Child Health and Mortality Prevention Surveillance (CHAMPS) Network
Bangladesh, Ethiopia, Kenya, Mali, Mozambique, Sierra Leone, South Africa
Emory Global Health Institute
The International Association of National Public Health Institutes
The Centers for Disease Control and Prevention
The Child Health and Mortality Prevention Surveillance (CHAMPS) Network works to close these gaps by gathering the evidence needed to save young lives. As a 20-year program supported by the Bill & Melinda Gates Foundation, CHAMPS seeks to identify definitive causes of death, and prevent child deaths through community engagement, diagnostic and laboratory innovations, surveillance network advances, policy-to-action activities and rapid, open access to data.
Countrywide Mortality Surveillance for Action (COMSA)
Mozambique, Sierra Leone
Johns Hopkins Bloomberg School of Public Health
Centre for Global Health Research
COMSA is being implemented in Mozambique by the government of Mozambique with technical assistance from the Institute for International Programs at Johns Hopkins University and a three-year’s funding from the Bill & Melinda Gates Foundation. Implemented by the National Institute of Statistics and the National Institute of Health, COMSA is building a national sample registration system for mortality and cause of death monitoring in Mozambique and promoting its sustainability through engagement of the key stakeholders to generate interest, demand for and use of the data. The project collaborates with the existing BMGF-funded project on Child Health and Mortality Prevention Surveillance (CHAMPS) in the Manhica district and is developing analytical approaches to improve verbal autopsy-based cause of death in children under-five using a more accurate cause of death data from minimally invasive tissue samples (MITS) implemented by CHAMPS.
KEMRI/Wellcome Trust Research Programme
Department of Global Health University of Washington, Seattle
Case fatality rates among children hospitalized with acute illness are unacceptably high, even when current standards of care are applied. The Childhood Acute Illness and Nutrition (CHAIN) Cohort study aims to identify risk factors for and causes of death (CoD) among hospitalized children aged 2-23 months. Exact CoD are often unknown and difficult to establish, especially for malnourished children. We will use MITS in a CHAIN sub-study to improve the understanding of CoD among well-characterized children who die during inpatient admission for acute illness across a spectrum of undernutrition in Malawi. We also introduce a novel strategy – post-mortem intestinal endoscopy and tissue sampling to assess its feasibility and as a method to understand the contribution of intestinal pathology to mortality. Additionally, we have commenced social sciences research to understand health worker, parent and community leader’s concerns about MITS and barriers and facilitators to acceptance of MITS in Malawi.
Child mortality in the community in low-income regions: Causes, etiologies, and risk factors in children under five years
The region of the suburbs of Buenos Aires where our program is conducted hosts ~15,000 live births every year living in a vulnerable region of low-income informal settlements. Our capture population lives within very vulnerable communities in the area. All deaths U5 in our communities are now routed to the Lomas de Zamora morgue. There, we conduct MITS and transfer the samples to our labs for processing and staining and use a web-based system to alert the Public Health Office of all deaths U5. At the PHO, we support a team of nurses and pediatricians to visit the community and conduct VAs between 1-3 months after death to respect the period of mourning. We face no problems with families when PHO visits homes for VAs. The program is to formally compare COD assignment by verbal autopsies, COD assigned by medical personnel linked to police authorities, and MITS + VA (gold standard). We expect through this comparative analysis to inform how to adjust the COD distribution from medical certificates or VA alone in order to reflect the presumably more accurate COD distribution obtained by going through the DeCoDe process with the MITS results
Continued validation of the minimally invasive tissue sampling (MITS) tool for cause of death investigation in young children and development of a training and research center for postmortem investigations (CaDMIA-plus)
This is a joint project with ISGlobal, CISM, UEM, Maputo Central Hospital (MCH) and University of Barcelona, was implemented in 2013-2015. Main main goal: to develop a new, minimally invasive, acceptable tool that can substitute complete diagnostic autopsies (CDA) to obtain tissue samples for an improved cause of death (CoD) diagnosis in rural areas. Cadmia plus project (started in 2017) is a continuation of CaDMIA and the main objective is continuing validation of MIA against CDA for CoD investigation in pediatric deaths. Another important objective is to establish a training and research center for postmortem investigations. MITS is done in the Department of Pathology of MCH, which is the teaching hospital and the national reference hospital of Mozambique. We already have organized several MITS training courses together with Barcelona, to people involved in other projects in other countries.
Addis Ababa University
This is a prospective, multi-centre, descriptive clinical study. Socio-demographic, obstetric, and maternal factors, and clinical and laboratory findings will be documented. The major causes of preterm mortality will be identified using clinical, laboratory, imaging, and autopsy methods and use the national Ethiopian guidelines on management of preterm infants including required investigations to reach final diagnoses. The study will document the clinical and management protocols followed in these settings. The approach consists of clinical examinations and monitoring, laboratory investigations, and determination of primary and contributory causes of mortality through both clinical means and by post-mortem examinations. An independent panel of experts will validate the primary and contributory causes of mortality. To obtain the estimated sample size of 5,000 preterm births, the study will be undertaken in five hospitals in three regions of Ethiopia, which are geographically distributed across the country. All preterm infants who are either born or transferred to these hospitals will be eligible for the study. Three methods (last menstrual period, physical examination using the New Ballard Score, and ultrasound) will be used to determine gestational age. All clinical procedures will be conducted per hospital protocol and informed consent will be taken from parents or caretakers prior to their participation in the study as well as for autopsy if the infant dies.
The Project to Understand & Research preterm Pregnancy Outcomes and Stillbirth-South Asia (PURPOSe)
KLE University’s JN Medical College
Aga Khan University
Preterm birth is a major cause of child mortality and morbidity. The Bill & Melinda Gates Foundation (BMGF) has initiated a study called “PURPOSe” to evaluate the cause of death among preterm births in Asia. The primary objective of this prospective study being conducted in two sites in Asia (Karachi, Pakistan, and Davangere, India) is to determine the cause of deaths among preterm births (both live births and stillbirths). Secondary outcomes include determining the specific pathogens responsible for infection-related deaths, potential preventability of these deaths and interventions which may be effective in reducing mortality. Each site will include a total sample size of 700 (350 stillbirths and 350 preterm neonatal deaths) cases. Minimally-invasive tissue sampling (MITS) will be a technique employed for better understanding of the causes of death. A panel of experts will review all data and use a validated method to determine the underlying cause of death. Our findings will be used to help develop interventions to improve pregnancy outcomes of women in Asia.
CDC Kenya NCIRD
Kenyatta National Hospital
Seeks to determine the appropriate (or maximum) time since death for sample collection, which would allow for reliable identification of etiologic agents associated with cause of death. Beginning May 2018, we will enroll 20 children with respiratory symptoms between the ages of 1 – 59 months who die while admitted at the Kenyatta National Teaching and Referral Hospital in Nairobi, Kenya. Blood, liver and lung tissue specimen will be collected using minimally invasive tissue sampling techniques. Specimen will be collected every 6 hours after death for the first 48 hours and then at 72 hours. The specimen will be processed using TaqMan Array Cards that detect several bacterial, viral and parasitic agents. Formalin-fixed lung and liver specimens will undergo advanced histopathology and immunohistochemistry analyses. This study will assist in understanding how time since death affects the type and concentration of pathogens detected post-mortem.
MITS pilot study to determine causes of death in under-five children in a tertiary hospital in India
India Council for Medical Research
This pilot project will be carried out to assess feasibility and acceptability of MITS in a hospital in Delhi, India, including examination of ethical considerations related to conducting postmortem MITS on under-five children and stillbirths. During the preparatory phase, formative research will be also carried out among various health care providers in the hospital and in the catchment area of the hospital using standard qualitative research methods. In depth interviews (IDI) among family members / care takers of deceased children will be carried out to understand their knowledge about underlying causes of child death/stillbirth, sociocultural practices around child death and MITS on deceased child/ still born to evaluate acceptability, practicality and implementation and ethical considerations of MITS in a facility setting. This would also provide insights for finalising tools for grief counseling. After training of key personnel and provision of required equipment/supplies, MITS will be conducted on a sample of at least 200 eligible under-five children and stillbirths to determine exact causes of death in Safdarjung Hospital located near high quality laboratory -ICMR National Institute of Pathology. It is also expected that MITS pilot site will be able to serve as a reference center for MITS-based mortality surveillance in India.
Evaluation of new alternatives to increase the accuracy of the determination of cause of death
University of São Paolo
The verbal autopsy (VA) method has increasingly been used to measure causes of death (COD) for non-hospital or uncertified deaths, or to replace poor quality death certificates, mainly in low and middle-income countries. The diagnostic methods used to assign underlying causes of death from VA questionnaires can be physician certified or based on automated coding procedures. In Brazil, although there is a well-consolidated universal system for mortality data, the quality of information on causes of death is not even among Brazilian regions, with a high proportion of ill-defined causes of deaths (IDCD) in some areas. Recently, the Institute of Health Metrics proposed a short VA form aiming for a reduction in the amount of time needed for data collection. However, the confidence in VA as a reliable data collection tool depends on how accurately the instrument and the coupled diagnostic method can assign the underlying cause of death compared with a “true” or reference underlying cause assigned by pathological autopsy (complete academic autopsy or minimally invasive autopsy (CT or Ultrasound guided) considered the gold standards.
Duke Global Health Institute (DGHI)
Kilimanjaro Christian Medical University College
The objective of the ‘investigating febrile deaths in Tanzania (INDITe) is to identify actionable patient management and health system interventions that could avert fatal outcomes among patients with fever living in low-resource areas. Fever is among the most common reasons for seeking health care in less developed countries and hospitalized patients with fever have high case fatality ratios. However, there is an incomplete picture of the causes of severe fever illness, especially among patients with fatal outcomes. Gaining a more complete picture of why persons with fever die is essential to design patient management strategies and health systems that improve survival. The specific aims of the INDITe study are: 1). To determine the microbiologic etiologies of fatal febrile illness among children and adults in northern Tanzania by augmenting the standard clinical diagnostic evaluation with autopsy; 2) To apply innovative pathogen discovery approaches and to evaluate new point-of-care diagnostics that could be used to guide the management of the febrile patient; and 3) To determine the contribution of non-biological factors to in-hospital mortality of severe febrile illness among children and adults in northern Tanzania. Aim 1 will be achieved using a prospective febrile illness cohort study in children and adults that employs an expanded pre-mortem clinical diagnostic evaluation for all participants enrolled, and in the case of fatal outcomes, a pre-specified infectious diseases pathology evaluation algorithm to identify neglected, non-neglected, and novel pathogens in tissues obtained via autopsy. Aim 2 will be achieved by applying novel pathogen discovery approaches and acute phase diagnostics to febrile deaths, and by selecting new point-of-care diagnostic tests for leading causes of febrile death with actionable patient management implications (e.g., those infections requiring specific antimicrobial therapy) identified in specific aim 1, for evaluation and validation against the augmented clinical diagnostic algorithm. Aim 3 will be achieved by adapting retrospective, community-based social autopsy surveys to the prospective, hospital-based, pre-mortem setting in order to assess potential risk factors such as failure by patients or families to recognize severe signs of illness, delays in care-seeking, lack of appropriate healthcare resources, and inadequate case management by healthcare providers.
Utilization of MITS to establish cause of death in HIV-infected Zambian adults with meningoencephalitis
Harvard Medical School
University of Zambia School of Medicine
Utilization of MITS to Establish Cause of Death in HIV-infected Zambian Adults with Meningoencephalitis Project: We will attempt to characterize the spectrum of central nervous system (CNS) infections causing mortality among HIV-infected Zambian adults. We recently demonstrated a 26% inpatient mortality in a predominantly HIV population of Zambian adults presenting acutely with meningoencephalitis. We previously demonstrated that more than 50% of these patients do not receive a definitive diagnosis. Our objective is to use MITS to determine causes of mortality in HIV-infected patients presenting with CNS symptoms suggestive of an infectious etiology. We hypothesize that there will be active CNS co-infection in one quarter of these patients. We postulate there will be a high rate of CNS tuberculosis (TB) that is not detected through currently available TB diagnostics but will be detected through MITS. We believe that MITS will more accurately inform causes of CNS mortality in Zambian adults, establish the accuracy of currently available diagnostics, and provide a guide for empiric treatment of CNS infections