, Pan American Health Organization World Health Organization

XVI PanAmericanSanitaryConference XIV RegionaCommitteel Meeting

Ninneapolis_ litinnesotat U.S.A. August-September 1962

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Draft Agenda Item 2.8 CSP16/36 (Eng.) 13 August 1962 ORIGINAL: ENGLISH

_REPORT ON THE PROGRAM ON MORTALITY STATISTICS IN THE AMERICAS

In accordance with the plans pr:e_ented by the Director to the XIII Meeting of the Directing Council(l) in October 1961, the Organization has initiated a research program in mortality statistics. The purpose of this project is to obtain basic data as comparable as possible to serve as background for epidemiological research in the Americas. Because of differences in extent of certification by medical personnel, terminology in use, nosological viewpoints, lack of diagnostic standards, and methods of certifying the underlying cause of death, mortality statistics for countries at present are not comparable. As a first step in obtaining satisfactory data it was considered advisable to collect information from large cities where some of these problems are not so great, since medical facilities are readily available and most deaths are certified by physi- cians. The method of procedure is to have each death in the study investigated through interviews in the home, hospital, and clinic, and with the to obtain as complete a record as possible of the fatal illness, including results of laboratory and other diagnostic procedures and autopsy findings. A study sample of approximately 2,000 deaths per year among persons between the ages of 15 and 75 years is planned from each of ten cities for 1962 and 1963, giving in all 40,000 questionnaires for analysis.

The Directing Council(2) in 1961 supported this research program by the following Resolution:

"l. To recommend to Member Governments to give full support to the furtherance of this research program on mortality statistics, so that the benefits of this intensive investigation of mortality

(1) Proceedings of the XIII Meeting of the Directing Counnil, Pan American Health Organization, Washington, D. C., October 196!_

(2) Regional Advisory Committee on Health Statistics, Second Report, So. Pub. 65 Pan American Sanitary BureSu, Augds_ _962. A

csP16/36(Eng.) Page 2

on a regional basis may be fully utilized not only to provide clues for epidemiological studies but also to improve the quality of mortality statistics which are essential for health planning.

2. To recommend to the Director of the Pan American Sanitary Bureau that the Organization assist the investigators in the cities selected so as to ensure that these coordinated investigations provide comparable basic data and that the results of this research program are fully utilized in health services, in epidemiological studies, and in teaching in medical schools."

During 1961, the planning phases for the research program were carried out, starting with a Planning Conference in May to consider the soundness of the proposal. Authorities on the subject of classification of diseases and causes of death --Dr. Percy Stocks, formerly Director of the WHO Center on Classification in Englan_ Dr. Darlo Curiel, Director of the Latin American Center on Classification in Venezuels_ and Dr. Iwao Moriyama of the National Center of Health Statistics-- participated in the development of plans and the design of the question- naire for the study of fatal illnesses and injuries in cities of the Americas. The Conference agreed that it was highly important to establish an accurate and comprehensive picture of mortality by age among the adult population in selected cities of the Americas, and that the effort and expense of such an investigation would be fully justified.

In order to select cities and collaborators with the necessary qualifications as outlined in the proposal, potential collaborators in medical schools, schools of public health, and National Health Services were visited. Pilot testing of the questionnaire was initiated in August 1961 and more than 500 questionnaires were completed in eight cities. The analysis of the pilot testing demonstrated that the structure and actual content of the questionnaire were in general suitable for the purposes of the study. In November 1961, the United States Public Health Service through the National Institutes of Health awarded a grant for the field work of the project, Inter-American Investigation of Mortality, for a two-year period beginning in 1962 and ending in 1964.

The protocol planning conference of the principal collaborators for development of the final standard questionnaire and procedures to be used in all cities in the Investigation was held from January 22-30, 1962. A Manual of Procedures was issued in order to maintain uniformity throughout the investigation.

Field work was started utilizing deaths of adults 15-74 years of age occurring in January 1962 in five cities; namely, Bogota, ; Caracas, Venezuel_ La Plata, Argentina; Lima, Peru_ and Sac Paulo, Brazil. Work started with the investigation of deaths occurring in March in Guatemala City, Guatemala and Mexico City, Mexico, and with those in May P J csPl6/3(E6 ng.) Page 3

in , Colombia_ Local circumstances del_ved the beginning of the project in Santiago, Chile. Delay was encountered in the development of plans for the inclusion of one or more cities in English-speaking countries. However, it is expected that two such cities will be included shortly. The principal collaborators (given in Appendix A) are epidemiologists_ statisticians, and other members of _aculties of schools of public health, medical schools and National Health Services. i By the end of June 1962 completed questionnaires in seven cities were available for analysis for this first preliminary report. These questionnaires were reviewed by the medical referees (Dr. Stocks and Dr. Curiel) and the underlying cause of death was assigned independently by the two referees according to the international standards. If in the judgment of the referee the evidence was not sufficient to justify the designation of a single cause, he designated two causes with certain weights.

Because work in the cities started a different times, the numbers of completed questionnaires available for processing from these cities varied considerably, as shown below:

Bogota 287 Lima 339

Caracas 335 MexicoCity 30

Guatemala City 130 Sac Paulo 56

La Plata 384

Since the numbers of deaths for Sac Paulo and Mexico were less than I00, they have been excluded from this analysis. Although the numbers of deaths in the other five cities were not large enough for detailed study, this preliminary analysis has been made principally to evaluate the procedures and to consider the suitability of the data for the purposes for which the project was designed.

Cities were selected for the study in which it was felt that hospital facilities and medical care would be readily available for residents and thus the medical histories and diagnostic evidence would be satisfactory. At this time a summary of such evidence is useful as a measure of the quality of the data from the cities.

The first method of evaluating the material in this respect is through consideration of the deaths according to place of death (Table I). In three of the five cities over b_If of the deaths occurred in a hospital. Deaths occurring in emergency services are included as hospital deaths, since these services usually have the necessary equipment and diagnostic facilities of a hospital. csP16/36(Eng.) Page 4

Table I

Deaths by Place of Occurrence for Five Cities in Inter-American Investigation of Mortality, Preliminary Data of June 1962

Bogota Caracas Guatemala La Plata Lima J,, , ,=,_ Place of Death Num- Per Num- Per Num- Per Num- Per Num- Per ber Cent ber Centl ber" Cent ber Cent ber Cent

Total 287 i00 335 lOO 130 lOO 384 1OO 339 1OO

Hospital(a) 161 56.1 195 58.2 49 37.7 186 48.4 177 52.2 Home 107 37.3 112 33.h 78 60.0 175 45.6_ 113 33.3 Publicplace(b) 15 5.2 24 7.2 2 1.51 19 5.0 13 3.9 Not stated and other 4 1.41 _ 1.2 i _ 0.8 4 I.O 36 10.6 (a) Including other institution and emergency service. (b) Including cases in transit to hospital, physician's office, etc.

Over 60 per cent of these deaths were of persons who had been in the hospital in the last year of life or died in the hospital (Table 2). The proportion without medical care in the last year is small. Many of those without care or for whom informat_6n could not be obtained, the group "not stated", died from an accident or other violence. Thus the medical care rendered in hospitals or by in clinics, offices or homes appears to be sufficient to give relatively complete information. To be sure some difficulties have been encountered in obtaining data in the field. On the whole, however, the situation is favorable and the principal collaborators are doing very well in overcoming many difficulties in locating families, physicians, hospital records, etc.

Table 2 '_

Recorded Medical Care in Five Cities in Inter-American Investigatio_ of Mortality, Preliminary Data of June 1962

Type of care in Bogota Caracas Guatemala La Plata Lima last year of Num- Per Num- Per N_ Per Num- Per Num- Per life ber Cent her Cent her Cent ber Cent ber Cent

Total 287 iO0 335 IOO 130 i00 384 I00 339 iOO • Hospital 182 63.4 233 69.6 88 67.7 245 63.8 207 61.1 Physician(a) 77 26.8 51 15.2 30 23.1 127 33.1 79 23.3 Other and none 13 4.6 16 _.8 IO 7.7 9 •_2.3 I O.3 Not stated 15 5.2 35 10.4 2 1.5 3 0.8 52 15.3

, , ,,, . (a) Exclu_ng patients also receiving hospital care. °

• CSP16/36 (Eng.) Page 5

The value of the data is increased if in addition to clinical historiesj laboratory and pathological findings are available for use in the assignments of the causes of death. The proportions of these deaths in which autopsies were carried out are given in Table 3. Here a marked variation is noted for the five cities. In Caracas and Bogota, the percentages were higb_ however, many of the medicolegal autopsies in Bogota were incomplete, performed principally for deaths from external causes. The percentage of the deaths with complete autopsies was highest for Caracas, namely 28.3. The ethers were 12.2 per cent for Bogota; 8o5 for Guatemal_ 2.7 for Lima and 1.8 for La Plata. Thus_ extension of pathological work in some of the cities is a matter of great urgency. It is expected that this research project will lead to further epidemiological research in cancer and cardiovascular diseases where pathological findings will be essential for accurate diagnosis. The lack of autopsies indicates the immediate need of training of pathologists for services in hospitals and medicolegal service so that complete autopsies can be carried out.

Table 3

Deaths by Type of Autopsy in Five Cities in Inter-American Investigation of Mortality, Preliminary Data of June 1962

= • , , , , ...... f Bogota Caracas Guatemala La Plata Lima Type of autopsy Num- Per Hum- Per !Num- Per Num- Per Num- LPer ber Cent ber Cent ber Cent ber Cent ber Cent

Total deaths 287 leO 335 • lO0 130 leO 382 leO 339 lOO

Deaths with autopsies 103 35.9 98 29.3 13 i0.O 17 4.4 67 19.8

Hospital autopsies 39 13.6 48 14.3 9 7.0 I0 2.6 17 5.0

Complete 30 i0.5 48 14.3 9 7.O 7 I.8 8 2-4 Incomplete 9 3.1 .... 3 0.8 2 0.6 Notstated ...... 7 2.1

Medicolegal autopsies 61 21.2 50 14.9 2 I.5 6 I.6 47 13.9

Complete 5 i.7 27 14oO 2 i.5 - - I O.3 Incomplete 56 19.5 .... 5 1.3 26 13•6 Not stated - - 3 0.9 - - I 0.3 - -

Type of autopsy not stated 3 I.O - - 2 1.5 i 0.3 3 0.9 csP16/36 _' Page6

Laboratory examinations, electrocardiograms, X-r_ _x_mination_ blood pressure readings etc. were carried out in varying proportions of the cases in these cities and in general indicated that such diagnostic procedures are being used relatively frequently and thus they are useful evidence in the determination of the cause of death.

After the data have been collected for the two-year period it is planned to calculate for each city age-specific and age-adjusted death rates by causes. This type of analysis is impossible at this time since the numbers of deaths in the investigation are small. However, the distribution of deaths by groups of causes is useful for preliminary information regarding mortality in the ,age group 15-74 years in these cities. The numbers of deaths for 17 cause groups are given in Table 4 with the percentage distributions_

Two medical referees have independently assigned the causes of death and their decisions have been combined. When a referee was in doubt, he assigned two causes, with the most likely cause given a weight of two and the less likely with a weight of one. Thus, as a result of this weighting, the numbers of deaths appearing in the table contain fractions. It is obvious that the causes of death differ in these five cities. The influence of age should be taken into consideration. The population of La Plata, Argentina, is somewhat older than that in the other cities and thus may have proportionately more deaths from certain causes. The distribution of deaths in these preliminary data in these five cities are given by age grQ_p in Table 5o Nearly two-thirds of the deaths in that city were of persons 55-74 years of age while in the other cities the prbportions were lower_ ¢ caP16D6 Page 7

Table 4

Assignments of Causes of Death by Medical Referees* for Five Cities_ Preliminary Data of June 1962 ,, , Groups of Causes Bogota Caracas Guatemala La Plata Lima

International Clas_ification Num- Per Num- Per Num- Per Num- Per Num- Per of Diseases ber Cent ber Cent ber Cent ber Cent ber _nl leo 335lO0 13oleo leo 339leo

Tuberculosis,all forms (001-019) 26.8 9.3 13.3 4.0 4.3 3.3 3.5 0.9! 48.5 14.j

Other infective and parasitic diseases(020-138) 7 5 2.6 10.2 3.0 5.8 4-5 5-5 1.4 4.0 i._ Malignant neoplasms (140-205) 41 i5 14.5 "79.0 23.6 33.8 26.0 119.2 31.1 68.0 20.] Diabetes me!litus (260) 6.0 2,1 9.8 2.9 4.5 3.5 13.O 3.4 6.5 I.,¢

Vascular lesions affecting cen- tral nervous system (330-)34) 18.2 6.3 23.3 ?.O 6.8 5.2 h0.3 10.5 23.8 7-(

Diseases of heart (b9-0_3) 48.7 17.0 82.3 24.6 14.2 10.9 8_.8 22.1i54.0 15o_

Other diseases of circu}atory system (400-402,4&_-4o8) 11.3 3.9 5.8 1.7 3.7 2.8 14.5 3.8 15.1 4.

Influenza andpneumonia (480-493)13.0 4.5 4.2 1.2 1.3 1.0 1.2 0.3 8.7 2.(

Bronchitis(500-502) 4.8 1.7 0.2 0.i 1.2 0.9 8.2 2.1 2.0 0._

Cirrhosis of Liver (581) 5.5 1.9 h.5 1.3 6.7 5.2 10.5 2.7 7.2 2.[

Other diseases of digestive system (530-580,582-587) 20.3 7.I 15.0 4.5 7.3 5.6 15.2 4.0 21.2 6.1

Nephritis andnephrosis (590-59_) 9.7 3.h 4.3 1.3 1.8 1.4 h.O 1.0 10.8 3.

Deliveries and complicabicns of

pregnancy,etc. (640-689) 6.3 2.2 1.7 0.5 3.0 2.3 h.O i.O 8.0 2.1

Accidents (E800-962) 28.2 9.8 I 27.5 8.2 6.3 4.9 13.? 3.6 27.8 8. Suicide, homicide and other I

violence (E963-999) 17.0 5"91130.3 9.0 2.0 1.5 I0.0 2.6 5.2 i. causes (Residual) i21.7 7.6 21.4 6.4 17.6 13.5 29.1 7.6 24.2 7.1

AllSymptoms,otherspecifiedsenility, and ill- I defined conditions (780-795) 0.5 0.2 _ 2.2 0.7 9.7 7.5 7.3 1.9 4.0 i.

* Fractions due to multiple assignments by referees. m

i csP16/36(Eng.) Page 8

•_Table 5

Deaths by Age Group in Five _iti_s in Inter-American Investigation of Mortality, preli_ary Data of June 1962

....Bogota Garacas Guatemala La Plata Lima Age group in N_m- Per Num- Per Num- Per Num- Per Num- Per years ber Cent ber Cent ber Cent her Cent ber Cent

15-74 287* iOO 335 iO0 130 IO0 384 I00 339 I00

15-34 60 20.9 77 23.0 23 17.7 26 6.8 81 23.9 35-54 103 35.9 96 28.6 33 25.4. IIO 28.6 104 30.7 55-74 123 42.9 162 48.4 74 56.9 248 64.6 154 45.4

,,...... ! ..... ! * Includes one with age not stated.

The two leading groups of causes in all cities were malignant neoplasms and diseases o_ the heart but their relative importance varied.

Although the numbers of deaths from these causes are not large enough for conclusions there appear to be differences in cancer by site and in the types of heart disease in these cities. Thus they suggest that this research project will reveal the background information needed as the basis for further epidemiologic research in the Americas.

Tuberculosis was an important cause of death in Lima (ranking third) but only a minor one in La Plata, Argentina. In Bogota, it was the fourth leading cause being exceeded by diseases of the heart, malignant neoplasms andaccidents.

The final assignments by the medical referees of causes of death were compared with those on the original death certificates. These comparisons could be made for four cities. It was clear that the additional data collected in this research project enabled assignments to more specific categories. An important group in which the additional information made a more specific assignment possible for each of the cities was maternal deaths, categories 640-689 (diseases of pregnancy, childbirth and the puerperium). For these four cities only 12 deaths were classified as maternal deaths on death certificates. However, the additional information from hospitals and physicians indicated that 20 should be so assigned_ This finding is not unexpected since facts of a delivery or abortion may not always be known to'the physician in attendance at the time of death. Also the additional data enabled changes in assignments to specific sites of malignant neoplasms and types of heart diseases as well as changes from one •group of diseases to another. i csP16/36(Eng.) Page 9

In this project, hospital and physician records and interviews with physicians are providing the additional information desired for stating the cause of the fatal illness and the nature of the injury with supporting evidence. Improvements are to be expected in the quality of data as work in the field progresses and as physicians become more famil- iar with data necessary for assignments of the causes of death.

Although this is only a preliminary report, the analysis indicates that data will be obtained to fulfill the objectives of the research project. Each one of the collaborators has an opportunity to undertake special studies in phases of the project of interest in his city. The development of this research marks the beginning of a new era in collaborative work in the field of statistics in the Americas. The products and by-products will be ma_y. It is believed that the continued interest and support of the Member Governments will contribute to the success of this Inter-American Invastigation of Mortality and thus the foundation will be laid for further collaborative research on the geographical studies of disease.

The Regional Advisory Committee in Health Statistics in its recent meeting in June 1962 reviewed progress of this research program. At that meeting the problem of excessive mortality in children in the age period 1-]34years in many areas of the Americas due to common communicable diseases of childhood such as measles, whooping cough and diphtheria, diarrheal diseases and respiratory diseases was discussed. In one of the participating cities a study of child mortality has already been started utilizing the procedures of the Investigation of Mortality. It is believed that careful investigation of the causes of excessive mortality in children in several of the cities with high death rates would be advisablet Since virus diseases may be involved in the excessive mortality it would be desirable that cities in which such an investigation is carried out have sufficient laboratory facilities including a virus laboratory for confirmation of diagnosis.

The Advisory Committee stated that it "believes that as the Organization makes progress in the Investigation of Mortality, it will be in a position to undertake additional research projects. The Committee supports and encourages the Organization to extend its research program for understanding patterns of mortality in the Regionj"

Also the Committee recommended that "The Organization proceed with the planning of epidemiological cancer research and with the promotion of study of incidence of this disease." A meeting of a group of specialists with specific interest and programs in the field was suggested to plan research in cancer epidemiology in early 1963.

The Organization is actively initiating geographical research for understanding disease in the Region. This program is possible because of the spirit of cooperation and collaboration expressed by the health leaders of the Americas in the establishment of the Pan American Health Organization, in the Pan American Sanitary Code and in actions of the Pan American Sanitary Conferences. csP16/36 Page 10

APPENDIX

PRINCIPAL COLLABORATORS OF INTER-AMERICAN INVESTIGATION OF MORTALITY

Bogo%a, Colombi_ Dr. Luis E. Giraldo, Assistant Professor, Department of Epidemiology, School of Public Health, National , Bogota, Colombia

Cali, Colombi_ Dr. Pelayo Correa, Professor of Pathology, and Head Department of Pathology, Faculty of Medicine, University of Valle, Cali, Colombia

Dr. Bernardo Aguilera, (Co-principal Collaborator) Sub-Chief of the Department of Preventive Medicine and Public Health, Faculty of Medicine, University of Valle, Cali, Colombia

Caracas, Venezuela: Dr. Carlos Luis Gonz_lez, Technical Adviser, Direction of Public Health, Ministry of Health and Social Welfare, Caracas, Venezuela

Guatemala City, Guatemala: Dr. J. Romeo de Le6n, Jr., Medical Officer, Epidemiology Branch, Division of Public Health_ Institute of Nutrition of Central America and Panama (INCAP), Guatemala City, Guatemala

La Plata, Argentins_ Dr. Carlos Ferrero, Director of Biostatistics, Ministry of Public Health of the Province of Buenos Aires, La Plata, Argentina, and Professor of Biostatistics, School of Public Health, University of Buenos Aires, Buenos Aires, Argentina

Lima, Peru: Dr. Abelardo Temoche, Public Health Officer, National Health Planning Commission, Ministry of Public Health, and Professor of Medical Statistics, San Marcos , Lima, Peru

Mexico City, Mexico: Dr. Miguel Angel Bravo Becherelle, Scientific Investigator, Laboratory of Epidemiology and Biostatistics, Institute of Health and Tropical Diseases, Mexico City, Mexico

Santiago, Ch_l_ Dr. Adela Legarreta, Professor of Department of Biostatistics, School of Public Health, , Santiago, Chile

Sao Paulo, Brazil: Dr. Elza Berqu6, Professor of Biostatistics, Department of Statistics, Faculty of Hygiene and Public Health, University of Sao Paulo, Sao Paulo, Brazil

Dr. Giraldo Garc_a Duarte (Collaborator for Investigation in Ribeirao Preto), Associate Professor of Hygiene of the Faculty of Medicine of Ribeirao Preto, Ribeirao Preto, Brazil. _: