Discrepancies between clinical diagnoses and autopsy findings: A comparative study conducted in South Africa

The anatomical pathology autopsy serves several purposes, notably as a quality management tool for evaluation of accuracy in clinical diagnosis. Despite its value, for various reasons there has been an international decline in autopsies conducted. In the modern medical era, with all its advances in technology, diagnostic techniques and interventions, there is still a high discrepancy between clinical diagnoses and postmortem findings.Objectives. To establish the discrepancies between clinical diagnoses and postmortem findings in anatomical pathology autopsies.Methods. A retrospective, descriptive study was conducted over the 4-year-period 2014 - 2017. The clinical diagnoses and postmortem findings of cases referred to the Department of Anatomical Pathology at the University of Pretoria, South Africa, were evaluated and compared using the modified Goldman criteria.Results. A total of 288 cases qualified for the study and were evaluated. The gender distribution was 155 (53.8%) male and 133 (48.2%) female, with the majority of cases in the age group 19 - 60 years (mean 36.4). The majority of the cases were referred by internal medicine, followed by paediatrics. The most common cause of death in major missed diagnoses was pulmonary conditions. Of the cases, 115 (39.3%) had a major discrepancy and 62 (21.5%) a minor discrepancy.Conclusion. This study showed that there is still a high discrepancy between clinical diagnoses and postmortem findings, similar to studies conducted globally. The current COVID-19 pandemic may be a driver for revival of the anatomical pathology autopsy, and future studies are recommended to evaluate whether the decline can be reversed

Practical tips to using formalin-fixed paraffin-embedded tissue archives for molecular diagnostics in a South African setting

Background: Formalin-fixed paraffin-embedded (FFPE) tissue archives in hospitals, biobanks, and others offer a vast collection of extensive, readily available specimens for molecular testing. Unfortunately, the use of tissue samples for molecular diagnostic applications is challenging; thus, the forensic pathology FFPE tissue archives in Africa have been a largely unexploited genetic resource, with the usability of DNA obtainable from these samples being unknown.Intervention: The study, conducted from January 2015 to August 2016, determined the usefulness of FFPE tissue as a reliable source of genetic material for successful post-mortem molecular applications and diagnostics. Formalin-fixed paraffin-embedded tissue samples were collected and archived from autopsies conducted over 13 years in the forensic medicine department of the University of Pretoria (Pretoria, South Africa). Deoxyribonucleic acid from FFPE tissue samples and control blood samples was amplified by high-resolution melt real-time polymerase chain reaction before sequencing. The procurement parameters and fixation times were compared with the quantity and quality of the extracted DNA and the efficiency of its subsequent molecular applications.Lessons learnt: This study has shown that FFPE samples are still usable in molecular forensics, despite inadequate sample preparation, and offer immense value to forensic molecular diagnostics.Recommendations: FFPE samples fixed in formalin for more than 24 h should still be used in molecular diagnostics or research, as long as the primer design targets amplicons not exceeding 300 base pairs.

Causes of death and post-mortem testing for SARS-CoV-2 in a tertiary hospital during the COVID-19 pandemic in Ghana

Background: Causes of death during the coronavirus disease 2019 (COVID-19) pandemic ranhttp://crossmark.crossref.org/dialog/?doi=10.4102/ajlm.v11i1.1766=pdf&date_stamp=2022-11-23ge from direct consequences of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection to deaths unrelated to SARS-CoV-2. Another feature of the pandemic is the post-mortem testing for SARS-CoV-2. Understanding these aspects of COVID-19 are essential in planning and limiting the impact of SARS-CoV-2 virus on healthcare systems. Objective: This study investigated the underlying causes of death and the presence of SARS-CoV-2 in bodies received at the 37 Military Hospital, Accra, Ghana, during the COVID-19 pandemic. Methods: The study was conducted from 4­27 May 2020. Deceased patients that met the inclusion criteria were prospectively selected during the expanded surveillance period for SARS-CoV-2 testing, autopsy and determination of underlying and immediate cause of death. Results: A total of 161 deceased patients were analysed with 53 autopsies. The overall positive test rate for SARS-CoV-2 was 14.9% (24/161 patients), with a positive rate of 5.0% (8/161 patients) for nasopharyngeal samples and 30.2% (16/161 patients) for bronchopulmonary samples. The underlying causes of death were not related to SARS-CoV-2 infection in 85.1% (137/161) of patients, SARS-CoV-2-associated 12.4% (20/161) and SARS-CoV-2-induced in 2.5% (4/161). Cardiovascular complications formed the most common cause of death in patients with or without SARS-CoV-2. Conclusion: There was a high positive rate of SARS-CoV-2 in post-mortem cases. However, most deaths were not caused by SARS-CoV-2 but by cardiovascular complications. The high rate of bronchopulmonary positive results for SARS-CoV-2 requires that autopsies be done in suspicious cases with negative nasopharyngeal sampling.

Pathologic changes in patients infected with SARS-CoV-2: a review

Severe acute respiratory syndrome­coronavirus-2 (SARS-CoV-2) enters cells using the angiotensin converting enzyme 2 (ACE2), which are expressed by the respiratory tract endothelium, epithelial cells of the stomach, duodenum, ileum, rectum, cholangiocytes, and hepatocytes. Pathological examinations of these organs are not feasible method of diagnosis but can explain pathological changes, pathogenesis of the disease, and the cause of death in COVID-19 cases. In this review, we performed a literature search for COVID-19-related pathological changes seen during post-mortem examinations in different organs of the body including the lungs, gastrointestinal tract, liver, kidney, skin, heart and blood. Our findings showed that SARS-CoV-2 has damaging effects on many organs, probably due to the host immune responses to the presence of the virus. It is recommended that both antiviral and immunomodulatory agents should be considered in the management of COVID-19 patients for better prognosis, and clinical outcome

COVID-19 autopsies from the Ga-East municipal and the 37 military hospitals, Accra, Ghana

Introduction: Since the declaration of COVID-19 by the World Health Organisation (WHO) as a global pandemic on 11th March 2020, the number of deaths continue to increase worldwide. Reports on its pathologic manifestations have been published with very few from the Sub-Saharan African region. This article reports autopsies on COVID19 patients from the Ga-East and the 37 Military Hospitals to provide pathological evidence for better understanding of COVID-19 in Ghana. Methods: Under conditions required for carrying out autopsies on bodies infected with category three infectious agents, with few modifications, complete autopsies were performed on twenty patients with ante-mortem and/or postmortem RT -PCR confirmed positive COVID 19 results, between April and June ,2020. Results: There were equal proportion of males and females. Thirteen (65%) of the patients were 55years or older with the same percentage (65%) having Type II diabetes and/or hypertension. The most significant pathological feature found at autopsy was diffuse alveolar damage. Seventy per cent (14/20) had associated thromboemboli in the lungs, kidneys and the heart. Forty per cent (6/15) of the patients that had negative results for COVID-19 by the nasopharyngeal swab test before death had positive results during postmortem using bronchopulmonary specimen. At autopsy all patients were identified to have pre-existing medical conditions. Conclusion: Diffuse alveolar damage was a key pathological feature of deaths caused by COVID-19 in all cases studied with hypertension and diabetes mellitus being major risk factors. Individuals without co-morbidities were less likely to die or suffer severe disease from SARS-CoV-2

Consent for critical care research after death from COVID-19: Arguments for a waiver

Pandemics challenge clinicians and scientists in many ways, especially when the virus is novel and disease expression becomes variable or unpredictable. Under such circumstances, research becomes critical to inform clinical care and protect future patients. Given that severely ill patients admitted to intensive care units are at high risk of mortality, establishing the cause of death at a histopathological level could prove invaluable in contributing to the understanding of COVID-19. Postmortem examination including autopsies would be optimal. However, in the context of high contagion and limited personal protective equipment, full autopsies are not being conducted in South Africa (SA). A compromise would require tissue biopsies and samples to be taken immediately after death to obtain diagnostic information, which could potentially guide care of future patients, or generate hypotheses for finding needed solutions. In the absence of an advance written directive (including a will or medical record) providing consent for postmortem research, proxy consent is the next best option. However, obtaining consent from distraught family members, under circumstances of legally mandated lockdown when strict infection control measures limit visitors in hospitals, is challenging. Their extreme vulnerability and emotional distress make full understanding of the rationale and consent process difficult either before or upon death of a family member. While it is morally distressing to convey a message of death telephonically, it is inhumane to request consent for urgent research in the same conversation. Careful balancing of the principles of autonomy, non-maleficence and justice becomes an ethical imperative. Under such circumstances, a waiver of consent, preferably followed by deferred proxy consent, granted by a research ethics committee in keeping with national ethics guidance and legislation, would fulfil the basic premise of care and research: first do no harm. This article examines the SA research ethics framework, guidance and legislation to justify support for a waiver of consent followed by deferred proxy consent, when possible, in urgent research after death to inform current and future care to contain the pandemic in the public interest

May a sample be legally removed or an autopsy undertaken without an advance directive or proxy consent to determine whether a critical care patient at risk of COVID-19 infection has died as a result of the virus?

It has recently been suggested that ethically and legally the obtaining of biological samples for research after death during the COVID-19 pandemic in South Africa justifies a waiver of consent followed by a deferred proxy consent. However, it is submitted that because deceased persons are not protected by the Constitution, and only partially protected by common law and statute law, such consent and the need for consent to autopsies may be dispensed with altogether under the common law doctrine of 'necessity'. It is pointed out that such information is in the public interest because it will inform critical care facilities on how to save lives of future patients and assist government in responding to the COVID-19 pandemic by adequate planning. It is also reasonably justifiable in the public interest to ascertain the COVID-19 status of deceased persons who may have been exposed to the virus, in order to protect their family, friends, healthcare practitioners, undertakers and staff members, and members of the public with whom they have been in contact. Finally, it is suggested that the law can be clarified by amending the Disaster Management COVID-19 regulations to do away with consent for such autopsies or tissue sample collections from deceased persons exposed to the risk of contracting the virus, subject to certain conditions

An autopsy study of pattern and yearly trend of homicide in Warri, Nigeria

Background: Homicide is a common cause of unnatural death and an index of the level of security of the state. The aim of this study was to analyze all autopsied unnatural homicide cases in Warri, Nigeria from 2003 to 2016 with emphasis on age, sex, regional distribution of injury, and circumstance of death. Materials and Methods: Six hundred and seventy-four cases were studied and relevant information extracted from police and autopsy records. These information were analyzed using SPSS 21. Results: Unnatural homicide cases accounted for 69.1% of 975 medicolegal deaths autopsied in this region, with a male to female distribution of 14:1. The mean age of the victims was 33.2 years with the highest incidence occurring in the 3rd decade. Firearms, sharp weapons, blunt weapons, suffocation, and burning were the methods used in 426 (63.2%), 162 (24.0%), 73 (10.8%), 11 (1.7%), and 2 (0.3%) cases, respectively. The chest, the head, and the neck were the most common parts of the body affected representing 275 (40.8%), 162 (24%), and 52 (7.7%) of cases. Conclusion: Unnatural death as a result of homicide is very common in the study area and mainly perpetrated using firearms and sharps with young males being the most vulnerable age group. The head, chest, and neck are more commonly affected regions of the body

Validation of verbal autopsy methods for assessment of child mortality in sub-Saharan Africa and the policy implication: a rapid review

Reliable data on the cause of child death is the cornerstone for evidence-informed health policy making towards improving child health outcomes. Unfortunately, accurate data on cause of death is essentially lacking in most countries of sub-Saharan Africa due to the widespread absence of functional Civil Registration and Vital Statistics (CRVS) systems. To address this problem, verbal autopsy (VA) has gained prominence as a strategy for obtaining Cause of Death (COD) information in populations where CRVS are absent. This study reviewed publications that investigated the validation of VA methods for assessment of COD. A MEDLINE PubMed search was undertaken in June 2018 for studies published in English that investigated the validation of VA methods in sub-Saharan Africa from 1990-2018. Of the 17 studies identified, 9 fulfilled the study inclusion criteria from which additional five relevant studies were found by reviewing their references. The result showed that Physician-Certified Verbal Autopsy (PCVA) was the most widely used VA method. Validation studies comparing PCVA to hospital records, expert algorithm and Inter VA demonstrated mixed and highly varied outcomes. The accuracy and reliability of the VA methods depended on level of healthcare the respondents have access to and the knowledge of the physicians on the local disease aetiology and epidemiology. As the countries in sub-Saharan Africa continue to battle with dysfunctional CRVS system, VA will remain the only viable option for the supply of child mortality data necessary for policy making

Postmortem forensic imaging: An essential tool in contentious cases

Background: Traditional autopsy (TA) is employed towards determining the cause and manner of death. Over the last decade, virtual autopsy (VA), involving the application of forensic imaging techniques have gained prominence and, with great precision in developed countries. Aim: This is to compare the findings at post-mortem using forensic imaging techniques and, those of TA. Materials and Methods: Post-mortem CT-Scan and MRI techniques were employed in the present case and for the first time in Nigeria, to identify the fatal injuries and determine their causation. The examination was done prior to the TA; the latter was done by a team of pathologists without the prior knowledge of the imaging findings. The results, using both methods, were subsequently compared. Results: Most of the VA and TA findings were the same except for the areas that were not readily accessible to the pathology team because of prior embalmment of the body. The inexperience of the radiologist in the area of post-mortem forensic imaging also contributed to the few discrepancies. Conclusion: This is the first virtopsy to be conducted in Nigeria and, with impressive results. The findings compare favourably with those of TA and, have the added advantage of identifying minor injuries that might easily be missed using TA method. Success is however hinged on the expertise of the forensic radiologist and forensic pathologist. While VA can be employed to solve the problems of religious opposition to TA, the cost of the former is astronomical

Morts toxiques et autopsies médico-légales à Abidjan (Côte d'Ivoire)

Introduction : L'objectif de cette étude était de déterminer les paramètres épidémiologiques et médico-légaux des morts toxiques à Abidjan.Patients et méthode : Il s'agissait d'une étude rétrospective descriptive sur les morts toxiques de diagnostic post mortem sur une période de 14 ans (de 2002 à 2015) dans le service d'anatomo-pathologie et de médecine légale du CHU de Treichville sis à Abidjan.Résultats : Neuf-cent-soixante-dix (970) autopsies judiciaires ont été pratiquées sur la période d'étude, parmi lesquelles 204 ont fait l'objet d'une expertise toxicologique sur des prélèvements biologiques réalisées en cours d'autopsies. Parmi ces expertises toxicologiques, 40 ont mis en évidence une intoxication mortelle. La majorité de ces cas d'intoxications mortelles était des adultes jeunes appartenant à la tranche des 25-34 ans (30%), de sexe masculin (82,5%). Ils exerçaient pour la plupart dans le secteur moderne (57,5%). Les prélèvements post-autopsiques étaient généralement effectués dans les deux jours qui suivaient le décès (25%) avec comme motifs d'expertise un accident de travail (25%) ou une catastrophe collective (30%). La voie d'intoxication était essentiellement respiratoire (28 cas sur 40) et les xénobiotiques le plus souvent retrouvés concernaient le monoxyde de carbone (10 cas sur 40) et l'hydrogène sulfuré (12 cas sur 40). L'accident était la circonstance de survenue la plus fréquente au cours des morts toxiques (55%).Conclusion : Les morts toxiques représentent une faible part de l'ensemble des décès pris en charge par la Médecine légale à Abidjan en Côte d'Ivoire. Le diagnostic de ces morts requiert une autopsie judiciaire et une expertise toxicologique qui sont incontournables mais malheureusement rarement financées par les autorités judiciaires. Nous insistons sur l'implication effective de ces autorités dans le financement de ces expertises pour une plus juste appréciation de ces décès dans nos régions

The forensic autopsy as a teaching tool: attitudes and perceptions of undergraduate medical students at the University of Pretoria, South Africa

Background. Numerous articles have been published on the use of autopsies in training medical students in anatomy and different branches of pathology. Some authors have described the emotional response of students who attend such postmortem sessions. Forensic pathology is an important subdivision of pathology. In some countries undergraduate medical students are expected to attend postmortem examinations on persons who died from traumatic causes. Objective. To determine the attitudes and perceptions of 5th-year medical students with regard to forensic postmortem examinations at the University of Pretoria; South Africa. Methods. A questionnaire was voluntarily completed by medical students on the last day of the practical rotation.Results. The overall rating of the practical rotation was 82%. The strengths; weaknesses; opportunities and threats (SWOT) analysis indicated the following as strengths: record keeping; legislation review and traumatology description; as weaknesses: emotional trauma and nightmares; as opportunities: the attendance of autopsies; and as threats: physical dangers. Conclusion. The current study was similar to international studies with regard to students' emotional response to attending autopsies. The autopsy remains a valuable teaching tool for undergraduate students. Emotional support is currently available for all students to assist them in overcoming their fear of attending forensic autopsy sessions

Relevance of Clinical Autopsy in Medical Practice in Sub-Saharan Africa

Autopsy is very important in medical practice and is being increasingly relegated both in the developed and developing countries. Though autopsy rate has been on the decline; the exact rates are difficult to determine because various reports are influenced by many factors. The danger of the decline in the developing countries is that equipment for proper diagnosis is not yet available; therefore; most diagnoses are not made and the cause of death would not have been known. This article reviews the benefits of autopsy in modern practice; the importance of perinatal autopsy and the shortcomings of modern technology in the diagnosis and determination of the cause of death. Electronic literature search combined with the review of both local publications and relevant texts were carried out. Clinicians should endeavor to request for postmortem examination as the benefits far outweigh the reasons proffered for the decline in the autopsy rate

Coroner Autopsy Findings among Children and Adolescents of Rivers State of Nigeria

BACKGROUND.Children / adolescents face avoidable deaths in Nigeria. This 11-year retrospective study of coroner autopsies carried out on children / adolescents aged between 0-19 years; evaluated the pattern; causes and demographic features of childhood deaths in Rivers state; Nigeria.METHODS.A retrospective review of case records of decedents' gender; age; and circumstances were of death and autopsy-defined causes of death in Port Harcourt were analyzed.RESULTS.Children /adolescents constituted 11.4% of 1;987 cases reviewed. The age range was 3 weeks to 19years and the mean was 14.4years. Adolescents; 15-19 years were most affected constituting 65.5% of cases. Male female ratio was 1.7:1. Accidents with 39.8% were the commonest manner of death followed by homicides (38.5%) and sudden natural deaths (12.8%). Maternal deaths and suicides constituted 7.1% and 1.8% respectively. Accidents; mainly of the road traffic type and homicides resulting from firearm injuries are significant causes of sudden deaths among children and adolescents of Rivers state.CONCLUSION.Instituting measures aimed at improving care of children and adolescents; especially during out-door activities will reduce the largely preventable deaths observed among this age group

Revue de 10 annees d'autopsies medico-legales en Cote d'Ivoire (2002 A 2011)

Introduction : Le but de cette etude etait de faire une analyse synoptique des resultats de 10 annees d'autopsies judiciaires afin de disposer de donnees statistiques nationales au plan epidemiologique et medico legal. Patients et Methode : Il s'agissait d'une etude retrospective descriptive sur les autopsies judiciaires pratiquees de 2002 a 20011 (10 ans) dans le service d'anatomo-pathologie et de medecine legale du CHU d'Abidjan Treichville. Resultats : 834 autopsies judiciaires sur 24227 deces enregistres ont ete realisees sur la periode d'etude; ce qui representait 3;4 des actes medico legaux. La majorite des sujets autopsies etait des adultes jeunes (moyenne d'age = 37;6 ans); de sexe masculin (87) et les deces survenaient le plus souvent sur la voie publique (36;2) des suites d'une agression physique (26). Ainsi les morts violentes predominaient (71;7) et etaient volontiers d'origine criminelle (55). Ces agressions criminelles etaient dans la majorite des cas perpetrees avec les armes a feu (60;8) qui representaient en outre la premiere origine des morts violentes. Les deces accidentels representaient 30;8 et etaient en rapport avec les accidents du trafic (31) tandis que les morts naturelles (23;6) etaient liees essentiellement a des pathologies cardio vasculaires (41;6). Conclusion : L'autopsie medico legale joue un role important dans la manifestation de la verite au plan judiciaire mais permet egalement de participer a la collecte de donnees en matiere de sante publique; d'ou l'interet d'encourager la pratique de cet acte medico legal qui merite egalement d'etre valoriser au plan des frais de justice criminelle

The prevalence of HIV in Pretoria's Medico-Legal Laboratory cases; RSA; in 2009

The purpose of this study was to determine the prevalence of Human Immunodeficiency Virus (HIV) amongst decedents admitted to the Pretoria Medico-Legal Laboratory (MLL). The study was designed as a cross sectional study. It is not standard procedure for the pathologist to do a HIV test at autopsy. Post mortem (PM) blood samples were obtained from all bodies admitted to the Pretoria MLL during one month in 2009. Analysis of the blood samples was performed using standardised laboratory procedures. Two hundred and thirty-eight PM blood samples were collected. In 43 cases (17); the test results were invalid. Of the 195 valid test samples; 51 (26.2) were HIV-positive. The prevalence of HIV in this study was 15 higher than that reported in a similar study done 10 years previously

The prevalence of HIV in Pretoria's Medico-Legal Laboratory cases; RSA; in 2009

The purpose of this study was to determine the prevalence of Human Immunodeficiency Virus (HIV) amongst decedents admitted to the Pretoria Medico-Legal Laboratory (MLL). The study was designed as a cross sectional study. It is not standard procedure for the pathologist to do a HIV test at autopsy. Post mortem (PM) blood samples were obtained from all bodies admitted to the Pretoria MLL during one month in 2009. Analysis of the blood samples was performed using standardised laboratory procedures. Two hundred and thirty-eight PM blood samples were collected. In 43 cases (17); the test results were invalid. Of the 195 valid test samples; 51 (26.2) were HIV-positive. The prevalence of HIV in this study was 15 higher than that reported in a similar study done 10 years previously

Rupture spontanee de l'aorte thoracique par une plaque d'atherome ulceree. A propos d'un cas decouvert au cours d'une autopsie

Introduction. La rupture spontanee de l'aorte thoracique sans formation d'anevrisme est rare. Le but de cette etude est de montrer la responsabilite de ce mecanisme dans la survenue des morts subites. Cas clinique. Nous rapportons l'observation d'un sujet age de 52 ans; qui est decede subitement au cours du sommeil a son domicile; necessitant la realisation d'une autopsie medico-legale accompagnee d'un examen histologique des organes et d'une analyse toxicologique des fluides biologiques. Resultat. Le diagnostic retenu etait celui d'un hemothorax massif gauche provoque par la rupture spontanee de l'aorte thoracique descendante favorisee par une plaque d'atherome. Conclusion. Dans la recherche des etiologies des hemothorax gauches; le praticien ne doit pas omettre de penser a une rupture spontanee de l'aorte thoracique favorisee par une plaque d'atherome ulceree

Suicide in Urban Kampala; Uganda: a Preliminary Exploration

Background: Suicide was investigated in the urban setting of Kampala; Uganda. Objectives: Firstly; to explore the use of two research methodologies; a retrospective review of patient records and the psychological autopsy methodology in suicide research in Uganda. Secondly to investigate the characteristics and correlates of urban suicide in Uganda. Results: A male to female ratio of suicide of 3.4:1 and a peak age of suicide in the 20-39 years age group were found. The main methods of suicide were hanging and ingestion of poison (organophosphates). Problems with social networks; negative life events; higher psychological distress and lower quality of life were associated with suicide at univariate analysis. It was only psychological distress that retained significance at multivariate analysis. Conclusion: The retrospective review of records at Mulago hospital was beset by incomplete records whereas a pilot psychological autopsy study was well accepted and might contribute valuable data in African settings

Verbal Autopsy: an Analysis of the Common Causes of Childhood Death in the Barekese Sub-District of Ghana

The availability of mortality data for any society plays an essential role in health monitoring and evaluation; as well as in the design of health interventions. However; most resource-poor countries such as Ghana have no reliable vital registration system. In these instances; verbal autopsy (VA) may be used as an alternative method to gather mortality data. In rural Ghana; the research team utilized a VA questionnaire to interview caretakers who were present with a child under the age of five prior to death. The data was given to two physicians who independently assigned the most probable cause of death for the child. A third; blinded physician analyzed the data in the cases where the first two physicians disagreed. When there was agreement between physicians; this was assigned as the cause of death for the individual child. During the study period; we recorded 118 deaths from 92 households. Twenty-nine (24.6) were neonatal deaths with the leading causes of death being neonatal sepsis; birth asphyxia and pneumonia. The remaining 89 (75.4) were post-neonatal deaths with the most common causes of death being pneumonia; malaria and malnutrition. While 63/118 (53.4) deaths occurred in the home; there is no statistically significant relationship between the location of the home and the time of travel to the nearest health facility (P=0.132). VA is an important epidemiological tool for obtaining mortality data in communities that lack reliable vital registration systems. Improvement in health care is necessary to address the large number of deaths occurring in the home