How has COVID-19 impacted the civil registration and vital statistics system in Loreto, Perú? Evidence using process mapping and qualitative analysis

ObjectivesAccurate civil registration and vital statistics (CRVS) systems are the primary data source to measure the impact of the COVID-19 pandemic on mortality. This study assesses how the pandemic impacted CRVS system processes in Loreto region of Peru, one of the worst affected countries globally.DesignQualitative study.SettingLoreto, a remote region, which had the highest reported mortality rate in Peru during the pandemic.ParticipantsSemistructured individual interviews and documentary analysis were conducted between September 2020 and May 2021 with 28 key informants from eight institutions involved in death certification. Key informants were identified using a purposive sampling strategy commencing at the Health Directorate of Loreto, and the snowball method was used where a participant suggested another organisation or person. Information from key informants was used to compare business process maps of the CRVS system before and during the pandemic.ResultsDuring early May 2020, there were seven times more registered deaths than in earlier years, but key informants believed this underestimated mortality by 20%–30%. During the pandemic, families had to interact with more institutions during the death certification process. Several issues disrupted death certification processes, including the burden of increased deaths, the Environmental Health Directorate often removing a body without the family’s express agreement, the creation of COVID-19 cemeteries where no death certificate was needed for burial, greater participation of funeral homes that often used outdated paper forms, and closure of civil registry offices. There was increased use of the online National Death System (SINADEF) but many users had problems with access.ConclusionsThe pandemic substantially disrupted CRVS processes in Loreto, making death certification more difficult, placing greater burden on the family and leading to more participation from unregulated organisations such as funeral homes or cemeteries. These disruptions were impacted by limitations of the CRVS system’s processes before the pandemic.

Fatal pulmonary thromboembolism in asymptomatic COVID-19

Background Coronavirus disease 2019 (COVID-19) has claimed the lives of millions of people globally. Aims This study aims to identify the pathological findings at autopsy of asymptomatic COVID-19 death, to compare the incidence of acute bilateral pulmonary thromboembolism (ABPTE) in asymptomatic COVID-19 deaths versus non-COVID-19 deaths and to explore the possible pathogenesis of thrombosis in COVID-19. We also consider the place of COVID-19 in the death certification of 4 cases who died from ABPTE. Methods This study primarily reviewed post-mortem reports of 6 asymptomatic COVID-19 deaths. Post-mortem reports for the years 2019 and 2020 were also reviewed to establish the incidence of ABPTE. Each post-mortem report was reviewed for gross examination, histology and toxicology findings. A literature review on COVID-19 autopsy findings, COVID-19 pathogenesis, thrombosis in COVID-19 and asymptomatic SARS-CoV-2 infection was also conducted using PubMed. Results Of the 6 asymptomatic COVID-19 deaths, 4 died as a result of ABPTE, 1 died of ischaemic and hypertensive cardiac disease caused by coronary artery disease and ventricular hypertrophy and the remaining case died of heart failure due to dilated cardiomyopathy caused by subendocardial fibrosis. There were 2 cases of bilateral pulmonary thromboembolism (BPTE) in 2019 out of 140 post-mortems. Excluding the 4 cases of ABPTE described already, there was 1 case of ABPTE in 2020 out of 156 post-mortems. A literature review on the pathogenesis of thrombosis in COVID-19 highlighted the significant role that the endothelium plays. Conclusions Massive pulmonary thromboembolism may be a significant cause of death in asymptomatic COVID-19 infection.

Cause of death in fatal cases associated with positive COVID-19 PCR tests

The response to the COVID-19 pandemic is heavily influenced by reported fatalities from the virus and, by implication, the criteria used to determine those fatalities. Given complications, such as the presence of comorbidities and limitations in testing, the World Health Organization (WHO) guidelines recommend counting both confirmed and suspected COVID-19 deaths as fatalities. While easily implementable, this method does little to indicate the degrees of certainty for a COVID-19 death, and thus concerns have arisen that this may overcount the number of COIVD-19 fatalities. In response, we developed and implemented a scoring system to determine the likelihood that COVID-19 contributed to patient death. Three reviewers independently assessed records of 47 patients who reportedly died from COVID-19. Greatest consensus was observed at the ends of the scoring spectrum, with twelve patients having complete consensus among reviewers. Intraclass correlation among the three reviewers was 0.52 (95% CI, 0.25-0.72). Middle scores had the greatest variability, possibly due to plausible alternative diagnoses, suggesting the potential for variability in death certification and the need for a scoring system that reports degrees of certainty. Although scoring rules can guide reviewers toward greater consensus about cause of death, in the absence of an objective criteria for COVID-19 disease, the determination of cause of death in paitents with positive PCR tests for SARS-CoV-2 who also have significant comorbid conditions will remain subjective. Keywords: COVID-19; fatality; cause of death

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.

Developing a nursing protocol for the remote verification of an expected death

Background: Homecare nurses play an important role in end-of-life care. A protocol is needed for the remote verification of expected deaths using information and communication technologies (ICT), that is consistent with Japanese guidelines. Aim: To clarify the processes that nurses use to verify deaths and to develop a tentative nursing protocol for verifying expected deaths, using home-based ICT. Methods: Using literature and semi-structured interviews, a tentative nursing protocol was developed for verifying expected deaths using home-based ICT. Findings: To protect the dignity of patients and their families, it is important that their understanding and consent is provided for the remote verification of expected deaths. Furthermore, the up-to-date legal and ethical responsibilities of nurses should be discussed regarding the verification of a patient's death to provide the best care for the patients and families when implementing the Death Certification Using Information and Communication Technology (DCUICT). Conclusion: This suggested protocol offers a framework for a new delivery of nursing care. It provides guidance for homecare nurses organising the care processes and nursing roles of DCUICT. Further revisions to this protocol must incorporate the specific requirement for the verification of nurses.