Improving cause of death certification in the Philippines: implementation of an electronic verbal autopsy decision support tool (SmartVA auto-analyse) to aid physician diagnoses of out-of-facility deaths.

BACKGROUND: The majority of deaths in the Philippines occur out-of-facility and require a medical certificate of cause of death by Municipal Health Officers (MHOs) for burial. MHOs lack a standardised certification process for out-of-facility deaths and when no medical records are available, certify a high proportion of ill-defined causes of death. We aimed to develop and introduce SmartVA Auto-Analyse, a verbal autopsy (VA) based electronic decision support tool in order to assist the MHOs in certifying out-of-facility deaths. METHOD: We conducted a stakeholder consultation, process mapping and a pre-test to assess feasibility and acceptability of SmartVA Auto-Analyse. MHOs were first asked to conduct an open-ended interview from the family members of the deceased, and if they were not able to arrive at a diagnosis, continue the interview using the standardised SmartVA questionnaire. Auto-Analyse then presented the MHO with the three most likely causes of death. For the pilot, the intervention was scaled-up to 91 municipalities. We performed a mixed-methods evaluation using the cause of death data and group discussions with the MHOs. RESULTS: Of the 5649 deaths registered, Auto-Analyse was used to certify 4586 (81%). For the remaining 19%, doctors believed they could assign a cause of death based on the availability of medical records and the VA open narrative. When used, physicians used the Auto-Analyse diagnosis in 85% of cases to certify the cause of death. Only 13% of the deaths under the intervention had an undetermined cause of death. Group discussions identified two themes: Auto-Analyse standardized the certification of home deaths and assisted the MHOs to improve the quality of death certification. CONCLUSION: Standardized VA combined with physician diagnosis using the SmartVA Auto-Analyse support tool was readily used by MHOs in the Philippines and can improve the quality of death certification of home deaths.

Health assessment for mercury exposure among schoolchildren residing near a gold processing and refining plant in Apokon, Tagum, Davao del Norte, Philippines.

Artisanal gold-mining activities in the Philippines have proliferated since the early 1980s. Presently, environmental and health monitoring conducted by several governmental agencies is limited to the determination of total mercury only. Previous studies undertaken focused mainly on the exposure of adults and workers to mercury during mining/processing operations. However, in one area in Mindanao, mined ores are brought down and processed in the lowlands where residential communities are exposed to environmental pollutants resulting from gold processing/refining operations. The area of study is Apokon, Tagum, Davao del Norte, which has 29 gold processing and refining plants. Health complaints among schoolchildren in Apokon Elementary School were received by the Department of Health and were attributed to the mercury pollution in the environment. As part of a collaboration with the Health Department, UP-National Poisons Control and Information Service, the National Institute for Minamata Disease (NIMD), Japan, provided technical assistance in the analytical determination of mercury in biological and environmental samples. Elevated mercury concentrations were noted in some of the river systems up to 15 km from the mining areas. Environmental quality monitoring showed T-Hg sediment levels ranged from 0.553 to 66.471 microg/g dry wt. while water samples from river systems exhibited mercury levels from 72.8 to 78.4 ng/ml. Twenty-seven sediment samples from river systems near mining operations and seven water samples were also brought to the Institute for analysis. Fish samples collected showed levels ranging from 1.07 to 438.8 ng/g for total mercury and 0.71-377.18 ng/g for methylmercury. Methylmercury content in fish is predominant. All water and sediment samples collected from three sampling sites have elevated T-Hg level while three fish species have elevated T-Hg and methylmercury levels (WHO/CDC, 1994). Blood and hair samples from 162 schoolchildren aged 5-17 years were collected and analyzed at the NIMD for mercury analysis. Analytical procedures used in the NIMD for mercury testing were applied. Laboratory results showed that total mercury hair samples ranged from 0.278 to 20.393 microg/g while methylmercury hair results were from 0.191 to 18.469 microg/g. Methylmercury in hair showed levels from 45.96 to 99.81%. Total blood mercury levels ranged from 0.757 to 56.88 microg/l while Me-Hg blood levels ranged from 1.36 to 46.73 microg/l. It was determined that 10 children had elevated T-Hg blood levels while one child had high total and methylmercury levels in hair. A summary of physical examination results showed that the predominant findings include under-height, gingival discoloration, adenopathy, underweight and dermatologic abnormalities among children examined.