Objective To assess civil registration and vital statistics completeness for births in World Health Organization's Member States and identify data completeness gaps.Methods For the 194 Member States, we sourced birth registration data from the United Nations Children's Fund database of national surveys, and, where available, vital registration reports.We acquired publicly available vital statistics compiled by national authorities.We determined civil registration completeness as the percentage of living children younger than five years whose births have been reported as registered.We evaluated vital statistics completeness against the United Nations World Population Prospects' live birth estimates, and grouped countries into seven categories based on their civil registration and vital statistics completeness.Findings Globally, civil registration completeness for births was 77%, exceeding vital statistics completeness for births at 63%.Twenty countries had limited civil registration (25% to 74% completeness) and had nascent or no vital statistics data (completeness < 25%) for births.Five countries had nascent or no civil registration and vital statistics for births.Twenty countries had functional civil registration (75% to 94% completeness) but nascent or no available vital statistics.Approximately half (96) of the countries had complete civil registration and vital statistics for births, but contributed to only 22% of global births. ConclusionThe gap in completeness between civil registration data and vital statistics for births is most pronounced in countries with lower civil registration completeness.Enhancing data transfer processes for birth registration, along with targeted investments to elevate registration rates, is crucial for yielding comprehensive fertility statistics for governmental planning.

Objective To assess the current state of the world's civil registration and vital statistics systems based on publicly available data and to propose strategic development pathways, including priority interventions, for countries at different levels of civil registration and vital statistics performance. Methods We applied a performance assessment framework to publicly available data, using a composite indicator highly correlated with civil registration and vital statistics performance which we then adjusted for data incomparability and missing values. Findings Globally, civil registration and vital statistics systems score on average 0.70 (0-1 scale), with substantial variations across countries and regions. Scores ranged from less than 0.50 in emerging systems to nearly 1.00 in the most developed systems. Approximately one fifth of the world's population live in the 43 countries with low system performance (< 0.477). Irrespective of system development, health sector indicators consistently scored lower than other determinants of civil registration and vital statistics performance. Conclusion From our assessment, we provide three main recommendations for how the health sector can contribute to improving civil registration and vital statistics systems: (i) enhanced health sector engagement in birth and death notification; (ii) a more systematic approach to training cause of death diagnostics; and (iii) leadership in the implementation of verbal autopsy methods. Four different civil registration and vital statistics improvement pathways for countries at different levels of system development are proposed, that can constitute a blueprint for regional civil registration and vital statistics strengthening activities that countries can adapt and refine to suit their capabilities, resources, and particular challenges.

In Myanmar 84% of deaths occur in the community, of which half are unregistered and none have a reliable cause of death (COD) recorded. Since 2018, Myanmar has introduced improved registration practices and verbal autopsy (VA) to assess whether such methods can produce policy relevant information on community COD. Community health midwives and public health supervisors grade II collected VAs on over 80,000 deaths which occurred between January 2018 and December 2019 in a nationwide sample of 42 townships in Myanmar. Electronic methods were used to collect and consolidate data. The most probable COD was assigned using the SmartVA Analyze 2.0 computer algorithm. Completeness of VA death reporting increased to 71% in 2019. Most adult (12+ years) deaths (82%) were due to non-communicable diseases, primarily stroke, ischemic heart disease and chronic respiratory disease, for both men and women. VA results were consistent with Global Burden of Disease (GBD) Study estimates, except for cirrhosis in men, which was more common, and had a younger age distribution of death than the GBD. Large scale implementation of improved death registration practices and COD diagnosis using VA is feasible and provides plausible, timely, disaggregated and policy relevant information on the leading causes of community death. Addressing the burden of non-communicable diseases, particularly cirrhosis in young men, is an important public health priority in Myanmar. Improving completeness of VA death reporting in poorly performing townships and in neonates, children and women will further improve the policy utility of the VA data.

Objective:To evaluate the utility and quality of death registration data across countries. Methods:We compiled routine death and cause of death statistics data from 2015-2019 from national authorities. We estimated completeness of death registration using the Adair-Lopez empirical method. The quality of cause of death data was assessed by evaluating the assignment of usable causes of death among people younger than 80 years. We grouped data into nine policy utility categories based on data availability, registration completeness and diagnostic precision. Findings:Of an estimated 55 million global deaths in 2019, 70% of deaths were registered across 156 countries, but only 52% had medically certified causes and 42% of deaths were assigned a usable cause. In 54 countries, which are mostly high-income, there is complete and high-quality mortality data. In a further 29 countries, located across different regions, death registration is complete, but cause of death data quality remains suboptimal. Additionally, 37 countries possess functional death registration systems with cause of death data of poor to moderate quality. In 30 countries, death registration ranges from limited to nascent completeness, accompanied by poor or unavailable cause of death data. Furthermore, 38 countries lack accessible data altogether. Conclusion:By implementing more proactive death notification processes, expanding the use of digitized data collection platforms, streamlining data compilation procedures and improving data quality assessment, governments could enhance the policy utility of mortality data. Encouraging the routine application of automated verbal autopsy methods is crucial for accurately determining the causes of deaths occurring at home.

Reliable mortality data are essential for the development of public health policies. In Brazil, although there is a well-consolidated universal system for mortality data, the quality of information on causes of death (CoD) is not even among Brazilian regions, with a high proportion of ill-defined CoD. Verbal autopsy (VA) is an alternative to improve mortality data. This study aimed to evaluate the performance of an adapted and reduced version of VA in identifying the underlying causes of non-forensic deaths, in São Paulo, Brazil. This is the first time that a version of the questionnaire has been validated considering the autopsy as the gold standard. The performance of a physician-certified verbal autopsy (PCVA) was evaluated considering conventional autopsy (macroscopy plus microscopy) as gold standard, based on a sample of 2060 decedents that were sent to the Post-Mortem Verification Service (SVOC-USP). All CoD, from the underlying to the immediate, were listed by both parties, and ICD-10 attributed by a senior coder. For each cause, sensitivity and chance corrected concordance (CCC) were computed considering first the underlying causes attributed by the pathologist and PCVA, and then any CoD listed in the death certificate given by PCVA. Cause specific mortality fraction accuracy (CSMF-accuracy) and chance corrected CSMF-accuracy were computed to evaluate the PCVA performance at the populational level. There was substantial variability of the sensitivities and CCC across the causes. Well-known chronic diseases with accurate diagnoses that had been informed by physicians to family members, such as various cancers, had sensitivities above 40% or 50%. However, PCVA was not effective in attributing Pneumonia, Cardiomyopathy and Leukemia/Lymphoma as underlying CoD. At populational level, the PCVA estimated cause specific mortality fractions (CSMF) may be considered close to the fractions pointed by the gold standard. The CSMF-accuracy was 0.81 and the chance corrected CSMF-accuracy was 0.49. The PCVA was efficient in attributing some causes individually and proved effective in estimating the CSMF, which indicates that the method is useful to establish public health priorities.

Official statistics in Australia and the United States show large recent increases in dementia mortality rates. In this study, we assessed whether these trends are biased by an increasing tendency of medical certifiers (predominantly physicians) to report on the death certificate that dementia was a direct cause of death. Regression models of multiple-cause-of-death data in Australia (2006-2016) and the United States (2006-2017) were constructed to adjust dementia mortality rates for changes in death certification practices. Compared with official statistics, the recent increase in adjusted age-standardized dementia death rates was less than half as large in Australia and about two-thirds as large in the United States. Further adjustment for changes in reporting of dementia anywhere on the death certificate implied even lower increases in dementia mortality. Declines in reporting of cardiovascular diseases as comorbid conditions also contributed to rises in dementia mortality rates. The increasing likelihood of dementia's being reported as directly leading to death largely explains recent increases in dementia mortality rates in both countries. However, studies have found that reported dementia on death certificates remains low compared with clinical evaluations of its prevalence. Improved guidance and training for certifiers in reporting of dementia on death certificates will help standardize mortality statistics within and between countries.

ObjectivesTo assess the quality of cause of death reporting in Shanghai for both hospital and home deaths.Design and settingMedical records review (MRR) to independently establish a reference data set against which to compare original and adjusted diagnoses from a sample of three tertiary hospitals, one secondary level hospital and nine community health centres in Shanghai.Participants1757 medical records (61% males, 39% females) of deaths that occurred in these sample sites in 2017 were reviewed using established diagnostic standards.InterventionsNone.Primary outcomeOriginal underlying cause of death (UCOD) from medical facilities.Secondary outcomeRoutine UCOD assigned from the Shanghai Civil Registration and Vital Statistics (CRVS) system and MRR UCODs from MRR.ResultsThe original UCODs as assigned by doctors in the study facilities were of relatively low quality, reduced to 31% of deaths assigned to garbage codes, reduced to 2.3% following data quality and follow back procedures routinely applied by the Shanghai CRVS system. The original UCOD had lower chance-corrected concordance and cause-specific mortality fraction accuracy of 0.57 (0.44, 0.70) and 0.66, respectively, compared with 0.75 (0.66, 0.85) and 0.96, respectively, after routine data checking procedures had been applied.ConclusionsTraining in correct death certification for clinical doctors, especially tertiary hospital doctors, is essential to improve UCOD quality in Shanghai. A routine quality control system should be established to actively track diagnostic performance and provide feedback to individual doctors or facilities as needed.

Background Despite compelling evidence on the health hazards of tobacco products accumulated over the past 70 years, smoking remains a leading cause of death worldwide. Policy action to control smoking requires timely, comprehensive, and comparable evidence on smoking levels within and across countries. This study provides a recent assessment of that evidence based on the methods used in the Global Burden of Disease (GBD) Study. Methods We estimated annual prevalence of, and mortality attributable to smoking any form of tobacco from 1970 to 2020 and 1990–2020, respectively, using the methods and data sources (including 3431 surveys and studies) from the GBD collaboration. We modelled annual prevalence of current and former smoking, distributions of cigarette-equivalents per smoker per day, pack-years for current smoking, years since cessation for former smokers and estimated population-attributable fractions due to smoking. Results Globally, adult smoking prevalence in 2020 was 32.6% (32.2% to 33.1%) and 6.5% (6.3% to 6.7%) among men and women, respectively. 1.18 (0.94 to 1.47) billion people regularly smoke tobacco, causing 7.0 (2.0 to 11.2) million deaths in 2020. Smoking prevalence has declined by 27.2% (26.0% to 28.3%) for men since 1990, and by 37.9% (35.3% to 40.1%) for women. Declines have been largest in the higher sociodemographic countries, falling by more than 40% in some high-income countries, and also in several Latin American countries, notably Brazil, where prevalence has fallen by 70% since 1990. Smoking prevalence for women has declined substantially in some countries, including Nepal, the Netherlands and Denmark, and remains low throughout Asia and Africa. Conversely, there has been little decline in smoking in most low- and middle-income countries (LMICs) with over half of all men continuing to smoke in large populations in Asia (China, Indonesia), as well as the Pacific Islands. Implications While global smoking prevalence has fallen, smoking is still common and causes a significant health burden worldwide. The unequal pace of declines across the globe is shifting the epidemic progressively to LMICs. Smoking is likely to remain a leading cause of preventable death throughout this century unless smoking cessation efforts can significantly and rapidly reduce the number of smokers, particularly in Asia. Funding XD and EG received funding through grant projects from Bloomberg Philanthropies (funding no. 66-9468) and the Bill & Melinda Gates Foundation (funding no. 63-3452).

Approximately 30% of deaths in Shanghai either occur at home or are not medically attended. The recorded cause of death (COD) in these cases may not be reliable. We applied the Smart Verbal Autopsy (VA) tool to assign the COD for a representative sample of home deaths certified by 16 community health centers (CHCs) from three districts in Shanghai, from December 2017 to June 2018. The results were compared with diagnoses from routine practice to ascertain the added value of using SmartVA. Overall, cause-specific mortality fraction (CSMF) accuracy improved from 0.93 (93%) to 0.96 after the application of SmartVA. A comparison with a "gold standard (GS)" diagnoses obtained from a parallel medical record review investigation found that 86.3% of the initial diagnoses made by the CHCs were assigned the correct COD, increasing to 90.5% after the application of SmartVA. We conclude that routine application of SmartVA is not indicated for general use in CHCs, although the tool did improve diagnostic accuracy for residual causes, such as other or ill-defined cancers and non-communicable diseases.

Parasites extracted from the lungs and the pterygoid sinus complex of 6 species of odontocetes stranded along the north-west Spanish coast (Northeast Atlantic) between 2009 and 2019 were morphologically identified. The samples belonged to 14 specimens, including 3 harbour porpoises, Phocoena phocoena, 6 short-finned pilot whales, Globicephala macrorhynchus, 1 long-finned pilot whale, Globicephala melas, 1 Risso's dolphin, Grampus griseus, 1 striped dolphin, Stenella coeruleoalba and 2 bottlenose dolphins, Tursiops truncatus. All animals (14/14) were infected by nematodes of the genus Stenurus spp.; moreover, two of them presented a mixed lung nematode infection by Stenurus spp. and Halocercus spp., and another two a mixed infection by Stenurus spp. and the trematode Nasitrema spp. in the pterygoid sinuses. The morphological characterization of the Stenurus specimens revealed the existence of three different species: Stenurus minor, present in the pterygoid sinuses of harbour porpoises with a mean intensity of 43.0 ± 9.0; Stenurus globicephalae, in the pterygoid sinuses of pilot whales and the Risso's dolphin (370.3 ± 579.4); and Stenurus ovatus infecting bottlenose and striped dolphins’ lungs (47.7 ± 76.5). This is the first citation of S. minor and S. ovatus in odontoceti from the Galician coast. Nematodes of the genus Stenurus are frequent in odontocetes stranded along the north-west Spanish coast. A clear host-parasite association was observed between S. minor and the Phocoenidae family, between S. globicephalae and the subfamily Globicephalinae and between S. ovatus and subfamily Delphininae. Different trophic position and niche segregation may lead to different patterns of specificity.

Objectives Gold standard cause of death data is critically important to improve verbal autopsy (VA) methods in diagnosing cause of death where civil and vital registration systems are inadequate or poor. As part of a three-country research study—Improving Methods to Measure Comparable Mortality by Cause (IMMCMC) study—data were collected on clinicopathological criteria-based gold standard cause of death from hospital record reviews with matched VAs. The purpose of this data note is to make accessible a de-identified format of these gold standard VAs for interested researchers to improve the diagnostic accuracy of VA methods. Data description The study was conducted between 2011 and 2014 in the Philippines, Bangladesh, and Papua New Guinea. Gold standard diagnoses of underlying causes of death for deaths occurring in hospital were matched to VAs conducted using a standardized VA questionnaire developed by the Population Health Metrics Consortium. 3512 deaths were collected in total, comprised of 2491 adults (12 years and older), 320 children (28 days to 12 years), and 702 neonates (0–27 days).

Introduction The measurement of progress towards many Sustainable Development Goals (SDG) and other health goals requires accurate and timely all-cause and cause of death (COD) data. However, existing guidance to countries to calculate these indicators is inadequate for populations with incomplete death registration and poor-quality COD data. We introduce a replicable method to estimate national and subnational cause-specific mortality rates (and hence many such indicators) where death registration is incomplete by integrating data from Medical Certificates of Cause of Death (MCCOD) for hospital deaths with routine verbal autopsy (VA) for community deaths. Methods The integration method calculates population-level cause-specific mortality fractions (CSMFs) from the CSMFs of MCCODs and VAs weighted by estimated deaths in hospitals and the community. Estimated deaths are calculated by applying the empirical completeness method to incomplete death registration/reporting. The resultant cause-specific mortality rates are used to estimate SDG Indicator 23: mortality between ages 30 and 70 years from cardiovascular diseases, cancers, chronic respiratory diseases and diabetes. We demonstrate the method using nationally representative data in Myanmar, comprising over 42 000 VAs and 7600 MCCODs. Results In Myanmar in 2019, 89% of deaths were estimated to occur in the community. VAs comprised an estimated 70% of community deaths. Both the proportion of deaths in the community and CSMFs for the four causes increased with older age. We estimated that the probability of dying from any of the four causes between 30 and 70 years was 0.265 for men and 0.216 for women. This indicator is 50% higher if based on CSMFs from the integration of data sources than on MCCOD data from hospitals. Conclusion This integration method facilitates country authorities to use their data to monitor progress with national and subnational health goals, rather than rely on estimates made by external organisations. The method is particularly relevant given the increasing application of routine VA in country Civil Registration and Vital Statistics systems.

Background The study aims to assess two approaches that apply the empirical completeness method to generate age-specific mortality statistics from incomplete death registration systems. Methods We use the empirical completeness method to calculate all-age death registration completeness, which is used with a model life table to generate mortality statistics and age-specific completeness using (1) the conventional method and (2) the equivalent deaths method. The results are compared with a capture-recapture (C-RC) study and three alternative mortality estimates for Brazilian states, and C-RC studies in Thailand, Oman and Vietnam, which independently estimate the level and age pattern of mortality or completeness. Results The empirical completeness method produces similar estimates of all-age completeness of registration to the C-RC studies. Compared with C-RC studies, at 15-59 years, the conventional method’s estimates of mortality and completeness are more concordant, while at 60-84 years the equivalent death method’s estimates are closer. Estimates of life expectancy from the two approaches each have similar concordance with the C-RC studies. For male adult mortality in Brazilian states, there is relatively strong average correlation of this study's estimates with three alternative estimates. Conclusions The two approaches produce mortality statistics from incomplete data that are mostly concordant with C-RC studies, and can be most usefully applied to subnational populations.

Background: Reliable cause of death (COD) data are not available for the majority of deaths in Papua New Guinea (PNG), despite their critical policy value. Automated verbal autopsy (VA) methods, involving an interview and automated analysis to diagnose causes of community deaths, have recently been trialled in PNG. Here, we report VA results from three sites and highlight the utility of these methods to generate information about the leading CODs in the country. Methods: VA methods were introduced in one district in each of three provinces: Alotau in Milne Bay; Tambul-Nebilyer in Western Highlands; and Talasea inWest New Britain. VA interviews were conducted using the Population Health Metrics Research Consortium (PHMRC) shortened questionnaire and analysed using the SmartVA automated diagnostic algorithm. Results: A total of 1655 VAs were collected between June 2018 and November 2019, 87.0% of which related to deaths at age 12 years and over. Our findings suggest a continuing high proportion of deaths due to infectious diseases (27.0%) and a lower proportion of deaths due to non-communicable diseases (NCDs) (50.8%) than estimated by the Global Burden of Disease Study (GBD) 2017: 16.5% infectious diseases and 70.5% NCDs. The proportion of injury deaths was also high compared with GBD: 22.5% versus 13.0%. Conclusions: Health policy in PNG needs to address a 'triple burden' of high infectious mortality, rising NCDs and a high fraction of deaths due to injuries. This study demonstrates the potential of automated VA methods to generate timely, reliable and policy-relevant data on COD patterns in hard-to-reach populations in PNG.

BACKGROUND:The widely-used estimates of completeness of birth registration collected by Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS) and published by UNICEF primarily rely on registration status of children as reported by respondents. However, these self-reported estimates may be inaccurate when compared with completeness as assessed from nationally-reported official birth registration statistics, for several reasons, including over-reporting of registration due to concern about penalties for non-registration. This study assesses the concordance of self-reported birth registration and certification completeness with completeness calculated from civil registration and vital statistics (CRVS) systems data for 57 countries.METHODS:Self-reported estimates of birth registration and certification completeness, at ages less than five years and 12-23 months, were compiled and calculated from the UNICEF birth registration database, DHS and MICS. CRVS birth registration completeness was calculated as birth registrations reported by a national authority divided by estimates of live births published in the United Nations (UN) World Population Prospects or the Global Burden of Disease (GBD) Study. Summary measures of concordance were used to compare completeness estimates.FINDINGS:Birth registration completeness (based on ages less than five years) calculated from self-reported data is higher than that estimated from CRVS data in most of the 57 countries (31 countries according to UN estimated births, average six percentage points (p.p.) higher; 43 countries according to GBD, average eight p.p. higher). For countries with CRVS completeness less than 95%, self-reported completeness was higher in 26 of 28 countries, an average 13 p.p. and median 9-10 p.p. higher. Self-reported completeness is at least 30 p.p. higher than CRVS completeness in three countries. Self-reported birth certification completeness exhibits closer concordance with CRVS completeness. Similar results are found for self-reported completeness at 12-23 months.CONCLUSIONS:These findings suggest that self-reported completeness figures over-estimate completeness when compared with CRVS data, especially at lower levels of completeness, partly due to over-reporting of registration by respondents. Estimates published by UNICEF should be viewed cautiously, especially given their wide usage.

Background Prevention, control, and treatment of respiratory tract cancers are important steps towards achieving target 3.4 of the UN Sustainable Development Goals (SDGs)-a one-third reduction in premature mortality due to non-communicable diseases by 2030. We aimed to provide global, regional, and national estimates of the burden of tracheal, bronchus, and lung cancer and larynx cancer and their attributable risks from 1990 to 2019. Methods Based on the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 methodology, we evaluated the incidence, mortality, years lived with disability, years of life lost, and disability-adjusted life-years (DALYs) of respiratory tract cancers (ie, tracheal, bronchus, and lung cancer and larynx cancer). Deaths from tracheal, bronchus, and lung cancer and larynx cancer attributable to each risk factor were estimated on the basis of risk exposure, relative risks, and the theoretical minimum risk exposure level input from 204 countries and territories, stratified by sex and Socio-demographic Index (SDI). Trends were estimated from 1990 to 2019, with an emphasis on the 2010-19 period. Findings Globally, there were 2.26 million (95% uncertainty interval 2.07 to 2.45) new cases of tracheal, bronchus, and lung cancer, and 2.04 million (1.88 to 2.19) deaths and 45.9 million (42.3 to 49.3) DALYs due to tracheal, bronchus, and lung cancer in 2019. There were 209 000 (194 000 to 225 000) new cases of larynx cancer, and 123 000 (115 000 to 133 000) deaths and 3.26 million (3.03 to 3.51) DALYs due to larynx cancer globally in 2019. From 2010 to 2019, the number of new tracheal, bronchus, and lung cancer cases increased by 23.3% (12.9 to 33.6) globally and the number of larynx cancer cases increased by 24.7% (16.0 to 34.1) globally. Global age-standardised incidence rates of tracheal, bronchus, and lung cancer decreased by 7.4% (-16.8 to 1.6) and age-standardised incidence rates of larynx cancer decreased by 3.0% (-10.5 to 5.0) in males over the past decade; however, during the same period, age-standardised incidence rates in females increased by 0.9% (-8.2 to 10.2) for tracheal, bronchus, and lung cancer and decreased by 0.5% (-8.4 to 8.1) for larynx cancer. Furthermore, although age-standardised incidence and death rates declined in both sexes combined from 2010 to 2019 at the global level for tracheal, bronchus, lung and larynx cancers, some locations had rising rates, particularly those on the lower end of the SDI range. Smoking contributed to an estimated 64.2% (61.9-66.4) of all deaths from tracheal, bronchus, and lung cancer and 63.4% (56.3-69.3) of all deaths from larynx cancer in 2019. For males and for both sexes combined, smoking was the leading specific risk factor for age-standardised deaths from tracheal, bronchus, and lung cancer per 100 000 in all SDI quintiles and GBD regions in 2019. However, among females, household air pollution from solid fuels was the leading specific risk factor in the low SDI quintile and in three GBD regions (central, eastern, and western sub-Saharan Africa) in 2019. Interpretation The numbers of incident cases and deaths from tracheal, bronchus, and lung cancer and larynx cancer increased globally during the past decade. Even more concerning, age-standardised incidence and death rates due to tracheal, bronchus, lung cancer and larynx cancer increased in some populations-namely, in the lower SDI quintiles and among females. Preventive measures such as smoking control interventions, air quality management programmes focused on major air pollution sources, and widespread access to clean energy should be prioritised in these settings. Copyright (C) 2021 The Author(s). Published by Elsevier Ltd.

BACKGROUND:In Bangladesh, a poorly functioning national system of registering deaths and determining their causes leaves the country without important information on which to inform health programming, particularly for the 85% of deaths that occur in the community. In 2017, an improved death registration system and automated verbal autopsy (VA) were introduced to 13 upazilas to assess the utility of VA as a routine source of policy-relevant information and to identify leading causes of deaths (COD) in rural Bangladesh.METHODS:Data from 22,535 VAs, collected in 12 upazilas between October 2017 and August 2019, were assigned a COD using the SmartVA Analyze 2.0 computer algorithm. The plausibility of the VA results was assessed using a series of demographic and epidemiological checks in the Verbal Autopsy Interpretation, Performance and Evaluation Resource (VIPER) software tool.RESULTS:Completeness of community death reporting was 65%. The vast majority (85%) of adult deaths were due to non-communicable diseases, with ischemic heart disease, stroke and chronic respiratory disease comprising about 60% alone. Leading COD were broadly consistent with Global Burden of Disease study estimates.CONCLUSIONS:Routine VA collection using automated methods is feasible, can produce plausible results and provides critical information on community COD in Bangladesh. Routine VA and VIPER have potential application to countries with weak death registration systems.

Background Good quality cause of death (COD) information is fundamental for formulating and evaluating public health policy; yet most deaths in developing countries, including the Solomon Islands, occur at home without medical certification of cause of death (MCCOD). As a result, COD data in such contexts are often of limited use for policy and planning. Verbal autopsies (VAs) are a cost-effective way of generating reliable COD information in populations lacking comprehensive MCCOD coverage, but this method has not previously been applied in the Solomon Islands. This study describes the establishment of a VA system to estimate the cause specific mortality fractions (CSMFs) for community deaths that are not medically certified in the Solomon Islands. Methods Automated VA methods (SmartVA) were introduced into the Solomon Islands in 2016. Trained data collectors (nurses) conducted VAs on eligible deaths to December 2020 using electronic tablet devices and VA responses were analysed using the Tariff 2.0 automated diagnostic algorithm. CSMFs were generated for both non-inpatient deaths in hospitals (i.e. 'dead on/by arrival') and community deaths. Results VA was applied to 914 adolescent-and-adult deaths with a median (IQR) age of 62 (45-75) years, 61% of whom were males. A specific COD could be diagnosed for more than 85% of deaths. The leading causes of death for both sexes combined were: ischemic heart disease (16.3%), stroke (13.5%), diabetes (8.1%), pneumonia (5.7%) and chronic-respiratory disease (4.8%). Stroke was the top-ranked cause for females, and ischaemic heart disease the leading cause for males. The CSMFs from the VAs were similar to Global Burden of Disease (GBD) estimates. Overall, non-communicable diseases (NCDs) accounted for 73% of adult deaths; communicable, maternal and nutritional conditions 15%, and injuries 12%. Six of the ten leading causes reported for facility deaths in the Solomon Islands were also identified as leading causes of community deaths based on the VA diagnoses. Conclusions NCDs are the leading cause of adult deaths in the Solomon Islands. Automated VA methods are an effective means of generating reliable COD information for community deaths in the Solomon Islands and should be routinely incorporated into the national mortality surveillance system.

BACKGROUND:Since 2013, Hong Kong has sustained the world's highest life expectancy at birth-a key indicator of population health. The reasons behind this achievement remain poorly understood but are of great relevance to both rapidly developing and high-income regions. Here, we aim to compare factors behind Hong Kong's survival advantage over long-living, high-income countries. METHODS:Life expectancy data from 1960-2020 were obtained for 18 high-income countries in the Organisation for Economic Co-operation and Development from the Human Mortality Database and for Hong Kong from Hong Kong's Census and Statistics Department. Causes of death data from 1950-2016 were obtained from WHO's Mortality Database. We used truncated cross-sectional average length of life (TCAL) to identify the contributions to survival differences based on 263 million deaths overall. As smoking is the leading cause of premature death, we also compared smoking-attributable mortality between Hong Kong and the high-income countries. FINDINGS:From 1979-2016, Hong Kong accumulated a substantial survival advantage over high-income countries, with a difference of 1·86 years (95% CI 1·83-1·89) for males and 2·50 years (2·47-2·53) for females. As mortality from infectious diseases declined, the main contributors to Hong Kong's survival advantage were lower mortality from cardiovascular diseases for both males (TCAL difference 1·22 years, 95% CI 1·21-1·23) and females (1·19 years, 1·18-1·21), cancer for females (0·47 years, 0·45-0·48), and transport accidents for males (0·27 years, 0·27-0·28). Among high-income populations, Hong Kong recorded the lowest cardiovascular mortality and one of the lowest cancer mortalities in women. These findings were underpinned by the lowest absolute smoking-attributable mortality in high-income regions (39·7 per 100 000 in 2016, 95% CI 34·4-45·0). Reduced smoking-attributable mortality contributed to 50·5% (0·94 years, 0·93-0·95) of Hong Kong's survival advantage over males in high-income countries and 34·8% (0·87 years, 0·87-0·88) of it in females. INTERPRETATION:Hong Kong's leading longevity is the result of fewer diseases of poverty while suppressing the diseases of affluence. A unique combination of economic prosperity and low levels of smoking with development contributed to this achievement. As such, it offers a framework that could be replicated through deliberate policies in developing and developed populations globally. FUNDING:Early Career Scheme (RGC ECS Grant #27602415), Research Grants Council, University Grants Committee of Hong Kong.