Research Article: Validity of a Minimally Invasive Autopsy for Cause of Death Determination in Adults in Mozambique: An Observational Study

Date Published: November 22, 2016

Publisher: Public Library of Science

Author(s): Paola Castillo, Miguel J. Martínez, Esperança Ussene, Dercio Jordao, Lucilia Lovane, Mamudo R. Ismail, Carla Carrilho, Cesaltina Lorenzoni, Fabiola Fernandes, Rosa Bene, Antonio Palhares, Luiz Ferreira, Marcus Lacerda, Inacio Mandomando, Jordi Vila, Juan Carlos Hurtado, Khátia Munguambe, Maria Maixenchs, Ariadna Sanz, Llorenç Quintó, Eusebio Macete, Pedro Alonso, Quique Bassat, Clara Menéndez, Jaume Ordi, Peter Byass

Abstract: BackgroundThere is an urgent need to identify tools able to provide reliable information on the cause of death in low-income regions, since current methods (verbal autopsy, clinical records, and complete autopsies) are either inaccurate, not feasible, or poorly accepted. We aimed to compare the performance of a standardized minimally invasive autopsy (MIA) approach with that of the gold standard, the complete diagnostic autopsy (CDA), in a series of adults who died at Maputo Central Hospital in Mozambique.Methods and FindingsIn this observational study, coupled MIAs and CDAs were performed in 112 deceased patients. The MIA analyses were done blindly, without knowledge of the clinical data or the results of the CDA. We compared the MIA diagnosis with the CDA diagnosis of cause of death.CDA diagnoses comprised infectious diseases (80; 71.4%), malignant tumors (16; 14.3%), and other diseases, including non-infectious cardiovascular, gastrointestinal, kidney, and lung diseases (16; 14.3%). A MIA diagnosis was obtained in 100/112 (89.2%) cases. The overall concordance between the MIA diagnosis and CDA diagnosis was 75.9% (85/112). The concordance was higher for infectious diseases and malignant tumors (63/80 [78.8%] and 13/16 [81.3%], respectively) than for other diseases (9/16; 56.2%). The specific microorganisms causing death were identified in the MIA in 62/74 (83.8%) of the infectious disease deaths with a recognized cause.The main limitation of the analysis is that both the MIA and the CDA include some degree of expert subjective interpretation.ConclusionsA simple MIA procedure can identify the cause of death in many adult deaths in Mozambique. This tool could have a major role in improving the understanding and surveillance of causes of death in areas where infectious diseases are a common cause of mortality.

Partial Text: Current estimates of major causes of mortality in middle- and low-income countries are hampered by the lack of direct and reliable data. Complete diagnostic autopsy (CDA), the gold standard method to determine the cause of death [1], is seldom performed in these countries due to limited human resources and cultural and/or religious backgrounds that negatively influence acceptance and consent in some regions [2,3]. In addition, many deaths occur outside the health system, which precludes not only postmortem evaluation but also frequently the basic medical assistance that allows certification of the death event. Verbal autopsy is a structured interview administered to relatives of the deceased individual and is currently recommended by WHO as an alternative to CDA to overcome this problem in low- and middle-income countries [4–7]. However, although verbal autopsy provides a broad syndromic approach, its performance for etiological diagnosis is very limited, and it tends to misclassify a substantial number of deaths [1]. Finally, clinical records generally show a high rate (10%–30%) of discordance with the results of CDAs [8,9], and this discordance further increases in resource-constrained settings, where the availability of ancillary diagnostic tests such as imaging or microbiological exams is scarce or suboptimal [10,11].

Coupled MIA and CDA procedures were performed in 112 adults (57 males and 55 females; median age 37 y, range 16–76). The interval between death and MIA and CDA ranged between 8 and 23 h. Seventy-three out of 112 patients (65.2%) tested positive for antibodies against HIV (all being HIV-1). The viral load was >50,000 copies/ml in 67 out of the 73 HIV-positive patients (91.8%).

This study shows that an easy, rapid, and non-disfiguring standardized minimally invasive sampling procedure designed for postmortem studies in Mozambique may provide a correct diagnosis in the majority of cases. This validation study shows a high degree of concordance (75.9%; kappa = 0.732) between the MIA and CDA diagnoses in a series of adults who died at a quaternary hospital in Mozambique. These findings are important since they open a new pathway for cause of death investigation in places where postmortem methods have not traditionally been used. This method may improve the current capacities to conduct cause of death surveillance in large parts of the world where mortality remains high but knowledge of what people die of is currently based on assumptions.



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