to the population surveillance area
 Consent for MITS obtained from family member
 Consent obtained within 24 hours of death
o Exclusion criteria:
 Deceased individual is from outside the population surveillance area
 Deaths due to accident and/or medicolegal cases (suicide, homicide)
 Death following burn or chemical injury to skin

8.4. Implementation
 Community engagement and sensitization strategy: At the sites, INCLEN team has an
existing community engagement and partnership process. INCLEN team has
established communication linkages with all the villages and the village leadership
(Local self-government head, Sarpanch and members), community health (ASHAs)
and nutrition (AWWs) functionaries and key influential persons (school teachers, and
community leaders). The team communicates and interacts with these key persons at
periodic intervals (every quarterly) and additionally for any project-specific purposes.
A team led by the DDESS Station Manager (social scientist) undertakes the
community engagement activities. The strategy shall be suitably revised based on the

10
MITS-INCLEN- 3 sites

formative research undertaken at the three sites for assessing the influencing factors
and persons for MITS acceptance and operations at the community level.
 Community Advisory Board (CAB): INCLEN has established CAB at the DDESS sites to
advise on the community engagement, mobilization and communication purposes.
The CAB includes 11-12 members, including 9-10 independent members and two
members from INCLEN DDESS. The independent members include the village
leadership, Officials from block administration, the Health Department, and local
community health and nutrition functionaries. At Mawphlang DDESS, the
representatives from the tribal council are also part of the CAB. The CAB meets every
six-monthly to review the progress and additionally prior to initiation of each project.
The community engagement, screening, recruitment and follow-up strategies are
discussed related to the projects and the activities are done as per the CAB guidance
considering the local community context. The formative research findings shall be
used as background for the guidance from CAB on community engagement and
sensitization strategy/activities.
 Planned community sensitization activities: Prior to the initiation of the project, based
on the experiences of socio-behavioral research conducted by INCLEN at Delhi and
Gorakhpur (Uttar Pradesh) for documenting the potential acceptance of MITS in
children, we shall conduct rapid formative research in these areas to understand the
practices and beliefs related to death for different age groups and explore the
acceptance for MITS. At each site, the formative research shall include the parents of
deceased children and family members of deceased adults (n~20), community
members (n~20), religious representatives from the area (Hindu, Muslim, Christian,
Sikh) and community level healthcare functionaries (n~8). Based on these findings
from formative research and with assistance from the CAB, we shall prepare
communication messages for sensitization of the communities and key
functionaries/facilitators for MITS. The sensitization shall be done in the villages in
phases 8-10 villages every quarter till all the targeted areas/populations are reached.
 Method for identifying and recruiting participants: We understand that there are
sensitivities for MITS. Considering the feasibilities, we propose to conduct the MITS at
the associated hospitals and include the individuals from the surveillance area who
die in the hospital/or are brought dead to the hospital. We propose the following
strategies for the identification and recruitment of the cases for MITS at the hospitals.
o Hospital level activities
 Screening of the sick patients in the hospitals: The project staff (Research Officer
and Nurse-cum-counsellor) shall screen the sick patients admitted to the hospital
to identify the patients from the surveillance areas.
 Tracking of the identified patients: These patients shall be tracked daily to capture
the deaths and engagement with the family members shall be initiated.
 Brought dead cases: The doctors, nurses and staff in the emergency room shall be
oriented to inform the project team on receipt of any brought dead case. If the
case belongs to the area
 Approach for consent: The patients dying shall be approached at the earliest after
the death declaration for consent to conduct MITS. The family members present
in the hospital around death shall be approached for consent using the PIS-ICF
and pictorial communication document prepared (to be done). As in the Indian
context, the decision for consent is collectively made by the family and usually,

11
MITS-INCLEN- 3 sites

consultations are done with elders (even if they are physically not present), the
counselling shall be done for all the family members present. Any additional
explanation to the other elder family member, if needed shall be done over
phone call/vision call. For an explanation to obtain consent, assistance from the
treating doctors (faculty/resident doctors) and nurses shall be taken, as needed.
 Conduct of the MITS: For the conduct of MITS, the body shall be shifted to the
MITS room (to be fabricated) in the hospital. The family members shall be seated
in the waiting room/area near the MITS room. After completion of the MITS, the
body shall be handed over to the family, as per the hospital protocol. The samples
shall be shifted to the laboratory for appropriate processing and storage.
 Sample collection and processing: For conduct of MITS, the surface of the body
shall be carefully cleaned and disinfected (using spirit and betadine) before
invasive body sample and tissue sampling to prevent skin contamination. The
samples proposed for collection from the deceased cases include body fluids
(blood, CSF, urine and any other collection), tissue samples/biopsies (CNS/Brain,
lungs-multiple areas, liver, any other tissues like bone marrow, spleen, kidney,
skin, hair, as needed), as soon as possible, within 24 hours of death. The non-
tissue/body fluid samples shall be collected as per the standard protocol of
sample collection and the tissue samples shall be collected following the standard
MITS sampling methodology. For the tissue samples or biopsy 16G biopsy samples
shall be used. We shall collect nasopharyngeal and anal swabs for molecular
diagnostics processing. The demographic, clinical course, treatment, vaccination,
family history, radiological imaging, nuclear scans (if done), anthropometry,
antemortem hematology, biochemistry, microbiological, and immunology test
findings shall be captured. The biological samples collected shall be submitted for
bacteriological culture (blood, urine, CSF), viral immunology testing (blood) for
common pathogens. The following information and samples shall be collected
from the individuals during the MITS procedure.

12
MITS-INCLEN- 3 sites

Table 1: The list of data collection to be done for the deceased child
Source Sample Processing/analysis
Demographic Age, gender, residence, occupation Data collection using
(deceased individual/ parents), CRF
Clinical history Disease presenting symptoms,
findings and evolution, past illnesses, signs and
course provisional diagnoses made,
treatment given/received,
vaccination exposure, antenatal
history, family history and
consanguinity, etc.
Imaging (x-ray/ultrasound/CT
scan/MRI) or nuclear scans
Microbiological, metabolic and any
other ante-mortem tests.
Anthropometry Weight (for children and stillbirth),
height/length, head circumference
(for children), mid-upper-arm
circumference (right arm), right leg
length (neonates/stillbirths), foot
length (neonates/stillbirths)
External Congenital malformation, trauma, Photographs
examination any lesions/bleeding, any rash,
depigmentation
Body palpation Organomegaly (liver, spleen,
abdominal mass) and lymph nodes
Non-tissue Blood (10 ml) by subclavian venous Blood culture, plasma,
samples puncture serum and EDTA
sample
CSF (5-10 ml)- occipital approach Cytology, culture, viral
and bacterial
immunological/PCR
analysis, virology panel
as per need for
encephalitis protocol
Urine (10-20 ml) by suprapubic Cytology, culture,
puncture metabolic analysis as
per need
Any other body fluid (peritoneal, Cytology, culture, any
pleural or any cyst), as per need additional as per need
Tissue samples CNS/Brain- through occipital and Histopathology,
transnasal approach immunohistochemistry
Lung- Right and left, upper, middle, as needed
and lower fields (left lungs may
also contain heart tissue samples)
Liver- subcostal approach
Bone marrow- anterior iliac crest

13
MITS-INCLEN- 3 sites

Any other tissue like spleen, kidney

skin, hair as needed
Stillbirths: Placenta and cord
samples
Swabs Nasopharyngeal swab Bacteriology and viral
Rectal swab isolation
Verbal autopsy For the deaths with inadequate For identification of
clinical investigation/information cause of death (after 2
for diagnosis weeks of death)

 Sample testing: The samples obtained shall be transferred immediately to

laboratory for analysis. The samples for different analysis shall be processed
following the processes:
 Bacteriology isolation from samples: The samples for culture (blood, CSF, urine,
nasopharyngeal swab, lung tissue/aspirate, any other fluid aspirate) shall be
transferred to laboratory for earliest inoculation into appropriate medium. The
microbiology samples shall be processed for bacterial culture using the
standard BACTEC methodology followed by species identification and
antibiotics sensitivity testing in the microbiology laboratory.
 Molecular analysis of samples: The blood, CSF and swabs (nasopharyngeal and
anal) for molecular analysis and other microbiological analysis shall be frozen
at −80°C as soon as possible after the end of the procedure. These samples
shall be processed for DNA/RNA extraction following the standard extraction
methodology using the commercially available kits. The DNA/RNA extracted
shall be subjected to molecular diagnostics testing for respiratory,
gastrointestinal and neuro-pathogenic pathogens using commercially available
PCR primers using PCR methodology. Common kits with primers and control
shall be used at all sites.
The panel of pathogens proposed for testing using the commercially available
PCR kits are summarised below in Table 2.
 Histopathology processing and diagnosis: Tissue specimens for histological
analysis shall be fixed in 10% neutral buffered formalin for 4 hours to prevent
antigen and nucleic acid degradation. After this short fixation, the samples
shall be immersed in 70% ethanol until histological processing. All samples shall
be evaluated using appropriate resolution microscopy for documenting the
histopathological changes in the organs to support the diagnosis. Any
additional immunohistochemistry testing/processing shall be done as per
need.
The clinical and microbiological test findings shall be entered into the database
using the computer data entry tool. The histopathological images shall be
uploaded to the database for the recruited subjects and the findings shall be
entered.

14
MITS-INCLEN- 3 sites
Table 2: The proposed pathogens for testing using the molecular analysis methods from different samples
Sample Bacteria
CSF  Escherichia coli K1
 Haemophilus influenzae
 Listeria monocytogenes
 Neisseria meningitidis
 Streptococcus agalactiae
 Streptococcus pneumoniae
Blood  Acinetobacter
 Bacteroides fragilis
 Enterobacterales
(Enterobacter cloacae, E. coli,
Klebsiella spp., Proteus spp.,
Salmonella spp. Serratia
marcescens)
 Haemophilus influenzae
NPswab  Bordetella parapertussis
and lungs  Bordetella pertussis
 Chlamydia pneumoniae
 Mycoplasma pneumoniae
Gastintesti  Campylobacter
nal/swab  Clostridioides
 Plesiomonas shigelloides
 Salmonella
 Yersinia enterocolitica
 Vibrio
 Neisseria meningitidis
Pseudomonas aeruginosa
 Enterococcus faecalis
 Enterococcus faecium
 Listeria monocytogenes
 Staphylococcus spp.
 Streptococcus spp.
 Enteroaggregative E. coli
 Enteropathogenic E. coli
 Enterotoxigenic E. coli
 Shiga-toxin-producing E. coli
 E. coli O157
 Enteroinvasive E. coli
Virus Fungal
 Cytomegalovirus  Cryptococcus (C.
 Enterovirus neoformans/ C. gattii)
 Herpes simplex virus-1 & 2
 Human herpesvirus-6
 Human parechovirus
 Varicella zoster virus
 Candida albicans
 Candida auris
 Candida glabrata
 Candida krusei
 Candida parapsilosis
 Candida tropicalis
 Cryptococcus (C.
neoformans/C. gattii)
 Adenovirus
 Coronavirus 2 (SARS-CoV-2)
 Human Metapneumovirus
 Human Rhinovirus/Enterovirus
 Influenza viruses (A, A/H1, A/H3,
A/H1-2009) and B
 Parainfluenza viruses (1, 2, 3, 4)
 Respiratory syncytial virus
 Adenovirus F40/41 
 Astrovirus
 Norovirus GI/GII
 Rotavirus A
 Sapovirus (I, II, IV, and V)
15
MITS-INCLEN- 3 sites

o Community-level activities
 Identification of key informants from the villages: In consultation with the village
leadership and CAB, we shall identify a suitable person as key information for
hospitalizations and deaths. The ASHAs and AWWs from the villages shall also
assist in the detection of such cases.
 Detection of hospitalized cases: If information about hospitalization of any person
from the surveillance area is received, the community team shall track the status
and outcome of the patient periodically. If any death is detected, the community
team member shall reach the hospital or home of the deceased person and
approach for MITS. If the family agrees for MITS, the body along with a few family
members shall be transferred to the designated hospital for the conduct of MITS.
The hospital team shall obtain the consent for MITS and facilitate the conduct of
MITS at the hospital. After the MITS, the body (and family members) shall be
transported back home.
 Detection of deaths at the community level: For the deaths occurring at the
community level without hospital attendance or discharge from the hospital, once
the information is received, the community team member shall reach the home of
the deceased person and approach for MITS. If the family agrees for MITS, the
body along with a few family members shall be transferred to the designated
hospital for the conduct of MITS. The hospital team shall obtain the consent for
MITS and facilitate the conduct of MITS at the hospital. After the MITS, the body
(and family members) shall be transported back home.
 Verbal autopsy for CoD: The team shall conduct verbal autopsy for understanding
the CoD. The data shall be collected by the research team. The data shall be used
for assigning the CoD.
 Communication of the CoD: The families shall be communicated about the CoD
and associated counselling, as appropriate in two phases- first, after two weeks
when the first batch of test results are available; second, after about 2-3 months
when most of the molecular tests are completed and CoD is assigned.
 Training of the teams: The study site clinical, microbiology and pathology teams shall
be trained for conduct of MITS, tissue sampling, sample handling and processing.
Following the training the trainees shall be assessed and certified by the
trainers/assessors based on the appropriateness of procedures performed, accuracy
of data collected and quality of samples obtained. Following the training while the
sites start the study activities, the central monitoring team members shall visit the
sites to assess the initiation and monitoring.
 Cause of death (CoD) assignment: A panel of 3-4 experts at each site institute
including a specialist from medicine, paediatrics, pathology, and microbiology shall
review all the available data (clinical, epidemiological, microbiology, histopathology
and verbal autopsy) to assign the cause of death. These data and cause of death shall
be reviewed by the centrally team of experts including the trained specialists on
medicine, paediatrics, pathology, microbiology and epidemiology to assign the final
cause of death. The central team shall provide feedback to the site review teams, and
shall discuss the differences and attempt to identify the potential causes. Web-
conferences shall be held to share the feedback and identify modalities ways that the
process can be improved. The panel will assign principal and contributory causes of
death using international cause of death (ICD) coding standards. The data collected

16
MITS-INCLEN- 3 sites

from multiple sources shall be used to assign the CoD by the panel of
multidisciplinary team.
The verbal autopsy data shall be also analysed by the trained experts for assigning the
probable cause(s) of death. The CoDs from the two methods, MITS and VA shall be
compared.
 Report sharing with the families and counselling: Based on the MITS, laboratory
findings and verbal autopsy data, the CoD and results shall be shared with the family
members. The families requiring additional care and counselling shall be sent to
respective clinician and care provider as appropriate at the site institute.
 Quality assurance: Multilevel quality assurance mechanisms shall be implemented
for ensuring high quality data collection.
o Uniform protocol and processes: The sites shall follow uniform protocol and use
the same DNA/RNA and PCR primer kits, which shall ensure uniformity and
comparability.
o Training of the site teams: The central investigators and experts shall train the site
teams on conducting the MITS, associated laboratory sample processing and
cause of death assignment.
o Site initiation visit: The central team shall make site visit prior to the launch of the
study to ensure all the preparation for MITS and laboratory processing are done.
Then during initial launch of the project following the trainings, the central team
shall make site visit to supervise and support the initial MITS and lab procedures.
o Monthly review calls: There shall be monthly monitoring and quality assurance
web-conference between the site teams and central team to check the progress
and review the findings.
o Periodic site visits: The central team shall make six monthly site visits to monitor
and supervise the progress and document the protocol adherence, conduct of the
procedures and quality of data collected.
o Laboratory quality assurance: For the samples collected, stored, temperature
monitoring shall be done. At the site institute laboratories, the standard internal
and external quality assurance protocols for sample handling and analysis shall be
followed.
o Cause of death assessment review: The cause of death assignment done by the
site teams shall be reviewed by the central team again to ensure that correct
cause assignment and categorisation is done. If needed the site teams shall be
provided support and refresher orientation during the periodic web conferences.
The results of the MITS (sample retrieval, quality), microbiology test findings
(comparison with antemortem tests, contaminant isolates, etc.), molecular test
findings and pathology findings shall be reviewed at weekly intervals for the first
three months followed by biweekly and then monthly basis. Technical experts with
experience in MITS sample processing, six monthly visits shall be made to the sites to
assess the protocol adherence and any additional visit as per need.
External quality assurance: The MITS Alliance team shall provide technical support for
harmonization of the data collection, molecular diagnosis and histopathological
procedures for across the different sites globally. Under the current call for proposal
by MITS Alliance, the study is planned to be undertaken in five countries (India,
Nepal, Ghana, South Africa, and Uganda). For better comparability, the data

17
MITS-INCLEN- 3 sites

harmonization is planned with assistance from MITS global. MITS global team shall
also assist in training of the team members from the sites.
The partners from Barcelona Institute for Global Health (ISGLOBAL) has long standing
expertise in MITS trainings (training of the trainers), guidance on the development of
the MITS kits, pathology expertise, and support for assigning the cause of death. The
ISGLBAL technical experts shall be supporting the pathology investigators in MITS
pathology sample processing and interpretations. The ISGLOBAL team experts shall
be participating virtually in the discussions for assigning the cause of death and
guiding the country teams.
The MITS Alliance and ISGLOBAL shall be supplying the MITS kits for the study sites.
 Data management and security: The data shall be collected using case record forms
developed and adapted into data entry formats in tablets/computers. Tablets and/or
computers shall be used for data entry from the sites. Specific data entry modules
shall be prepared for the clinical, demographic, microbiology, histopathology and
other laboratory tests, and verbal autopsy. The data shall be entered by the research
staff at the sites. These data will be then transferred to coordinating unit database.
The data quality check team will check for completeness, consistencies and
timeliness. All data will be stored in a secure study database. Each study participant
will be given a unique identifier, and all personal data in the database will be masked.
The key linking personal details to each identifier will be stored securely in a separate
password-protected database. The paper CRFs and study records will be kept secure
at all times under the secured custody of the site investigators. The data analysis will
be done as per preapproved plan of analysis by the central coordinating team. No raw
data shall be shared with the foreign collaborators or funders. The biological sample
collected shall be analyzed at the Indian Institutes only. The analysis processes
proposed shall be done at the study site institute laboratories.
The data generated under the project shall remain in the custody of the Indian
Investigators and shall be owned by the Indian investigators and Indian organizations.
No raw data and data with identifiers shall be shared with the foreign collaborators or
funder. The summary and analyzed data shall be shared with the funder and
collaborators.
 Data analysis: The formative (qualitative) data translated shall be entered into the
INCLEN Qualitative Data Analysis Software (IQDAS) which allows entry in English and
also in local languages. The data entered shall be saved into server and backed up on
daily basis. The data entered shall be checked for correctness and completeness. The
data shall be accessible to only authorized research team members. The data shall be
read by the research team members trained by the Investigators with experience in
qualitative data analysis. The data analysis team shall be undertaking the qualitative
data analysis processes including free listing, domain identification, coding, and cross
tabulation under supervision of the Investigators.
The quantitative data shall be summarized using the descriptive analysis methods for
the CoD and findings from clinical, microbiology, molecular biology and pathology
tests. The data for the groups of participants and according to the sites shall be
compared to identify the differences in the test findings, profiles of CoD, infectious
agents and pathological findings. Appropriate statistical methods shall be applied to
document any statistical significance in the profiles, findings using the parametric or
non-parametric tests, as appropriate. Also, the CoDs from MITS and VA shall be

18
MITS-INCLEN- 3 sites

compared to document the agreement using kappa statistics. The summary and
analyzed data shall be shared with the funder and collaborators. The data generated
under the project shall remain in the custody of the Indian Investigators and shall be
owned by the Indian investigators and Indian organizations. No raw data and data
with identifiers shall be shared with the foreign collaborators or funder.
 Sample size: It is proposed to conduct a total of 300 MITS including approximately
100 under-five deaths, 100 older children and adolescents and 100 adults. The
number of MITS from the sites may vary.
 Timeline: Total 36 months;
o Phase 1- Preparatory phase: 6 months (including MITS room set up, training of
teams, and formative research);
o Phase 2- Implementation phase: 27 months (including the conduct of MITS,
samples processing and testing, CoD determination, communication to family,
and community and hospital surveillance, continued community
engagement);
o Analysis and report: 3 months (including the final analysis and report writing)
The activities for the proposed project are summarised below according to quarterly
timelines.
Activity/Period Year 1 Year 2 Year 3
Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10 Q11 Q12
Admin & regulatory approvals X
MITS room and processes set X
up
Personnel hiring and trainings X X
Formative research X
Community surveillance X X X X X X X X X X
Hospital surveillance X X X X X X X X X X
MITS conduct X X X X X X X X X X
Laboratory analysis X X X X X X X X X X
Assigning causes of death X X X X X X X X X X
CAB meetings X X X X X X X
Data analysis X
Final report X

 Ethics issues: Participation in the study (for MITS) will be on a voluntary basis and
will follow an explanation of the project and participants (and the family members)
giving their informed consent in line with the National Ethical Guidelines for
Biomedical and Health Research Involving Human Participants by Indian Council of
Medical Research (2017). Informed consent form in local or English or Hindi language
(as desired by the participant) shall be used. Approval of institutional ethics
committees of all the participating institutes shall be obtained prior to
implementation.

19
MITS-INCLEN- 3 sites

9. Facilities in terms of equipment, etc. available at the sponsoring institution for the
proposed investigation.
• INCLEN: The project shall be led and coordinated by INCLEN. INCLEN is a public
health research organisation undertaking multisite and network research studies of
national and international relevance. INCLEN with its long standing experience in
multisite research technical leadership, research management, quality assurance and
data management, shall provide the research management and coordination
support to the project. INCLEN has established the two population DDESS sites at
Bareilly and Mawphlang (Shillong) and operationalising several research projects at
these sites. INCLEN has field project offices and field teams with adequate
infrastructure to support the proposed research. At the population study sites, the
INCLEN team shall be collaborating with the medical colleges for the clinical and
laboratory activities. The project team shall be supported by the DEESS/site
surveillance and core teams. The Hospital MITS team shall conduct the MITS of the
patients dying at the hospital and cases brought for MITS from the community level.
The activities at the hospital shall be supported and guided by the investigators and
specialists from the departments and supported by the doctors and nurses from
these wards and the laboratory staff.
• Facilities at the partner site institutes: The three hospitals are teaching tertiary care
hospitals and have operational laboratories with all the equipment required for
undertaking the tests: microbiological tests (BACTEC, VITEK, anaerobic culture,
mycobacterial culture), PCR sequencing systems for molecular analysis, ELISA,
immunohistochemistry/immunofluorescence testing, flow cytometry, centrifuge and
others; histopathology tests including immunohistochemistry and imaging to support
the activities proposed to be conducted for the MITS samples. These institutes have
refrigerated space for storing the samples, but for ensuring no storage space
challenge for the study samples, one -800C, and one 2-80C refrigerator per study site
has been proposed.

10. Expected Outcome

The expected outcomes of the project are:
1. The information about the causes of under-five child deaths from these three
sites in India;
2. The information about the causes of stillbirth from these three sites in India;
3. The information about the causes of death in older children and adults from
these three sites in India;
4. The comparison of the causes of deaths across different age groups with the
medically certified causes of death and documented by verbal autopsy for these
deaths and other MITS efforts in India to document the similarities and
differences.
The evidence generated from this project shall contribute to the national newborn
and child health program and assist in refining the clinical practices and programs,
especially in the post-COVID era.
Also the experience from this study shall inform the potential use and expansion of
MITS for older children and adults in India.

20