Spatial factors for COVID-19 associated community deaths in an urban area of Lusaka, Zambia: an observational study

We retrospectively analyzed spatial factors for coronavirus disease 2019 (COVID-19)-associated community deaths i.e., brought-in-dead (BID) in Lusaka, Zambia, between March and July 2020. A total of 127 cases of BID with geocoordinate data of their houses were identified during the study period. Median interquartile range (IQR) of the age of these cases was 49 (34-70) years old, and 47 cases (37.0%) were elderly individuals over 60 years old. Seventy-five cases (75%) of BID were identified in July 2020, when the total number of cases and deaths was largest in Zambia. Among those whose information regarding their underlying medical condition was available, hypertension was most common (22.9%, 8/35). Among Lusaka's 94 townships, the numbers (median, IQR) of cases were significantly larger in those characterized as unplanned residential areas compared to planned areas (1.0, 0.0-4.0 vs 0.0, 0.0-1.0; p=0.030). The proportion of individuals who require more than 30 minutes to obtain water was correlated with a larger number of BID cases per 105 population in each township (rho=0.28, p=0.006). The number of BID cases was larger in unplanned residential areas, which highlighted the importance of targeted public health interventions specifically to those areas to reduce the total number of COVID-19 associated community deaths in Lusaka. Brought-in-dead surveillance might be beneficial in monitoring epidemic conditions of COVID-19 in such high-risk areas. Furthermore, inadequate access to water, sanitation, and hygiene (WASH) might be associated with such distinct geographical distributions of COVID-19 associated community deaths in Lusaka, Zambia.

The profile and causes of death among medical doctors and dental surgeons in Uganda: 1986 to 2016

Background: The loss of health workers through death is of great importance and interest to the public, media and the medical profession as it has very profound social and professional consequences on the delivery of health services. Objective: To describe the profile, causes and patterns of death among medical doctors and dental surgeons in Uganda between 1986 and 2016. Methods: We conducted a retrospective descriptive study of mortality among registered medical doctors and dental surgeons. Information on each case was collected using a standard questionnaire and analyzed. Cause of death was determined using pathology reports, and if unavailable, verbal autopsies. We summarized our findings across decades using means and standard deviations, proportions and line graphs as appropriate. Cuzick's test for trend was used to assess crude change in characteristics across the three decades. To estimate the change in deaths across decades adjusted for age and sex, we fit a logistic regression model, and used the margins command with a dy/dx option. All analyses were done in Stata version 14.0 (Stata Corp, College Station, TX). Results: There were 489 deaths registered between 1986 and 2016. Of these, 59 (12.1%) were female. The mean age at death was 48.8 years (Standard Deviation (SD) 15.1) among male and 40.1 years (SD 12.8) among females. We ascertained the cause of death for 468/489 (95.7%). The most common causes of death were HIV/AIDS (218/468, 46.6%), cancer (68/468, 14.5%), non-communicable diseases (62/48, 13.3%), alcohol related deaths (36, 7.7%), road traffic accidents (34, 7.3%), gunshots (11, 2.4%), among others. After adjusting for age and sex, HIV/AIDs attributable deaths decreased by 33 percentage points between the decade of 1986 to1995 and that of 2006 to 2016 ­0.33 (­0.44, ­0.21. During the same period, cancer attributable deaths increased by 13 percentage periods 0.13 (0.05,0.20). Conclusion: The main causes of death were HIV/AIDS, cancer, non-communicable diseases, alcohol-related diseases and road traffic accidents. There was a general downward trend in the HIV/AIDS related deaths and a general upward trend in cancer related deaths. Doctors should be targeted for preventive and support services especially for both communicable and non-communicable diseases

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

COVID deaths in South Africa: 99 days since South Africa's first death

Background. Understanding the pattern of deaths from COVID-19 in South Africa (SA) is critical to identifying individuals at high risk of dying from the disease. The Minister of Health set up a daily reporting mechanism to obtain timeous details of COVID-19 deaths from the provinces to track mortality patterns.Objectives. To provide an epidemiological analysis of the first COVID-19 deaths in SA.Methods. Provincial deaths data from 28 March to 3 July 2020 were cleaned, information on comorbidities was standardised, and data were aggregated into a single data set. Analysis was performed by age, sex, province, date of death and comorbidities.Results. SA reported 3 088 deaths from COVID-19, i.e. an age-standardised death rate of 64.5 (95% confidence interval (CI) 62.3 - 66.8) deaths per million population. Most deaths occurred in Western Cape (65.5%) followed by Eastern Cape (16.8%) and Gauteng (11.3%). The median age of death was 61 years (interquartile range 52 - 71). Males had a 1.5 times higher death rate compared with females. Individuals with two or more comorbidities accounted for 58.6% (95% CI 56.6 - 60.5) of deaths. Hypertension and diabetes were the most common comorbidities reported, and HIV and tuberculosis were more common in individuals aged <50 years.Conclusions. Data collection for COVID-19 deaths in provinces must be standardised. Even though the data had limitations, these findings can be used by the SA government to manage the pandemic and identify individuals who are at high risk of dying from COVID-19

Gestion sécurisée des dépouilles de personnes décédées de la COVID-19 en Afrique sub-Saharienne: et si on laissait les familles enterrer leurs morts?

La pandémie à Coronavirus 2019 (COVID-19) touche les pays d´Afrique sub-Saharienne depuis le mois de mars 2020. Au-delà des désastres sanitaire et économique causés, se pose un problème psycho-socio-culturel en rapport avec la gestion des corps de personnes décédées de cette maladie; ce problème est susceptible d´entraver la bonne marche de la stratégie de riposte. Au Cameroun par exemple, la gestion actuelle de ces dépouilles ne fait pas l´unanimité. En effet, les restrictions appliquées à l´inhumation, bien que récemment assouplies proscrivent entre autres tout transfert interurbain des dépouilles. A la lumière des considérations culturelles africaines de la personne décédée, des dissensions créées entre les familles et le corps médical, de la législation et des données scientifiques disponibles, cet article analyse les risques et les bénéfices de l´inhumation des dépouilles par les familles. Il propose ensuite des solutions qui concilient la dignité (en laissant les familles enterrer leurs morts dans les domiciles), et la sécurité (en assurant une conservation hermétique et la surveillance d´un officier de police judiciaire). L´application de ces solutions pourraient améliorer la confiance de la population envers le système de santé et contribuer positivement aux stratégies de prévention, d´identification et de prise en charge des cas de COVID-19

Risk factors for under-five mortality in Ethiopia: Evidence from the 2016 Ethiopian Demographic and Health Survey

Background. The under-five child mortality (U5CM) rate is the most important sensitive indicator of the socioeconomic and health status of a community, and the overall development of a nation. Despite the world having made substantial progress in reducing child mortality since 1990, the global U5CM rate was 41 per 1 000 in 2016. The rate is higher in Ethiopia than in several other low- and middle-income countries. Objectives. To estimate the effects of socioeconomic and demographic factors on U5CM in Ethiopia. Methods. A community-based cross-sectional study was conducted on 10 641 under-five children. The 2016 Ethiopian Demographic and Health Survey data were used for this research. Binary logistic regression was employed to identify factors affecting the U5CM rate. Results. The U5CM rate was 60 deaths per 1 000 live births. Children who were delivered at home (adjusted odds ratio (aOR) 1.30; 95% CI 1.04 - 1.63) and male (aOR 1.36; 95% CI 1.15 - 1.60) were at an increased risk of death. Children whose family size was between 1 and 3 (aOR 5.54; 95% CI 4.08 - 7.54), and 4 and 6 (aOR 1.94; 95% CI 1.55 - 2.43) were more likely to die before age 5 than those whose family size was ≥6. First-born (aOR 0.49; 95% CI 0.36 - 0.67), second- or third-born (aOR 0.51; 95% CI 0.39 - 0.67) and fourth- or fifth-born (aOR 0.71; 95% CI 0.56 - 0.91) children were less likely to die than those who were sixth-born and above. Similarly, singleton children (aOR 0.20; 95% CI 0.15 - 0.28), children residing in urban communities (aOR 0.55; 95% CI 0.40 - 0.76) and children whose families had protected sources of water (aOR 0.84; 95% CI 0.71 - 0.99) had reduced risks of death compared with their respective counterparts. Conclusions. The present study identified risk factors for under-five mortality in Ethiopia. Programmes to reduce under-five mortality in Ethiopia must focus on the place of delivery, households with unprotected sources of drinking water and families residing in rural areas

Tuberculosis and HIV co-infection in Congolese children: risk factors of death

Introduction: Human immunodeficiency virus (HIV) and tuberculosis (TB) are the leading causes of death from infectious disease worldwide. The prevalence of HIV among children with TB in moderate to high prevalence countries ranges between 10% and 60%. This study aimed to determine the prevalence of HIV infection among children treated for TB in Directly Observed Treatment Short-Course (DOTS) clinics in Lubumbashi and to identify risk of death during this co-infection.Methods: this is a cross-sectional study of children under-15, treated for tuberculosis from January 1, 2013 to December 31, 2015. Clinical, paraclinical and outcome data were collected in 22 DOTS of Lubumbashi. A statistical comparison was made between dead and survived HIV-infected TB children. We performed the multivariate analyzes and the significance level set at p-value <0.05.Results: a total of 840 children with TB were included. The prevalence of HIV infection was 20.95% (95% CI: 18.34-23.83%). The mortality rate was higher for HIV-infected children (47.73%) compared to HIV-uninfected children (17.02%) (p<0.00001). Age <5 years (aOR=6.50 [1.96-21.50]), a poor nutritional status (aOR=23.55 [8.20-67.64]), and a negative acid-fast bacilli testing (aOR=4.51 [1.08-18.70]) were associated with death during anti-TB treatment. Conclusion: TB and HIV co-infection is a reality in pediatric settings in Lubumbashi. High mortality highlights the importance of early management

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

Seizure-related death in children with epilepsy

Children with epilepsy have a significantly higher rate of death than the general population. The cause of premature death among epileptics is contributed by the underlying cause, coexisting neurologic compromise and the epilepsy itself. Mortality directly related to seizures in paediatric epilepsy is the subject of this review. Seizure-related deaths in epileptics arise from status epilepticus, aspiration pneumonia, as well as sudden and unexpected death in epilepsy (SUDEP). Epilepsy per se enhances the risks of accidents and suicide. Children with epilepsy who are otherwise neurologically intact and with normal neuroimaging findings have an exceedingly low risk of seizure-related death. Poor compliance to antiepileptic drugs (AED) , poor ly co nt rol led (intractable and refractory) seizures, impaired cognition, structural/ metabolic aetiology and antiepileptic drug polypharmacy tend to carry poor prognosis. Therefore, parents need to be appropriately advised about the risk of seizurerelated premature death. Early identification, compliance with AED prescription, and treatment of comorbid conditions can reduce mortality risk and improve health outcomes in children with epilepsy. Children with intractable types of epilepsy may benefit from medical marijuana and neurosurgery

Cardiac Death Risk in Diabetic Haemodialysis Patients Increased Due to Thyroid Problems

A prospective study found that diabetic haemodialysis patients' subclinical hyperthyroidism and euthyroid sick syndrome might increase the risk of sudden cardiac-related deaths. Dr Christiane Drechsler; of University Hospital Wurzburg in Wurzburg; Germany; and colleagues conducted a study that included 1 000 patients undergoing haemodialysis for diabetes. Of those patients; 78.1 had euthyroidism; 13.7 had subclinical hyperthyroidism; 1.6 had subclinical hypothyroidism and 5.4 had euthyroid sick syndrome

Rationale and Design of the Pan-African Sudden Cardiac Death Survey: the Pan-African SCD Study : Cardiovascular Topic

Background: The estimated rate of sudden cardiac death (SCD) in Western countries ranges from 300 000 to 400 000 annually; which represents 0.36 to 1.28 per 1 000 inhabitants in Europe and the United States. The burden of SCD in Africa is unknown. Our aim is to assess the epidemiology of SCD in Africa. Methods: The Pan-Africa SCD study is a prospective; multicentre; community-based registry monitoring all cases of cardiac arrest occurring in victims over 15 years old. We will use the definition of SCD as 'witnessed natural death occurring within one hour of the onset of symptoms' or 'unwitnessed natural death within 24 hours of the onset of symptoms'. After approval from institutional boards; we will record demographic; clinical; electrocardiographic and biological variables of SCD victims (including survivors of cardiac arrest) in several African cities. All deaths occurring in residents of districts of interest will be checked for past medical history; circumstances of death; and autopsy report (if possible). We will also analyse the employment of resuscitation attempts during the time frame of sudden cardiac arrest (SCA) in various patient populations throughout African countries. Conclusion: This study will provide comprehensive; contemporary data on the epidemiology of SCD in Africa and will help in the development of strategies to prevent and manage cardiac arrest in this region of the world

A 20 Year Retrospective Analysis of Medicolegal Deaths in a Tertiary Hospital Setting in Nigeria

Objective: To determine and classify the various types of medicolegal deaths as seen at University of Benin Teaching Hospital (UBTH); Benin City; Nigeria.Materials and Methods: This is a retrospective study of all the medicolegal deaths seen in the Department of Histopathology; (UBTH; Benin City over a 20 year period (January 1990-December 2009) as recorded in the autopsy registers of the department.Result: A total of 5035 autopsies were done during the period; 89 of which were coroner cases. Four thousand; four hundred and eighty-one coroner cases representing 12.5 of all bodies received by the mortuary during the period were studied. The male to female ratio was 1.9:1; with an overall mean age of 38.3 years. The ages ranged from 1 day to 101 years with a peak incidence in the 25-44 years age group. A total of 553 children and 3928 adults were involved. The commonest indication for coroner's autopsy was sudden unexpected natural deaths (SUNDs) which accounted for 65.5 of the cases. Other causes of death were accidents; homicide; suicide; and undetermined causes representing 28.6; 5.0; 0.5; and 0.4; respectively. Commonest cause of SUND was cardiovascular diseases with complications of hypertension being the most common CVS disease (26.9). Road traffic accident was the commonest form of accident causing death (88.7). Public enlightenment and health education about routine medical screening will help to reduce causes of natural deaths.Conclusion: This study shows the pattern of medicolegal autopsies in UBTH and this preliminary data will provide a baseline for future research and help in formulating policies to help in reduction of preventable causes of death

Emotional Reactions of Medical Doctors and Students Following the Loss of their Patients at the Dr George Mukhari Hospital Emergency Unit; South Africa

Background: Studies on death and dying predominantly emphasise the needs of the dying patient and the process of bereavement. Few studies have focused on the reactions of medical doctors and students when the patients they have cared for die. Methods: The aim of the study was to explore the thoughts and feelings of doctors and medical students who have lost patients while under their care at the Dr George Mukhari Hospital emergency unit in Ga-Rankuwa; South Africa. The participants included 10 medical doctors and final-year medical students. A qualitative study methodology using a phenomenological approach was used. Results: Meanings were formulated from transcriptions and themes were identified. The following themes emerged: emotional reactions; which included anger; helplessness; guilt and pain; recurrent thoughts about the incident; blame; perceived incompetence; detachment from emotions; religion; death of a paediatric patient; medical training; psychological services; work environment; coping with the family of the deceased; and facing mortality. Conclusion: From the study it was concluded that doctors needed enhanced training in communication skills and communicating death to the patients' families. Bereavement counselling and debriefing should be available to provide them with an opportunity to share emotional responses and reflect on patients' fatality

Emotional Reactions of Medical Doctors and Students Following the Loss of Their Patients at the Dr George Mukhari Hospital Emergency Unit; South Africa

Background: Studies on death and dying predominantly emphasise the needs of the dying patient and the process of bereavement. Few studies have focused on the reactions of medical doctors and students when the patients they have cared for die. Methods: The aim of the study was to explore the thoughts and feelings of doctors and medical students who have lost patients while under their care at the Dr George Mukhari Hospital emergency unit in Ga-Rankuwa; South Africa. The participants included 10 medical doctors and final-year medical students. A qualitative study methodology using a phenomenological approach was used. Results: Meanings were formulated from transcriptions and themes were identified. The following themes emerged: emotional reactions; which included anger; helplessness; guilt and pain; recurrent thoughts about the incident; blame; perceived incompetence; detachment from emotions; religion; death of a paediatric patient; medical training; psychological services; work environment; coping with the family of the deceased; and facing mortality. Conclusion: From the study it was concluded that doctors needed enhanced training in communication skills and communicating death to the patients' families. Bereavement counselling and debriefing should be available to provide them with an opportunity to share emotional responses and reflect on patients' fatality

Implantable Cardioverter Defibrillators: Uses; Abuses; Gains and Complications

Sudden cardiac death (SCD) due to a ventricular arrhythmia is one of the most common causes of death; yet its management continues to be a challenge. Controlled clinical trials have provided evidence that implantable cardioverter defibrillators (ICDs) are effective in reducing the risk of SCD in selected patients with ischaemic or non-ischaemic cardiomyopathy and/or ventricular arrhythmias. As increasing numbers of patients become eligible for ICDs; deciding whom should receive these becomes more complex; especially in patients with borderline risk factors and those with co-morbidities in whom the risk of death from nonarrhythmic cardiovascular cause is higher. What type of ICD a patient should receive remains a challenge. While ICD shocks themselves can affect outcomes adversely; no other therapy has proven more effective to date. Risks of implantation include infection; lead dislodgement and perforation. An ongoing challenge which also needs to be addressed includes whom will be footing the bill for device implants. More data is required to determine which patient population will benefit the most from ICD implants

A 7-year retrospective study of diabetesrelated deaths in a Nigerian tertiary hospital

A total of 362 diabetics were admitted over a 7-year period (January 1995 to December 2002) to a Nigerian tertiary hospital. Forty (40) of these (8.8%) died as in-patients. Twenty-six (26) were male and 14 were female. Thirteen (32%) were newly diagnosed with diabetes. Seventy percent (70%) of deaths occurred within 1 week of admission. A case-controlled study of the diabetic deaths revealed that presentation with any of the following were associated with in-patient death: diabetic emergencies (p<0.001), infective process (p<0.001), fever (p<0.001), systolic hypertension (p=0.001), and short duration of hospitalisation (p=0.001). It is suggested that greater awareness of diabetes and education of newly diagnosed cases may reduce this high mortality. In addition, the national health insurance system should cover all disease care, including diabetes

Low rate of reporting of confirmed AIDS-related deaths using BI-1663 forms by private medical practitioners in the Mafikeng, North West Province

The aim of the study was to investigate the experiences and perceptions of medical practitioners about the implementation of the current death notification form (BI-1663) in cases of confirmed AIDS-related deaths. The study focused on reporting patterns by private medical practitioners of the deceased's underlying causes of death in BI-1663; together with reasons advanced for the reporting patterns. Using self-administered questionnaires; data were collected from 31 medical practitioners in the Mafikeng area of the North West Province. The findings revealed that the majority of medical practitioners either did not disclose; did omit or mis-report information that HIV/AIDS-related disease was the underlying cause of death in BI-1663 during notification of confirmed AIDS-related death. Reasons advanced for the phenomenon were fears of unauthorised breach of the deceased's confidential information by unintended parties that often led to invalidation of the deceased's insurance and funeral benefits; as well as stigmatisation and social discrimination of the relatives of the deceased. The study recommends that third parties (informants) should be relieved of the duties of conveying the deceased's confidential medical information to the state during death notification processes. Medical practitioners themselves should submit part 2 of BI-1663 that contains the deceased's confidential information directly to public health officials. The study also recommends that the Department of Health should provide formal training to the medical practitioners with respect to death certification to enable them to certify causes of death in a manner that is useful for epidemiological analysis and public policy

Medical Mortality in the Accident and Emergency Unit of the University of Port Harcourt Teaching Hospital

Background:The quality of care in the emergency room is an indirect indicator of the standard of healthcare delivery in a given health institution. Mortality in the emergency room may result from various factors including incompetence of the attending junior physicians; delays in presentation and inadequate facilities. The aim of the study is to highlight the causes of mortality; age and sex distribution of the deaths and the duration of admission before death among medical cases in the accident and emergency unit of the University of Port Harcourt Teaching Hospital. Methods: A one year (January to December; 2005) clinical audit of all adult medical admissions in the accident and emergency department of the University of Port Harcourt Teaching Hospital (UPTH). Results: Of the 5304 admitted over the study period; 349 (6.8) patients died. Two hundred and thirty three (66.8) of these deaths were due to medical cases only.These medical deaths were made up of 126 males and 107 females giving a male to female ratio of 1.2:1. The presumed causes of deaths were stroke in 56(24.5); HIV/AIDS in 53 (22.7); sepsis in 20 (8.6); while 14 (6.0) died from meningitis. Ten patients (4.3) died from diabetic ketoacidosis; and hepatic encephalopathy and tetanus were responsible for 10(4.3) and 7 (3.0) deaths respectively. Conclusion: In the period studied; medical mortality was high in the accident and emergency room of UPTH. The major causes of deaths were cerebrovascular accidents and HIV/AIDS