Sources Of Morbidity And Mortality Data PDF

Ramon Jason M. Javier, MD, MSTM, FPAFP, FPASCOM Professor / Past Chair Department of Preventive and Community Medicine College of Medicine, UERMMMCI Founding Chair Department of Family and Comm...

Ramon Jason M. Javier, MD, MSTM, FPAFP, FPASCOM Professor / Past Chair Department of Preventive and Community Medicine College of Medicine, UERMMMCI Founding Chair Department of Family and Community Medicine UERM Memorial Hospital Family and Community Medicine – Tropical Medicine Specialist The Medical City Clinic ProSer Health Services, Inc. At the end of the session, the students shall be able to: 1. Identify the various sources of morbidity and mortality data used in public health studies and epidemiologic investigations; 2. Accomplish pertinent public documents related to civil registries of vital events; and 3. Determine important community health indices which are of public health significance. Primary Data These are 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. For example, 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. Community Diagnosis with UERMMMCI DPCM Faculty San Juan City, April 2024 Secondary Data These are obtained by other researchers for purposes not necessarily the same as those of the investigators’ and are considered as previously existing information, which might just be helpful in their study. Generally, this type of information has a large bearing with regard to the quality of facts obtained since the investigator has no control over how the data were collected, the objectives behind the data collection, and the definitions used in classifying individuals into different categories of the variables considered. Barangay Health Records Community Visit Social Hygiene Clinic, Brgy. Batis, San Juan City August 2022  There are certain diseases that are required by law to be notified or reported to health authorities, upon the recommendation of the Department of Health. These Reports of Occurrence of Notifiable Diseases provide information regarding the morbidity status of the community. The reporting of these diseases is generally done on a weekly basis and is required for the purposes of surveillance and monitoring of important communicable diseases.  Data on notifiable diseases are based on information submitted by health personnel of different rural health units (RHUs), city health offices (CHOs) or provincial health offices (PHOs), and municipal health offices (MHOs). The Law on Reporting of Notifiable Diseases (Republic Act 3573) mandates the immediate accounting of any communicable disease of public health interest to the nearest health officer. Source: Google Images, Public Domain Elimination Eradication reduction to zero of the permanent reduction to zero incidence of a specified of the worldwide incidence of disease in a defined infection caused by a specific geographical area as a result agent as a result of deliberate of deliberate efforts; efforts; intervention measures continued intervention are no longer needed measures are required Source: Google Images, Public Domain  For those seen by health authorities, the quality of diagnosis poses a limitation to this data source. Since facilities for doing laboratory tests are usually lacking, diagnosis is, in most cases, solely based on clinical grounds. 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. Mandatory Reporting of Notifiable Diseases and Health Events of Public Health Concern Act of 2020 Disease control refers to the reduction of disease incidence, prevalence, morbidity, or mortality to a locally acceptable level as a result of deliberate efforts and continued intervention measures to maintain the reduction.  Disease response refers to the implementation of specific activities to control further spread of infection, outbreaks or epidemics and to prevent re-occurrence. ü It includes verification, contact tracing, rapid risk assessment, case measures, treatment of patients, risk communication, conduct of prevention activities, and Source: Google Images, Public Domain rehabilitation and reintegration.  Disease response refers to the implementation of specific activities to control further spread of infection, outbreaks or epidemics and to prevent re-occurrence. ü This shall include, but is not limited to, movement restrictions, partial or complete closure of schools and businesses, imposition of quarantine in specific geographic areas and international or domestic travel restrictions, construction of facilities for the quarantine of health and emergency front liners, and the prepositioning and distribution of personal protective equipment for health workers.  Source: Google Images, Public Domain Quarantine versus Isolation  Disease surveillance refers to the on-going systematic collection, analysis, interpretation, and dissemination of outcome-specific data for use in the planning, implementation, and evaluation of public health practice in terms of epidemics, emergencies, and disasters. ü A disease surveillance system includes the functional capacity for data analysis, as well as the timely dissemination of these data to persons who can undertake effective prevention and control activities.  have not occurred in humans before; have occurred previously but affected only small numbers of people in isolated areas; have occurred throughout human history but have only recently been recognized as a distant disease due to an infectious agent; are caused by previously undetected or unknown infectious agents; are due to mutant or resistant strains of a causative organism; or once were major health problems in the country, and then declined dramatically, but are again becoming health problems for a significant proportion of the population. The following diseases / syndromes The following diseases / syndromes shall be categorized as immediately shall be categorized as weekly notifiable (Category I): notifiable (Category II): Acute Flaccid Paralysis Acute Bloody Diarrhea Adverse Event Following Immunization Acute Encephalitis Syndrome Anthrax Acute Hemorrhagic Fever Syndrome Acute Viral Hepatitis COVID-19 Bacterial Meningitis Hand-Foot-and-Mouth Disease (HFMD) Cholera Human Avian Influenza Dengue Measles Diphtheria Meningococcal Disease Influenza-Like Illness Middle East Respiratory Syndrome (MERS) Leptospirosis Neonatal Tetanus Malaria Paralytic Shellfish Poisoning Non-Neonatal Tetanus Pertussis Rabies Typhoid and Paratyphoid Fever Severe Acute Respiratory Syndrome (SARS).  Civil registration is the continuous, permanent compulsory recording of the occurrence and characteristics of vital events, as defined and provided through decree or regulation in accordance with the legal requirements of each country. It is done primarily for their value as important records or legal documents, and secondarily for their usefulness as sources of statistics.  The Certificate of Death is a permanent legal record which contains an individual’s death information. It provides important information and data on the circumstances surrounding the death. The information from the death certificate has various uses --- i.e., it is used for settlement of claims, inheritance, insurance benefits as well as proof of death. The Certificate of Death is likewise provided to the family members since it is a requirement for burial arrangement.  The cause of death as certified by a licensed doctor is a record of an individual’s death information. ü Being responsible for the clinical diagnosis of the cause of death, the physician plays a pivotal role in the cause of death certification. ü The clinical diagnosis by a physician is the basis for certifying the cause of death. ü When entered into a Certificate of Death, it establishes the cause of death of that particular individual.  The information on the Certificate of Death, which is coded using the International Classification of Diseases Version 11, is entered into a database and consolidated by the Philippine Statistics Authority. Source: Google Images, Public Domain  The consolidated mortality statistics is the foundation for the country’s health policies, plans and programs. 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 data should be of good quality. Source: Philippine Statistics Authority, November 2024  The road to good quality data starts with the clinical diagnosis of the physician as to the cause of death. This is followed by precise manner of certifying the cause of death with immediate, antecedent, and underlying causes, entered accurately and in correct order.  For the many deaths occurring in the Philippines that are not attended by a physician, the best way of ascertaining the cause of death by the local health authority is through verbal autopsy. This is done by interviewing family members who are knowledgeable as to the probable cause of death. Source: Google Images, Public Domain This is the task of the local health officer since he or she signs the Certificate of Death for those not medically attended.  The World Health Organization (WHO) has recommended verbal autopsy as a partial solution to the problem of lack of cause of death information in cases when there is no medical attendance. Verbal autopsy is one way of determining the cause of a death based on an interview with next of kin or other caregivers. This method is undertaken using a standard questionnaire that asks information on signs, symptoms, medical history, and circumstances preceding death. Verbal autopsy instruments are based on the following assumptions: Each cause of death has a distinct pattern of signs, symptoms, severity, and other characteristics. The signs and symptoms experienced by the deceased can be recognized, remembered, and reported by family members and relatives. It is possible to correctly diagnose deaths based on the reported information and to categorize them into groups of causes of death that are useful for public health purposes. Source: Google Images, Public Domain The main objective of a verbal autopsy is to describe the causes of death at the community level or population level, where civil registration and death certification systems are weak and where most people die at home without having had contact with the health system. There are two stages involved in physician-coded verbal autopsy procedure: 1. An interviewer (i.e., preferably a trained lay person or health worker but not a medical doctor) visits the household where a death has occurred to interview the family using a predesigned questionnaire, and to record all responses in a standardized manner. 2. The pattern of responses is reviewed by a licensed physician to determine the probable cause of death, based on the signs and symptoms reported by the respondents.  If there is a medical attendant at death, the certifying officer is the attendant at death. If there is no medical attendant at death, the certifying officer is the local health officer. If there is no medical attendant at death and the local health officer is not available, the Mayor or any member of the Sangguniang Bayan or the Municipal Secretary may issue a Certificate of Death for burial purposes only. In medico-legal cases, the certifying officer is the medico-legal officer.  prima facie evidence of death claim of benefits, pensions, insurance, or tax exemption evidence for settlement of estate re-marriage purpose of surviving spouse designation of a guardian or foster parent for minor determine health priorities for prevention of deaths due to similar causes in the future  The information is also significant for family members so that they know what caused the death and are aware of conditions that may occur or could be prevented in other family members.  provide the indicators of existing infectious diseases and epidemics that need immediate control measures basis for designing programs to promote public safety and strategies for disease prevention and eradication serve administrative purposes, specifically, in the clearing of files like disease-case registers, social security, military service files, electoral rolls, and tax registers  for the control of infectious diseases basis for design of programs in public safety, accident prevention and crime eradication mortality surveillance, health and epidemiologic research, health policy / program planning study of mortality differentials  The most recent condition written on the top-most line of the certificate that directly leads to death is the immediate cause. Other intervening cause/s of death occurring between the underlying and immediate causes is/are called the antecedent cause.  The underlying cause of death is the disease or injury which initiated the train of morbid events leading to death, or the circumstances of the accident or violence which produced the fatal injury. It is the most important entry in the certificate since mortality statistics is based on this underlying cause. Part II 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 I.  In most cases, the interval will have to be estimated, and it is acceptable to list the interval as “unknown” or “approximately,” if such is the case. General intervals, such as seconds, minutes, hours, days, weeks, months, and several years are also acceptable. 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. If it occurs that after filling out the time interval, the antecedent, or the immediate cause is older or has longer time interval than the underlying cause, then there could have been a mistake in the order or sequence of the cause of death. As a rule, the underlying cause occurred first in the sequence of events and would logically have the longest time interval. Hyaline Membrane Disease Prematurity Pre-eclampsia High-Risk Teen-Age Pregnancy*  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.  A common error is to report specific organ failure or the mode of dying as the underlying cause of death. These conditions are also considered ill-defined and should not be reported as the underlying cause of death since they do not usually occur without a precipitating cause. Therefore, if an organ failure is reported on the death certificate, the underlying condition responsible for the failure should also be reported. Modes of Dying  The so-called “garbage codes” include the following ill-defined or residual categories of major disease groups that do not provide meaningful information on the underlying disease or injury that caused death. Mechanistic Terminal Events These are pathophysiologic or biochemical derangements that are common final pathways that explain how a cause of death exerts its lethal effect. In general, mechanistic terminal events have an almost limitless differential diagnoses 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. Mechanistic Terminal Events Respiratory Arrest Cardiac Arrest Source: Google Images, Public Domain Cardiopulmonary Arrest Asystole Electromechanical Dissociation  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 female 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 in 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) post-partum bleeding; (2) complications from unsafe abortion; (3) hypertensive disorders of pregnancy; (4) post-partum infections; and (5) obstructed labor.  If there is uncertainty in the entries for causes of death, it is always acceptable to use qualifying terms, such as “probable” or “presumed.” If the cause of a death cannot be determined with reasonable medical probability but seems to be due solely to a natural cause, the certifier may report “Undetermined Natural Cause” as entry in the cause of death statement in the Medical Certificate.  Use “X” mark when filling in appropriate boxes or spaces. Verify the accuracy of the identification data, including the 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. If the condition on line (a) resulted from another condition, put this other condition on line (b), and so on, until the full sequence is reported. Always enter the underlying cause of death on the lowest used line in Part I. Additional lines may be added if necessary.  The approach to writing causes of death involving external injuries is to report the external cause or event as the underlying cause and identify the bodily trauma caused by the external event and report it as antecedent cause, and lastly report the fatal derangement resulting from the bodily trauma as the immediate cause. The external event refers to an “outside” agent or force, usually physical or chemical in nature that causes trauma, an injury or damage to bodily tissues or its functions; the trauma, in turn, may result in anatomic or functional fatal 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.” For deaths due to infections, the certifier has to report the: manifestation or body site (e.g., pneumonia, pyelonephritis, meningitis, hepatitis) causative agent, if known; write “cause unknown,” if unknown source and route of infection (e.g., food poisoning, contaminated blood product, health care associated infection), if known any underlying disease that may have suppressed the patient’s immunity that made him/her susceptible to the infection that led to his/her demise  It is important to indicate or report the specific site of neoplasm because public health prevention strategies differ markedly from one type of neoplasm to another. The primary site must be stated on the Certificate of Death, even if it has long been removed before death. If a secondary growth is included in the sequence of events leading to death, state the site of secondary growth as due to the site of primary growth.  If the primary site is unknown, record on the Certificate of Death, “primary unknown.” The Certificate of Death should always state the primary site as this will help identify the underlying cause of death. More often than not, the Source: Google Images, Public Domain primary site is the underlying cause of death.  Fetal death refers to the demise prior to the complete expulsion of a product of conception, irrespective of the period of pregnancy. The death is indicated by the fact that after such separation, the fetus does not breathe nor show any other evidence of life, such as the beating of the heart, pulsation of the umbilical cord, or definitive movement of voluntary muscles. Source: Google Images, Public Domain  For all fetal deaths aged 20 weeks and above, as calculated from the start of the last menstrual period to the date of delivery, a different form called Certificate of Fetal Death (Municipal Form No. 103A) must be prepared and the causes of death completely filled out by the certifier. Source: Google Images, Public Domain  The single most important or main disease / condition in the fetus is entered in line (a) and the remainder, if any, in line (b). In lines (c) and (d), the certifier reports all diseases / conditions in the mother which had some effect on the fetus. The main maternal disease or condition should be entered in line (c) and the rest, if any, in line (d). Line (e) is for reporting of other relevant circumstances which have bearing on the death of the fetus, but cannot be identified as a disease or condition of the fetus or the mother.  Periprocedural death refers to demise that is known or suspected as having resulted in whole or in part from diagnostic, therapeutic, anesthetic, or operative procedures. It is also referred to as misadventure, iatrogenic, or errors and accidents in medical care. Although such words may connote negligence, many procedural deaths do not actually involve negligence, mistake, or culpability. Source: Google Images, Public Domain  The structure and format used in writing cause of death statements for periprocedural death depends on the manner of the patient’s demise, whether natural or accidental. A periprocedural death is considered natural if death was imminent and that it would have occurred anyway even if the procedure was not done to the patient. A periprocedural death is considered accidental, on the other hand, if death would not have occurred in the procedure’s absence (i.e., the patient would not have died if the procedure was not done).  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 Source: Google Images, Public Domain National Police (PNP) or the National Bureau of Investigation (NBI). There is violence or crime when the cause of death was due, but not Source: Google Images, Public Domain limited, to the following: stab wounds gunshot wounds suicide of any kind strangulation accident resulting to death actual physical assault inflicting injuries upon a person resulting to death any other acts of violence upon a person resulting to death sudden death of undetermined cause  Emergency room (ER) deaths refer to patient mortality occurring in the ER, including patients who were revived by initial resuscitative measures at the ER but eventually died there, regardless of the time of stay in ER. In such cases, the Certificate of Death shall be accomplished by the ER Officer if he/she can provide a definite diagnosis. Otherwise, the death should be referred to the medico-legal officer of the hospital or the local health officer who shall cause the issuance of the Certificate of Death.  Gravidity: denotes a pregnant state, both present and past, irrespective of the period of gestation Parity: denotes a previous state of pregnancy beyond the period of viability Both gravidity and parity refer to pregnancy and not babies. A woman who delivers twins in the first pregnancy is still G1P1. Source: Google Images, Public Domain Illegitimate Children Legitimate vs. Illegitimate vs. Legitimated Children  Abortus vs. Fetus Source: Google Images, Public Domain The US National Center for Health Statistics defines an abortus as a fetus or embryo removed or expelled from the uterus during the first half of gestation --- i.e., 20 weeks or less, or in the absence of accurate dating criteria, born weighing less than 500 grams.  Gravidity and Parity Full Term First Time Pregnant Woman Who Pre-Term Delivers Two Live Twins: Abortion G1P1 (1002) Living Children Source: Google Images, Public Domain  Various sources of morbidity and mortality data (i.e., primary and secondary data) may be used in public health studies and epidemiologic investigations. Some pertinent public documents related to civil registries of vital events include the Certificate of Death, Certificate of Fetal Death, and Certificate of Live Birth. Important community health indices which are of public health significance include cause-specific incidence and prevalence rates.  Review Notes and Manual in Epidemiology and Research Methods I, Department of Preventive and Community Medicine, College of Medicine, UERMMMCI, 2024-2025 Medical Certification of Death: Handbook for Filipino Physicians – Guidelines and Procedures, Second Edition, Department of Health, 2016 Revised 2020 Implementing Rules and Regulations of Republic Act 11332 or the Mandatory Reporting of Notifiable Diseases and Health Events of Public Health Concern Act