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This is the published version of a paper published in The Lancet Global Health.
Citation for the original published paper (version of record):
Byass, P. (2020)
MITS: an interim step towards improved cause of death data The Lancet Global Health, 8(7): e865-e866
https://doi.org/10.1016/S2214-109X(20)30235-7
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Comment
www.thelancet.com/lancetgh Vol 8 July 2020 e865
MITS: an interim step towards improved cause of death data
In the Lancet Global Health, Allan Taylor and colleagues1 present the first population-based study of minimally invasive tissue sampling (MITS) as a mid-spectrum approach for the determination of cause of death, positioned in robustness between clinical diagnostic autopsies and medical certification or verbal autopsy.
In this descriptive study, the authors included data obtained in the first 2 years after the implementation of the Child Health and Mortality Prevention Surveillance (CHAMPS) Network in Asia and Africa.
The findings from 933 childhood deaths across five countries (Mozambique, South Africa, Kenya, Mali, and Bangladesh) provide proof of principle for the scale-up of MITS. Although this study was not designed to be statistically generalisable in terms of mortality patterns, it provides insight regarding cause-specific childhood mortality and underlying pathophysiology.
The ranked causes of death, which were pooled across disparate samples obtained from five considerably different countries, represent the overall potential of MITS rather than generalisable epidemiological findings.
The CHAMPS Network has been successful in the completion of high-quality biomedical science despite challenging circumstances and logistical issues associated with shipping MITS samples to the Centers for Disease Control and Prevention (Atlanta, GA, USA) for further analysis. The authors did not indicate the costs involved per case, which might not have been a major issue in this internationally funded research study, but represents an important factor when considering the global potential of MITS. A previous study has estimated that costs for minimally invasive autopsies exceed €1000 per case.2 Considering such costs, widespread implementation of MITS by national authorities in African and Asian countries is unlikely, particularly when compared with the relatively small costs of incorporating verbal autopsy into civil registration procedures.
Thus, understanding how MITS findings from studies such as CHAMPS, which has so far analysed data for a relatively limited numbers of deaths, can be best used to leverage greater understanding of global mortality patterns is crucial. WHO estimates that only around half of deaths worldwide are registered with a reliable
cause, with most unregistered deaths occurring in Africa and Asia.3 Thus, connections must be made between the millions of deaths that occur without a registered cause and the insights provided by the application of expensive MITS methods to a small proportion of deaths.
The CHAMPS Network applied the 2016 WHO verbal autopsy instrument4 to the deaths that the MITS approach had been applied to. Thus, the next logical step would be to process the CHAMPS verbal autopsy data using available automated verbal autopsy cause of death models, and to compare modelled causes of death with MITS findings. Observed differences might highlight possible improvements to the knowledge base that drive standard verbal autopsy models. Thus far, the CHAMPS Network has focused on deaths in children, however, extending the MITS concept to older children and adults could also be worthy of consideration, to provide additional knowledge for automated cause of death models.
A number of the UN Sustainable Development Goal (SDG) targets are associated with adult mortality, for example SDG 3.4, which aims to reduce premature mortality from non-communicable diseases by a third by 2030.5 Unless substantial improvements are made to improve the reliability of methods and systems used for monitoring all-age cause-specific mortality across Africa and Asia, the accuracy with which SDG 3.4 and other targets will be evaluable globally in 2030 is unclear. Some adult MITS data could be useful, in addition to childhood data, to inform and improve verbal autopsy models for this purpose. Furthermore, as COVID-19 potentially spreads into populations where testing and clinical data are likely to be limited, MITS procedures could be similarly informative.
MITS should be considered an innovative and informative component of the global quest for more complete cause-specific mortality data, and as a resource for enhancing other tools for measuring mortality.
The MITS approach might also be useful for cases in which aetiology-specific cause of death determination is crucial, such as in vaccine trials. Generally, however, MITS alone is unlikely to become a widely applicable solution to fill global gaps in the routine assessment of individual cause of death.
See Articles page e909
Comment
e866 www.thelancet.com/lancetgh Vol 8 July 2020
I declare no competing interests.
Copyright © 2020 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license.
Peter Byass
peter.byass@umu.se
Department of Epidemiology and Global Health, Umeå University, 901 87 Umeå, Sweden
1 Taylor AW, Blau DM, Bassat Q, et al. Initial findings from a novel population-based child mortality surveillance approach: a descriptive study. Lancet Glob Health 2020; 8: e909–19.
2 Wagensveld IM, Hunink MGM, Wielopolski PA et al. Hospital
implementation of minimally invasive autopsy: a prospective cohort study of clinical performance and costs. PLoS One 2019; 14: e0219291.
3 WHO. Completeness of cause-of-death data, 2007–2016. Geneva: World Health Organization, Geneva, 2018. http://gamapserver.who.int/
mapLibrary/Files/Maps/Global_CivilRegistrationDeaths_2007_2016.png (accessed April 23, 2020).
4 Nichols E, Byass P, Chandramohan D, et al. The WHO 2016 verbal autopsy instrument: an international standard suitable for automated analysis by InterVA, InSilicoVA and Tariff 2.0. PLoS Med 2018; 15: e1002486.
5 UN. Sustainable development goal 3. https://sustainabledevelopment.
un.org/sdg3 (accessed April 23, 2020).
