Sources of Morbidity & Mortality Data PDF

EPIDEMIOLOGY: LE 4 | TRANS 3 Sources of Morbidity and Mortality Data RAMON JASON M. JAVIER, MD MSTM, FPAFP | Lecture Date (01/23/2025) OUTLINE I.​ Sources of Data B.​ Quarantine vs A.​ Primary Data...

EPIDEMIOLOGY: LE 4 | TRANS 3 Sources of Morbidity and Mortality Data RAMON JASON M. JAVIER, MD MSTM, FPAFP | Lecture Date (01/23/2025) OUTLINE I.​ Sources of Data B.​ Quarantine vs A.​ Primary Data Isolation B.​ Secondary Data IV.​ Civil Registration of II.​ Reports of Occurrence Vital Events of Notifiable Diseases A.​ Certificate of Death III.​ Republic Act of 11332 B.​ Certificate of Live A.​ Mandatory Birth Reporting of V.​ Summary Notifiable Diseases VI.​ Review Questions and Health Events VII.​ References of Public Health Concern Act of 2020 SUMMARY OF ABBREVIATIONS RA Republic Act RHU Rural Health Units CHO City Health Offices PHO Provincial Health Offices MHO Municipal Health Offices ICD International Classification of Diseases Figure 1. Community Diagnosis with UERMMMCI DPCM Faculty San Juan City, April 2024 ❗️ Must know 📣 Lecturer 📖 Book 📋 Previous Trans B. SECONDARY DATA LEARNING OBJECTIVES ✔​ Identify the various sources of morbidity and mortality ​ Obtained by other researchers for purposes not data used in public health studies and epidemiologic necessarily the same as those of the investigators’ and investigations are considered as previously existing information, ✔​ Accomplish pertinent public documents related to civil which might just be helpful in their study. registries of vital events; and ​ Large bearing with regard to the quality of facts obtained ✔​ Determine important community health indices that since the investigator has no control over: are of public health significance. →​how the data were collected →​the objectives behind the data collection I. SOURCES OF DATA →​definitions used in classifying individuals into different A. PRIMARY DATA categories of the variables considered ​ Obtained by the investigator himself/herself, first hand, specifically to aid him/her in answering the different objectives or purposes he/she has set for his/her study. ​ Data gathered from surveys, interviews, tests, or examinations done on subjects to determine if a respondent fulfills the definition of a case of a particular disease entity, are considered primary to the investigator/s. →​e.g. blood examinations, ancillary diagnostic procedures, community diagnosis →​Help determine whether or not a respondent would fulfill Figure 2. Barangay Health Records Community Visit, Social or meet the criteria for him/her to be diagnosed with a Hygiene Clinic, Brgy. Batis,, San Juan City, August 2022 particular medical condition 📣 Example of Secondary Data: Brgy. Batis Social Hygiene Clinic is an HIV/AIDS treatment hub. Registration under the HIV/AIDS Registry is required to avail services from the hub. Data from PLHIV are stored in a database within the Social hygiene clinic E.g. You would like to conduct research on PLHIV. You can coordinate with the city health officer and gain access to data relevant to your study. LE 4 TRANS 3 TG-B4: T. Fajardo, C.Falcutila, K. Famaran, M. Figueras, A. TE: S. Falcatan, M. AVPAA: E. Gonzales Page 1 of 11 VER 4 Figueroa, H. Fuentes Fernandez*  II. REPORTS OF OCCURRENCE OF NOTIFIABLE III. REPUBLIC ACT 11332 DISEASES A. MANDATORY REPORTING OF NOTIFIABLE ​ There are certain diseases that are required by law to be DISEASES AND HEALTH EVENTS OF PUBLIC HEALTH notified or reported to health authorities, upon the CONCERN ACT OF 2020 recommendation of the Department of Health. ​ Disease control refers to the reduction of disease ​ These Reports of Occurrence of Notifiable Diseases incidence, prevalence, morbidity, or mortality to a locally provide information regarding the morbidity status of the acceptable level as a result of deliberate efforts and community. continued intervention measures to maintain the reduction. ​ The reporting of these diseases is generally done on a ​ Disease response refers to the implementation of specific weekly basis and is required for the purposes of activities to control further spread of infection, outbreaks or surveillance and monitoring of important epidemics and to prevent re-occurrence. communicable diseases. →​includes verification, contact tracing, rapid risk ​ Data on notifiable diseases are based on information assessment, case measures, treatment of patients, risk submitted by health personnel of different rural health communication, conduct of prevention activities, and units (RHUs), city health offices (CHOs) or provincial rehabilitation and reintegration. health offices (PHOs), and municipal health offices →​shall include, but is not limited to, movement (MHOs). restrictions, partial or complete closure of schools ​ The Law on Reporting of Notifiable Diseases (Republic and businesses, imposition of quarantine in specific Act 3573) mandates the immediate accounting of any geographic areas and international or domestic travel communicable disease of public health interest to the restrictions, construction of facilities for the quarantine nearest health officer. of health and emergency front liners, and the Table 1. Philippine Integrated Disease Surveillance and prepositioning and distribution of personal protective Response/PIDSR [Lecturer’s PPT] equipment for health workers. B. QUARANTINE VS. ISOLATION ​ Quarantine →​is used to separate and restrict the movement of well persons who may have been exposed to a communicable disease to see if they become ill. →​has origins in the French for “forty” or “a forty day period”. The current practice of 14 days of quarantine has more to do with modern medicine than with any etymological connection to the Latin root of “four”. Fourteen and forty are similar is just a coincidence of epidemiology and etymology. →​You put the person in quarantine if the person is still ​ Under RA 3573, the Philippine Integrated Disease Surveillance and Response (PIDSR) was created confirmed case. 📣 healthy, but he or she was already exposed to a →​You put the person in quarantine, wait for the natural →​Identified several medical conditions that are of public history, wait for the incubation period to pass, and you health relevance →​Those that are considered epidemic prone are targeted for eradication or elimination and other disease or eventually become sick. ​ Isolation 📣 will determine whether or not that healthy person will conditions of public health importance. →​Is used to separate ill persons who have a →​Newer version: 2020 Implementing Rules and communicable disease from those who are healthy. Regulations of RA 11332 →​The first permanent hospital for treating plague victims ​ Elimination was established in Venice in 1423 on a nearby island →​reduction to zero of the incidence of a specified called Santa Maria di Nazaret. The hospital’s location disease in a defined geographical area as a result of on an island is a vivid and relevant example of the root deliberate efforts of the word isolation, which ultimately derives from the →​continued intervention measures are required Latin word insula, meaning “island”. →​If there is zero incidence: →​For isolation, you already have a confirmed ▪​ Actively do a public health intervention to maintain or individual to be sick and you try to minimize his or sustain the zero incidence ​ Eradication →​permanent reduction to zero of the worldwide transmission. 📣 her movement so there will be lesser chances of ​ Disease surveillance refers to the on-going systematic incidence of infection caused by a specific agent as a collection, analysis, interpretation, and dissemination result of deliberate efforts. of outcome-specific data for use in the planning, →​intervention measures are no longer needed implementation, and evaluation of public health practice ​ For those seen by health authorities, the quality of in terms of epidemics, emergencies, and disasters. diagnosis poses a limitation to this data source. →​This includes the functional capacity for data ​ Since facilities for doing laboratory tests are usually analysis as well as the timely dissemination of these lacking, diagnosis is, in most cases, solely based on data to persons who can undertake effective prevention clinical grounds. and control activities. ​ In the rural areas where volunteer health workers and midwives act as frontline health practitioners, symptom diagnosis is practiced --- i.e., only the occurrence of signs and symptoms is reported and not the diagnosis. EPIDEMIOLOGY Sources of Morbidity and Mortality Data Page 2 of 11  EMERGING AND RE-EMERGING INFECTIOUS ​ The cause of death as certified by a licensed doctor is a DISEASES record of an individual’s death information. ​ Have not occurred in humans before; →​Being responsible for the clinical diagnosis of the ​ Have occurred previously but affected only small cause of death, the physician plays a pivotal role in the numbers of people in isolated areas; cause of death certification. ​ Have occurred throughout human history but have only →​The clinical diagnosis by a physician is the basis for recently been recognized as distant disease due to an certifying the cause of death. infectious agent; →​When entered into a Certificate of Death, it establishes ​ Are caused by previously undetected or unknown the cause of death of that particular individual. infectious agents; ​ The information on the Certificate of Death, which is coded ​ Are due to mutant or resistant strains of a causative using the International Classification of Diseases organism; or Version 11, is entered into a database and consolidated ​ Once were major health problems in the country, and then by the Philippine Statistics Authority. declined dramatically, but are again becoming health →​The licensed doctor should include diagnoses that have problems for a significant proportion of the a corresponding ICD 11 code. If the diagnosis does not population. have a corresponding ICD 11 code, then the diagnosis ​ Examples of re-emerging infectious diseases are poliomyelitis and leprosy. Nomenclature of Diseases. 📣 is wrong and it does not conform with the International ​ The consolidated mortality statistics is the foundation NOTIFIABLE DISEASES for the country’s health policies, plans, and programs. ❗️ ​ The following disease/syndromes shall be categorized as: Table 2. Classification and Examples of Notifiable Diseases ​ It informs the policy makers and planners on the leading causes of mortality and its patterns and trends. ​ Thus, it is of utmost importance that the country’s mortality Immediately Notifiable Weekly Notifiable data should be of good quality. (Category I) (Category II) ​ Acute Flaccid Paralysis ​ Acute Bloody Diarrhea ​ Adverse Event ​ Acute Encephalitis Following Immunization Syndrome ​ Anthrax ​ Acute Hemorrhagic Fever ​ COVID-19 Syndrome ​ Hand-Foot-and-Mouth ​ Acute Viral Hepatitis Disease (HFMD) ​ Bacterial Meningitis ​ Human Avian Influenza ​ Cholera ​ Measle ​ Dengue ​ Meningococcal Disease ​ Diphtheria ​ Middle East ​ Influenza-like Illness Respiratory Syndrome ​ Leptospirosis (MERS) ​ Malaria ​ Neonatal Tetanus ​ Non-Neonatal Tetanus ​ Paralytic Shellfish ​ Pertussis Poisoning ​ Typhoid and Paratyphoid ​ Rabies Fever Figure 3. All Causes of Mortality (Top 20), Philippines: ​ Severe Acute January to April, 2023 and 2024 [Lecturer’s PPT] Respiratory Syndrome ​ Leading causes of death in Filipinos: (SARS) →​1st: Ischemic Heart Disease →​2nd: Malignant Cancers/Neoplasms IV. CIVIL REGISTRIES OF VITAL EVENTS →​3rd: Cerebrovascular Diseases (Stroke) ​ Civil registration is the continuous, permanent →​4th: Diabetes Mellitus compulsory recording of the occurrence and →​5th: Pneumonia characteristics of vital events, as defined and provided ​ The road to good quality data starts with the clinical through decree or regulation in accordance with the legal diagnosis of the physician as to the cause of death. requirements of each country. ​ This is followed by a precise manner of certifying the ​ It is done primarily for their value as important records or cause of death with immediate antecedent, and legal documents, and secondarily for their usefulness as underlying cause, entered accurately and in correct sources of statistics. order. A. CERTIFICATE OF DEATH ​ The Certificate of Death is a permanent legal record which Special Circumstances: 📖 ​ Based on the AO, the requirement for a death certificate contains an individual’s death information. before burial may be waived in the case of special ​ It provides important information and data on the circumstances when the death certificate cannot be circumstances surrounding the death. issued in time. These include, but are not limited to: ​ The information from the death certificate has various uses →​The deceased died from a dangerous communicable – i.e., it is used for settlement of claims, inheritance, disease and must be buried within 12 hours insurance benefits as well as proof of death. ▪​ Declared Dangerous Communicable Diseases ​ The certificate of death is likewise provided to the family −​ Hepatitis B and C members since it is a requirement for burial −​ Rabies arrangements. −​ Invasive Group A Streptococcal Infections EPIDEMIOLOGY Sources of Morbidity and Mortality Data Page 3 of 11  −​ Transmissible Spongiform Encephalopathies: →​ Each cause of death has a distinct pattern of signs, e.g. Creutzfeldt-Jakob Disease (CJD) and Mad symptoms, severity, and other characteristics. Cow Disease →​ The signs and symptoms experienced by the deceased −​ HIV/AIDS can be recognized, remembered, and reported by family −​ Meningococcemia members and relatives. −​ Viral Hemorrhagic fever: e.g., African Ebola, →​ It is possible to correctly diagnose deaths based on the Lassa or Marburg reported information and to categorize them into groups −​ Yellow Fever of causes of death that are useful for public health −​ Plague purposes. −​ SARS ​ The main objective of a verbal autopsy is to describe the →​The family members of the deceased have causes of death at the community level or population level, requested immediate cremation without embalming where civil registration and death certification systems are or viewing weak and where most people die at home without having →​The kin opt for immediate burial had contact with the health system. →​Religious beliefs or tradition, such as Islam or the ​ There are two stages involved in physician-coded Jewish faith calls for burial within 12 hours after verbal autopsy procedure: death. →​An interviewer (i.e., preferably a trained lay person or ​ In these cases, death certificate issuance shall be health worker but not a medical doctor) visits the completed within 12 hours after burial or sanction shall household where a death has occurred to interview the be imposed by the local health authority. family using a predesigned questionnaire, and to record ​ No remains shall be buried without a burial permit all responses in a standardized manner. issued by the city or municipality where the burial will →​The pattern of responses is reviewed by a licensed take place. Funeral parlors or embalming physician to determine the probable cause of death, establishments shall not hold unclaimed bodies longer based on the signs and symptoms reported by the than 60 days or sanction shall be imposed by the local respondents. health authority. WHO CERTIFIES A DEATH OF A PERSON? ​ Requirements when the cause of death is dangerous ​ If there is a medical attendant at death, the certifying communicable disease officer is the attendant at death. →​The remains shall be placed in a plastic cadaver bag ​ If there is no medical attendant at death, the certifying or other durable, airtight container at the point of officer is the local health officer. death ​ If there is no medical attendant at death and the local →​Attached biohazard tag health officer is not available, the Mayor or any member of →​Container shall not be opened for viewing or any the Sangguniang Bayan or the Municipal Secretary may other purposes prior to burial or cremation issue a Certificate of Death for burial purposes only. ​ Requirements in the shipment or transfer of cadavers ​ In medico-legal cases, the certifying officer is the from one place to another medico-legal officer. →​Certificate of Death shall be secured →​Transfer permit from local health authority of the USES OF CERTIFICATE OF DEATH point of origin ​ Prima facie evidence of death →​Remain shall be properly embalmed ​ Claim of benefits, pensions, insurance, or tax exemption →​Transfer permit from places where the remains will ​ Evidence for settlement of estate pass if local ordinance of such place so require ​ Re-marriage purpose of surviving spouse →​Shipment of remains to and from abroad shall be ​ Designation of a guardian or foster parent for minor governed by National Quarantine Office ​ Determine health priorities for prevention of deaths due to similar causes in the future VERBAL AUTOPSY ​ The information is also significant for family members so ​ For the many deaths occurring in the Philippines that are that they know what caused the death and are aware of not attended by a physician, the best way of ascertaining conditions that may occur or could be prevented in other the cause of death by the local health authority is through family members. verbal autopsy. USES OF DEATH STATISTICS ​ This is done by interviewing family members who are ​ Provide the indicators of existing infectious diseases knowledgeable as to the probable cause of death. and epidemics that need immediate control measures. ​ This is the task of the local health officer since he or she ​ Basis for designing programs to promote public safety signs the certificate of death for those not medically and strategies for disease prevention and eradication. attended. ​ Serve administrative purposes, specifically, in the ​ The World Health Organization (WHO) has clearing of files like disease-case registers, social security, recommended verbal autopsy as a partial solution to the military service files, electoral rolls, and tax registers. problem of lack of cause of death information in cases ​ For the control of infectious diseases when there is no medical attendance. ​ Basis for design of programs in public safety, accident ​ Verbal autopsy is one way of determining the cause of prevention and crime eradication death based on an interview with the next of kin or ​ Mortality surveillance, health and epidemiologic research, other caregivers. health policy / program planning ​ This method is undertaken using a standard ​ Study of mortality differentials questionnaire that asks information on signs, symptoms, medical history, and circumstances WRITING A DEATH CERTIFICATE preceding death. ​ The most recent condition written on the top-most line of ​ Verbal autopsy instruments are based on the following the certificate that directly leads to death is the immediate assumptions: cause EPIDEMIOLOGY Sources of Morbidity and Mortality Data Page 4 of 11  ​ Other intervening cause/s of death occurring between the characterized by the inability of premature infants to underlying and immediate causes is/are called the produce sufficient lung surfactant. Moreover, the infant's antecedent cause. premature delivery was caused by pre-eclampsia, a ​ The underlying cause of death is the disease or injury maternal complication commonly associated with high-risk which initiated the train of morbid events leading to death, teenage pregnancies, which ultimately led to the infant's or the circumstances of the accident or violence which death. produced the fatal injury. ​ It is the most important entry in the certificate since mortality statistics is based on this underlying cause. ​ Part Il of the Medical Certificate portion of the Certificate of Death includes all other significant or contributory co-existing or pre-existing diseases or conditions that contributed to death but do not directly lead to the underlying cause of death listed in Part 1. Figure 5. Infant Death [Lecturer’s PPT] ILL-DEFINED AND NON-SPECIFIC CAUSES OF DEATH ​ The ill-defined causes of death under ICD-11 are vague categories and conditions that include signs and symptoms and abnormal clinical and laboratory findings. ​ Deaths assigned to ill-defined causes are insufficiently detailed to be of value for public health purposes. ​ Hence, as a rule, ill-defined conditions should never be entered as an underlying cause of death on the Certificate of Death, unless nothing else is known about the deceased. Figure 4. Medical Certificate [Lecturer’s PPT] ​ A common error is to report specific organ failure or the ​ Notice that in the death certificate, there is an interval box mode of dying as the underlying cause of death. ​ These conditions are also considered ill-defined and time of demise that these conditions develop. 📣 (refer to Figure 4) that would look into how long from the ​ In most cases, the interval will have to be estimated, and it should not be reported as the underlying cause of death since they do not usually occur without a precipitating is acceptable to list the interval as "unknown" or cause. "approximately," if such is the case. ​ Therefore, if an organ failure is reported on the death ​ General intervals, such as seconds, minutes, hours, days, certificate, the underlying condition responsible for the weeks, months, and several years are also acceptable. failure should also be reported. ​ A time range (i.e., seconds to minutes, minutes to hours, or terms, such as "known for five years") may be used. ​ The stated time interval between onset of cause and death helps to check that the causes of death are written in correct sequence - i.e., the underlying cause leading to antecedent cause, leading to the immediate cause. →​The general rule is that the underlying cause occurred if you are to accomplish the time of death. 📣 first, and therefore should have the longest time interval ​ If it occurs that after filling out the time interval, the antecedent, or the immediate cause is older or has a longer time interval than the underlying cause, then there Figure 6. Modes of Dying[Lecturer’s PPT] could have been a mistake in the order or sequence of the ​ These are examples of modes of dying. When referring to cause of death. heart failure, the term can be vague or unclear. However, ​ As a rule, the underlying cause occurred first in the specifying the underlying cause or etiology, such as heart sequence of events and would logically have the longest time interval. precise and acceptable. 📣 failure secondary to ischemic heart disease, makes it more INFANT DEATH ​ In a death certificate, there is a special area or box if particular mode of dying. 📣 ​ You have to identify what triggered or precipitated that as 7 days of age or below. 📣 your patient happens to be an infant. Infant is described ​ Aside from putting the pertinent data, you have to think of which triggered the death of the infant. 📣 a condition, not just of the baby, but also of the mother ​ Infant death is sometimes connected to maternal conditions. ​ An example is Hyaline Membrane Disease, also referred to as Respiratory Distress Syndrome (RDS), identified as the main disease or condition in Figure 5. This condition is EPIDEMIOLOGY Sources of Morbidity and Mortality Data Page 5 of 11  ​ A common mistake is listing cardiopulmonary arrest as the cause of death, which is incorrect since all deceased patients experience a cessation of breathing and heartbeat, defined as cardiopulmonary arrest. What you need to identify is what triggered the cardiopulmonary arrest. ​ When talking about sepsis, determine if it is caused by urinary tract infection, decubitus ulcer or pneumonia. If you identify it as caused by pneumonia, narrow it down to whether it is community acquired, hospital acquired or ventilator acquired pneumonia. DEATH OF WOMEN OF CHILD-BEARING AGE ​ In the revised Certificate of Death there is a new item (19c), labeled Maternal Condition, which must be filled out by the certifier for all deaths involving females aged 15 to 49 years, whether pregnant or not. ​ The fact that a woman died during pregnancy or within 42 days of the termination of pregnancy should be clearly indicated under Maternal Condition because this information, aside from its use in health research and statistics, is often used to identify those cases that need to be included in a Maternal Death Review. ​ A maternal death refers to death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes. ​ The top causes of maternal death are (1) postpartum bleeding; (2) complications from unsafe abortion; (3) Figure 7. Ill-defined and non-specific causes of death [Lecturer’s hypertensive disorders of pregnancy; (4) postpartum PPT] infections; and (5) obstructed labor. ​ The so-called "garbage codes" include the following ill-defined or residual categories of major disease groups OTHER IMPORTANT POINTS ❗️ ​ If there is uncertainty for causes of death, it is always that do not provide meaningful information on the acceptable to use qualifying terms, such as “probable” or underlying disease or injury that caused death. “presumed”. death certificate.📣 ​ We still don’t want the garbage codes to be reported in the ​ If the cause of a death cannot be determined with reasonable medical probability but seems to be due solely MECHANISTIC TERMINAL EVENTS to a natural cause, the certifier may report “Undetermined ​ These are pathophysiologic or biochemical Natural Cause” as entry in the cause of death statement derangements that are common final pathways that in the Medical Certificate. explain how a cause of death exerts its lethal effect. ​ In general, mechanistic terminal events have an almost limitless differential diagnosis and should never be reported in the Certificate of Death as one of the causes of mortality. ​ They are extremely non-specific and are of little epidemiologic value for mortality statistics that are derived from Certificates of Death. ❗️ we want to avoid writing in the death certificate. ​ Examples: 📣 ​ These mechanistic terminal events are also something that → Respiratory Arrest → Cardiac Arrest → Ventricular Fibrillation → Cardiopulmonary Arrest 📖 Figure 9. Certificate of Death[Lecturer’s PPT] ​ Use the “X” mark when filling in appropriate boxes or spaces. → Asystole ​ Verify accuracy of the identification data, including the → Electromechanical Dissociation correct spelling of the name of the deceased. ​ Do not make alterations or erasures. ​ Do not use abbreviations or medical symbols ​ For all signatures, use pen with permanent black ink; rubber stamps or facsimile signatures are not acceptable. ​ Record only one etiology per line in the cause of death portion. ​ Line (a) – immediate cause — must always have an entry Figure 8. Mechanistic Terminal Events [Lecturer’s PPT] EPIDEMIOLOGY Sources of Morbidity and Mortality Data Page 6 of 11  ​ If the condition on line (a) resulted from another condition, FETAL DEATH put this other condition on line (b), and so on, until the full ​ Refers to the demise prior to the complete expulsion of a sequence is reported. product of conception, irrespective of the period of ​ Always enter the underlying cause of death on the pregnancy. lowest used line in Part I. ​ The death is indicated by the fact that after such ​ Additional lines may be added if necessary. separation, the fetus does not breathe or show any DEATH INVOLVING EXTERNAL INJURIES other evidence of life, such as the beating of heart, pulsation of the umbilical cord, or definitive movement of ​ The approach to writing causes of death involving external voluntary muscles. injuries is to report the external cause or event as the ​ For all fetal deaths aged 20 weeks and above, as underlying cause and identify the bodily trauma caused calculated from the start of the last menstrual period to by the external event and report it as antecedent cause, the date of delivery, a different form called Certificate of and lastly report fatal derangement resulting from the Fetal Death (Municipal Form N0. 103A) must be prepared bodily trauma as immediate cause. and the causes of death completely filled out by the ​ The external event refers to an ”outside” agent or force, certifier. usually physical or chemical in nature that causes trauma, ​ For fetal death, we also identify not just only the an injury or damage to bodily tissues or its functions; the circumstances surrounding the death of fetus trauma, in turn, may result in anatomic or functional fatal →​Also the main maternal condition derangement that leads to the patient’s demise. ​ If the certifier is not certain of the manner of death, the physician can indicate “Undetermined Intent”. ​ Example of a patient who was rushed to ER due to vehicular accident Figure 11. Fetal Death Certificate[Lecturer’s PPT] [Lecturer’s PPT] Abruptio Placenta 📣 ​ Placenta prematurely separates from the uterus before Figure 10. Death involving External Injuries 📣 ​ In these circumstances, we have to identify the manner of birth death and where did it occur for medicolegal purposes →​Requires immediately delivery of baby →​ To know If autopsy is required or not →​Often associated with preterm labor →​Common in women with cocaine intoxication DEATH FROM INFECTIOUS DISEASE ​ The single most important or main disease / condition in ​ For death due to infections, the certifier has to report the: the fetus is entered in line (a) and the remainder, if any, in →​Manifestations or body site (e.g. pneumonia, line (b). pyelonephritis, meningitis, hepatitis) ​ In lines (c) and (d), the certifier reports all disease/ →​Causative agent, if known; write “cause unknown,” if conditions in the mother which had some effect on the unknown fetus. →​Source and route of infection (e.g., food poisoning, ​ The main maternal disease or condition should be contaminated blood product, health care associated entered in line (c) and the rest, if any, in line (d). infection), if known ​ Line (e) is for reporting of other relevant circumstances →​Any underlying disease that may have suppressed the which have bearing on the death of the fetus, but patient’s immunity that made him/her susceptible to the cannot be identified as disease or condition of the fetus or infection that led his/her demise mother. DEATH FROM NEOPLASMS PERIPROCEDURAL DEATH ​ It is important to indicate or report the specific site of ​ Periprocedural death refers to demise that is known or neoplasm because public health prevention strategies suspected as having resulted in whole or in part from differ markedly from one type of neoplasm to another. diagnostic, therapeutic, anesthetic, or operative ​ The primary site must be stated on the Certificate of procedures. Death, even if it has long been removed before death. ​ It is also referred to as misadventure, iatrogenic, or ​ If a secondary growth is included in the sequence of errors and accidents in medical care. events leading to death, state the site of secondary ​ Although such words may connote negligence, many growth as due to the site of primary growth. procedural deaths do not involve negligence, ​ If the primary site is unknown, record on the Certificate of mistakes, or culpability. Death, “primary unknown”. ​ The structure and format used in writing the cause of death ​ The Certificate of Death should always state the statements for periprocedural death depend on the primary site as this will help identify the underlying cause manner of the patient’s demise, whether natural or of death. accidental ​ More often than not, the primary site is the underlying ​ A periprocedural death is considered natural if death was 📣 cause of death. imminent and that it would have occurred anyway even if →​Secondary sites are the metastatic sites the procedure was not done to the patient. EPIDEMIOLOGY Sources of Morbidity and Mortality Data Page 7 of 11  ​ The death of the patient would have occurred even if there B. CERTIFICATE OF LIVE BIRTH was no intervention involved. (i,e., terminal patients who ​ Gravidity: denotes a pregnant state, both present and natural periprocedural death.) 📣 pass away after a procedure are commonly classified as a ​ A periprocedural death is considered accidental, on the past, irrespective of the period of gestation. ​ Parity: denotes a previous state of pregnancy beyond the period of viability. other hand, if death would not have occurred in the ​ Both gravidity and parity refer to pregnancy and not babies procedure’s absence (i.e., the patient would not have died ​ A woman who delivers twins in the first pregnancy is still if the procedure was not done) G1P1 DEATH UNDER MEDICO-LEGAL EXAMINATION ISSUES ON PATERNITY ​ If the physician has reason to believe or suspect that the cause of death was due to violence or crime (or that he/she is dealing with a medico-legal case), then he/she is duty-bound to immediately report to the authorities of the Philippine National Police (PNP) or the National Bureau of Investigation (NBI). due, but not limited, to the following: →​Stab wounds ❗️ ​ There is violence or crime when the cause of death was →​Gunshot wounds →​Suicide of any kind →​Strangulation →​Accident resulting to death →​Actual physical assault inflicting injuries upon a person resulting in death Figure 12. Family code of the Philippines (left) and Affidavit of →​Any other acts of violence upon a person resulting to acknowledgment/admission of paternity[Lecturer’s PPT] death ​ Illegitimate children are typically a cause of drama →​Sudden death of undetermined cause especially in inheritance cases. DEAD ON ARRIVAL ​ The back portion of the Certificate of Live Birth contains ​ Emergency room (ER) deaths refer to patient mortality the affidavit of acknowledgment or the admission of occurring in the ER, including patients who were revived paternity. by initial resuscitation measures at the ER but →​If the biological father is present, he can sign the eventually died there, regardless of the time of stay in affidavit proving he is the father of the child. ER. ​ In the Family Code of the Philippines, one must clearly ​ In such cases, the Certificate of Death shall be differentiate between Legitimate, Illegitimate, and accomplished by the ER officer if he/she can provide a Legitimated Children. definite diagnosis. LEGITIMATION ​ Otherwise, the death should be referred to the ​ Legitimate vs. Illegitimate vs. Legitimated Children medico-legal officer of the hospital or the local health →​Who are legitimate children? officer who shall cause the issuance of the Certificate of ▪​ Children born after one hundred and eighty days Death. following the celebration of the marriage, and before ​ Scenario: What if the patient has low vital signs three hundred days following its dissolution or the (bradycardic already, 60 palpatory, etc.) when they reach separation of the spouses shall be presumed to be the ER and after 12 hours post-treatment in the ER they legitimate (Art. 225, Civil of the Philippines) suddenly die, is this case still classified as dead-on-arrival? ▪​ Children conceived or born during the marriage of the →​If the death is less than 24-hours since the time of parents are legitimate. admission, the ER doctor can tell the family of the ▪​ Children conceived as a result of artificial deceased that the patient was dead on arrival. The insemination of the wife with the sperm of the death would be referred to the medico-legal officer of husband or that of a donor are likewise legitimate cause of death. 📣 the hospital for further evaluation and issuance of the ▪​ It is also common for the ER doctor to issue the children of the husband and his wife, provided both of them authorized or ratified such insemination in a written instrument executed and signed by them death certificate to lessen the grief and out of before the birth of the child. The instrument shall be deceased. 📣 humanitarian purposes towards the family of the recorded in the civil registry together with the birth 📖 certificate of the child (Art 164, Family Code of the DEATHS OF FILIPINO MUSLIM/INDIGENOUS PEOPLE Philippines). ​ For Filipino Muslim, Indigenous Cultural →​Is the child considered legitimate although the Communities/Indigenous People (ICC/IPs), the dead body mother may have declared against its legitimacy? may be buried without a Certificate of Death provided ▪​ The child shall be considered legitimate although the that the death shall be reported to the local health officer mother may have declared against its legitimacy or within 48 hours after the date of burial. may have been sentenced as an adulteress (Art. 167, ​ The local health officer shall prepare the Certificate of Family Code of the Philippines). Death (COD), certify the cause of death and submit the →​What are the rights of legitimate children? COD to the Local Civil Registrar for registration. ▪​ Legitimate children shall have the right: −​ To bear the surnames of the father and the mother EPIDEMIOLOGY Sources of Morbidity and Mortality Data Page 8 of 11  −​ To receive support from them, from their →​Scenario 3: A child is born from parents having either a ascendants, and in a proper case, from the brother (1) adulterous, (2) bigamous, or (3) incestuous and sisters in conformity with article 291 and, relationship. The child is ILLEGITIMATE. −​ To legitimate and other successional rights which →​Scenario 4: If the parents are minors. The child is this Code recognizes in their favor. ( Art. 263, Civil ILLEGITIMATE Code of the Philippines) →​Scenario 5: Difference between a legitimated child and →​Who are illegitimate children? an illegitimate child. The legitimated child can be part of ▪​ Children conceived and born out of a valid marriage the INHERITANCE AND SUCCESSION. are illegitimate unless otherwise provided in the →​Scenario 6: If a live-in partner bears a child and then Family Code (Art. 165, F.C.) eventually becomes married. At first, the child is →​Who are considered illegitimate children? considered ILLEGITIMATE but once the parents get ▪​ The following are illegitimate children: married, the child becomes a LEGITIMATED child. −​ Children born to couples who are not legally ▪​ A legitimated child and a legitimate child have the married or common-law marriages; same rights and claim to the inheritance and −​ Children born of incestuous marriages; succession of their parents. −​ Children born of bigamous marriages; ▪​ The rights of an illegitimate child will FOREVER be −​ Children born of adulterous relations between less than the legitimated and legitimate child. parents; →​Scenario 7: Husband and wife get separated (but not −​ Children born of marriages are void for reasons of public policy under Art. 38 of the Family Code; annulled or divorced). The husband then enters a new −​ Children born of couples below 18, whether they relationship and gets the girl pregnant. The offspring are married (which married is void) or not; and, would be an ILLEGITIMATE CHILD. −​ Children born of other void marriages under Art. ▪​ What if annulled or divorced then remarried? 15 unless otherwise provided (OCRG Cir. No. −​ If the offspring were BORN before the annulment 89-13 dated July 17, 1989) or divorce of the original wife, the child is →​What is the rule on the registration of births of considered ILLEGITIMATE since he/she was born illegitimate children who were born on August 03, in an adulterous relationship. 1988 and thereafter? −​ If the offspring was born AFTER the annulment or ▪​ The following rules shall govern the registration of divorce and then gets remarried. The child is illegitimate children who were born on August 3, 1988 LEGITIMATE. and thereafter: CONCEPT CHECK: −​ An illegitimate child shall use the surname of his ​ If the scenario falls under the classifications of mother (Art. 176, F.C.) regardless of whether or relationships that are either (1) adulterous, (2) not his father admits paternity (opinion of Civil bigamous, (3) incestuous, or (4) under legal age, the Code Revision Committee, September 23, 1988) child is always illegitimate. −​ The name of the father of the illegitimate child may →​A child is always legitimate if they are born under a be indicated on the birth certificate of the latter legal and recognized union by the Philippine whenever the former executes an affidavit of Government. (May slightly differ depending on the admission of paternity, provided that such affidavit family laws of each country). shall not affect the naming of the illegitimate child →​A child can be legitimized in scenarios such as: (opinion of Civil Code Revision Committee, ▪​ If the parents were under legal age during the birth September 23, 1988). of the child and got married later on when they are −​ The only time an illegitimate child may use the in legal age. The child is LEGITIMIZED. surname of the father is when the biological father ▪​ If a live-in partner bears children and gets married files an affidavit to use the surname and the Family Court approves of that affidavit. −​ The affidavit mentioned in the immediately 📣 later on. The child is LEGITIMIZED. preceding paragraph, if executed by the father, shall be permanently attached to and shall form part of the birth certificate of the illegitimate child. The birth certificate in such a case must have a remark “With Attached Affidavit of Admission of Paternity” impressed with a rubber stamp at the upper left-hand margin and duly signed by the local civil registrar or authorized civil registry personnel. −​ Illegitimate children falling under this classification who were not registered within the prescribed Figure 13. Criteria for a Legitimate Child. Taken from Title VI: period of registration shall comply with the Paternity and Filiation of the Family Code of the Philippines[Lecturer’s PPT] requirement of delayed registration of births ​ Listed below are the scenarios provided: →​Scenario 1: A guy and girl get married and have a 📣 (Section 4 Circular No. 89-13 dated 17 July 1989). FETAL DEATH IN UTERO ​ Abortus vs. Fetus →​The US National Center for Health Statistics defines child: The child is LEGITIMATE. an abortus as a fetus or embryo removed or expelled →​Scenario 2: Common law arrangements such as from the uterus during the first half of gestation - i.e., live-ins that bear a child. The child is ILLEGITIMATE 20 weeks or less, or in the absence of accurate dating criteria, born weighing less than 500 grams. EPIDEMIOLOGY Sources of Morbidity and Mortality Data Page 9 of 11  d.​ Screening for depression and dementia among elderly OBSTETRICAL-GYNECOLOGICAL CODE individuals by doing the comprehensive geriatric ​ Gravidity and Parity assessment (CGA) →​Gravidity (G)- denotes a pregnant state, both present 2.​ When certifying the CAUSE OF DEATH of an INFANT, and past, irrespective of the period of gestation. the following are also reported or indicated in the →​Parity (P)- ​denotes a previous state of pregnancy CERTIFICATE OF DEATH, EXCEPT: beyond the period of viability. a.​ main paternal condition affecting the infant →​Early Term: 37 weeks through 38 weeks and 6 days b.​ main maternal condition affecting the infant →​Full Term: 39 weeks through 40 weeks and 6 days c.​ main disease/condition of the infant →​Late Term: 41 weeks through 41 weeks and 6 days d.​ other relevant circumstances →​Post-term: 42 weeks and beyond 3.​ If a person dies in the absence of any licensed →​4 Digit OB Code (TPAL) physician/health professional, who may issue a ▪​ Full Term (No. of times a full-term baby is delivered) CERTIFICATE OF DEATH for BURIAL PURPOSES? ▪​ Pre-Term (No. of times a preterm baby is delivered) a.​ Barangay health worker ▪​ Abortion (No. of times the woman had an abortion) b.​ Medico-legal officer (Philippine National Police) ▪​ Living Children (No. of currently living children) c.​ All of the options Additional Examples: d.​ City/Municipal Mayor ​ First-Time Pregnant Woman Who Delivers Two Live 4.​ When accomplishing the CERTIFICATE OF DEATH, Twins = G1P1 (1002) which will logically have the LONGEST INTERVAL in →​G1 → it is her first pregnancy, hence, G1 terms of onset until the time of demise? →​P1 → completed 1 pregnancy after delivery, P1 a.​ underlying cause of death (counts the number of completed pregnancy, not b.​ immediate cause of death number of children delivered. A pregnancy with twins c.​ antecedent cause of death is still considered as 1 Full Term) d.​ other conditions contributing to death →​(1002) 5.​ When accomplishing the CERTIFICATE OF DEATH, ▪​T = 1 → Full Term Pregnancy the following are considered ill-defined and ▪​P = 0 → No Pre-Term baby delivered non-specific MECHANISTIC TERMINAL EVENTS, ▪​A = 0 → No abortion/miscarriage reported EXCEPT: ▪​L = 2 → Living children = Twins a.​ Chronic bedridden state ​ First Pregnancy (Twins) Preterm, One Stillbirth, One b.​ Asystole Living. First pregnancy: Delivered twins preterm, one c.​ Electromechanical Dissociation was a stillbirth. Currently pregnant again (second d.​ Respiratory Arrest pregnancy). = G2P1 (0101) 6.​ In the Philippines, the following are top causes of →​G2 → 1 previous pregnancy, and is on her 2nd MATERNAL DEATH, EXCEPT: pregnancy a.​ pregnancy-induced hypertension →​P1 → Still counts as one completed pregnancy b.​ gestational diabetes mellitus complications despite the twins, will only count it as 2 after c.​ complications from unsafe abortion delivery (term or preterm only, abortion/miscarriage d.​ postpartum hemorrhage are not counted under parity) ANSWER KEY →​(0101) 1. C Primary Data is data obtained by the ▪​T = 0 → No term deliveries. investigator himself. ▪​P = 1 → One preterm delivery. Secondary Data is data obtained by other ▪​A = 0 → No abortion/miscarriage researchers. ▪​L = 1 → One living child. 2. A A - Not included in the list B - Entered in Line C V. SUMMARY C - Entered in Line A ​ Various sources of morbidity and mortality data (i.e., D - Entered in Line E primary and secondary data) may be used in public 3. D In the absence of a health professional, the health studies and epidemiologic investigations Mayor, any member of the Sangguniang ​ Some pertinent public documents related to civil Bayan, or the Municipal Secretary may issue registries of vital events include the (1) Certificate of a Certificate of Death for burial purposes only. Death, (2) Certificate of Fetal Death, and (3) Certificate of 4. A A - Longest interval Live Birth B - Shortest interval ​ Important community health indices which are of public C - Between immediate and antecedent causes health significance include cause-specific incidence and of death prevalence rates. 5. A Mechanistic Terminal Events: VI. REVIEW QUESTIONS ​ Respiratory Arrest 1.​ The following are PRIMARY SOURCES OF DATA, ​ Cardiac Arrest EXCEPT: ​ Cardiopulmonary Arrest a.​ Calculating the body mass index (BMI) of obese ​ Asystole patients by measuring their height and weight ​ Electromechanical Dissociation b.​ Determining the FEV1/FVC ratio using spirometry of 6. B The top causes of maternal death (based on patients with chronic obstructive pulmonary disease Philippine Statistics): c.​ Getting records of the viral load and CD4 count of 1.​ postpartum bleeding; people living with HIV from the social hygiene clinic 2.​ complications from unsafe abortion; 3.​ hypertensive disorders of pregnancy; EPIDEMIOLOGY Sources of Morbidity and Mortality Data Page 10 of 11  4.​ postpartum infections; and 5.​ obstructed labor. VII. REFERENCES ​ Depart of Preventive and Community Medicine. (2025). Review Notes and Manual in Epidemiology and Research Methods ​ Javier, Ramon Jason M. (2025). Sources of Morbidity and Mortality Data [PPT slides] ​ Synchronous Lecture: EPIDEMIOLOGY Sources of Morbidity and Mortality Data Page 11 of 11