Objectives To assess completeness and accuracy of the family folder in terms of capturing community-level health data.Study design A capture–recapture method was applied in six randomly selected districts of Tigray Region, Ethiopia.Participants Child health data, abstracted from randomly selected 24 073 family folders from 99 health posts, were compared with similar data recaptured through household survey and routine health information made by these health posts.Primary and secondary outcome measures Completeness and accuracy of the family folder data; and coverage selected child health indicators, respectively.Results Demographic data captured by the family folders and household survey were highly concordant, concordance correlation for total population, women 15–49 years age and under 5-year child were 0.97 (95% CI 0.94 to 0.99, p<0.001), 0.73 (95% CI 0.67 to 0.88) and 0.91 (95% CI 0.85 to 0.96), respectively. However, the live births, child health service indicators and child health events were more erratically reported in the three data sources. The concordance correlation among the three sources, for live births and neonatal deaths was 0.094 (95% CI −0.232 to 0.420) and 0.092 (95% CI −0.230 to 0.423) respectively, and for the other parameters were close to 0.Conclusion The family folder system comprises a promising development. However, operational issues concerning the seamless capture and recording of events and merging community and facility data at the health centre level need improvement.

Objectives Cardiovascular diseases are the second leading cause of mortality behind HIV/AIDS in South Africa. This study investigates cardiovascular disease mortality trends in rural South Africa over 20+ years and the associated barriers to accessing care, using verbal autopsy data. Design A mixed-methods approach was used, combining descriptive analysis of mortality rates over time, by condition, sex and age group, quantitative analysis of circumstances of mortality (CoM) indicators and free text narratives of the final illness, and qualitative analysis of free texts. Setting This study was done using verbal autopsy data from the Health and Socio-Demographic Surveillance System site in Agincourt, rural South Africa. Participants Deaths attributable to cardiovascular diseases (acute cardiac disease, stroke, renal failure and other unspecified cardiac disease) from 1993 to 2015 were extracted from verbal autopsy data. Results Between 1993 and 2015, of 15 305 registered deaths over 1 851 449 person-years of follow-up, 1434 (9.4%) were attributable to cardiovascular disease, corresponding to a crude mortality rate of 0.77 per 1000 person-years. Cardiovascular disease mortality rate increased from 0.34 to 1.12 between 1993 and 2015. Stroke was the dominant cause of death, responsible for 41.0% (588/1434) of all cardiovascular deaths across all years. Cardiovascular disease mortality rate was significantly higher in women and increased with age. The main delays in access to care during the final illness were in seeking and receiving care. Qualitative free-text analysis highlighted delays not captured in the CoM, principally communication between the clinician and patient or family. Half of cases initially sought care outside a hospital setting (50.9%, 199/391). Conclusions The temporal increase in deaths due to cardiovascular disease highlights the need for greater prevention and management strategies for these conditions, particularly for the women. Strategies to improve seeking and receiving care during the final illness are needed.

Background: NCDs are non-infectious, long-term conditions that account for 40 million deaths per annum. 87% of premature NCD mortality occurs in low- and middle-income countries.Objective: The aims were:develop methods to provide integrated biosocial accounts of NCD mortality; and explore the practical utility of extended mortality data for the primary health care system.Methods: We drew on data from research programmes in the study area. Data were analysed in three steps: [a]analysis of levels, causes and circumstances of NCD mortality [n = 4,166] from routine census updates including Verbal Autopsy and of qualitative data on lived experiences of NCDs in rural villages from participatory research; [b] identifying areas of convergence and divergence between the analyses; and [c]exploration of the practical relevance of the data drawing on engagements with health systems stakeholders.Results: NCDs constituted a significant proportion of mortality in this setting [36%]. VA data revealed multiple barriers to access in end-of-life care. Many deaths were attributed to problems with resources and health systems [21%;19% respectively]. The qualitative research provided rich complementary detail on the processes through which risk originates, accumulates and is expressed in access to end-of-life care, related to chronic poverty and perceptions of poor quality care in clinics. The exploration of practical relevance revealed chronic under-funding for NCD services, and an acute need for robust, timely data on the NCD burden.Conclusions: VA data allowed a significant burden of NCD mortality to be quantified and revealed barriers to access at and around the time of death. Qualitative research contextualised these barriers, providing explanations of how and why they exist and persist. Health systems analysis revealed shortages of resources allocated to NCDs and a need for robust research to provide locally relevant evidence to organise and deliver care. Pragmatic interdisciplinary and mixed method analysis provides relevant renditions of complex problems to inform more effective responses.

In the Lancet Global Health, Allan Taylor and colleagues1Taylor AW Blau DM Bassat Q et al.Initial findings from a novel population-based child mortality surveillance approach: a descriptive study.Lancet Glob Health. 2020; 8: e909-e919Google Scholar present the first population-based study of minimally invasive tissue sampling (MITS) as a mid-spectrum approach for the determination of cause of death, positioned in robustness between clinical diagnostic autopsies and medical certification or verbal autopsy. In this descriptive study, the authors included data obtained in the first 2 years after the implementation of the Child Health and Mortality Prevention Surveillance (CHAMPS) Network in Asia and Africa. The findings from 933 childhood deaths across five countries (Mozambique, South Africa, Kenya, Mali, and Bangladesh) provide proof of principle for the scale-up of MITS. Although this study was not designed to be statistically generalisable in terms of mortality patterns, it provides insight regarding cause-specific childhood mortality and underlying pathophysiology. The ranked causes of death, which were pooled across disparate samples obtained from five considerably different countries, represent the overall potential of MITS rather than generalisable epidemiological findings. The CHAMPS Network has been successful in the completion of high-quality biomedical science despite challenging circumstances and logistical issues associated with shipping MITS samples to the Centers for Disease Control and Prevention (Atlanta, GA, USA) for further analysis. The authors did not indicate the costs involved per case, which might not have been a major issue in this internationally funded research study, but represents an important factor when considering the global potential of MITS. A previous study has estimated that costs for minimally invasive autopsies exceed €1000 per case.2Wagensveld IM Hunink MGM Wielopolski PA et al.Hospital implementation of minimally invasive autopsy: a prospective cohort study of clinical performance and costs.PLoS One. 2019; 14e0219291Crossref Scopus (5) Google Scholar Considering such costs, widespread implementation of MITS by national authorities in African and Asian countries is unlikely, particularly when compared with the relatively small costs of incorporating verbal autopsy into civil registration procedures. Thus, understanding how MITS findings from studies such as CHAMPS, which has so far analysed data for a relatively limited numbers of deaths, can be best used to leverage greater understanding of global mortality patterns is crucial. WHO estimates that only around half of deaths worldwide are registered with a reliable cause, with most unregistered deaths occurring in Africa and Asia.3WHOCompleteness of cause-of-death data, 2007–2016. World Health Organization, Geneva, Geneva2018http://gamapserver.who.int/mapLibrary/Files/Maps/Global_CivilRegistrationDeaths_2007_2016.pngDate accessed: April 23, 2020Google Scholar Thus, connections must be made between the millions of deaths that occur without a registered cause and the insights provided by the application of expensive MITS methods to a small proportion of deaths. The CHAMPS Network applied the 2016 WHO verbal autopsy instrument4Nichols E Byass P Chandramohan D et al.The WHO 2016 verbal autopsy instrument: an international standard suitable for automated analysis by InterVA, InSilicoVA and Tariff 2.0.PLoS Med. 2018; 15e1002486Crossref PubMed Scopus (40) Google Scholar to the deaths that the MITS approach had been applied to. Thus, the next logical step would be to process the CHAMPS verbal autopsy data using available automated verbal autopsy cause of death models, and to compare modelled causes of death with MITS findings. Observed differences might highlight possible improvements to the knowledge base that drive standard verbal autopsy models. Thus far, the CHAMPS Network has focused on deaths in children, however, extending the MITS concept to older children and adults could also be worthy of consideration, to provide additional knowledge for automated cause of death models. A number of the UN Sustainable Development Goal (SDG) targets are associated with adult mortality, for example SDG 3.4, which aims to reduce premature mortality from non-communicable diseases by a third by 2030.5UNSustainable development goal 3.https://sustainabledevelopment.un.org/sdg3Date accessed: April 23, 2020Google Scholar Unless substantial improvements are made to improve the reliability of methods and systems used for monitoring all-age cause-specific mortality across Africa and Asia, the accuracy with which SDG 3.4 and other targets will be evaluable globally in 2030 is unclear. Some adult MITS data could be useful, in addition to childhood data, to inform and improve verbal autopsy models for this purpose. Furthermore, as COVID-19 potentially spreads into populations where testing and clinical data are likely to be limited, MITS procedures could be similarly informative. MITS should be considered an innovative and informative component of the global quest for more complete cause-specific mortality data, and as a resource for enhancing other tools for measuring mortality. The MITS approach might also be useful for cases in which aetiology-specific cause of death determination is crucial, such as in vaccine trials. Generally, however, MITS alone is unlikely to become a widely applicable solution to fill global gaps in the routine assessment of individual cause of death. I declare no competing interests. Initial findings from a novel population-based child mortality surveillance approach: a descriptive studyCause of death determination using MITS enabled detailed characterisation of contributing conditions. Global estimates of child mortality aetiologies, which are currently based on a single syndromic cause for each death, will be strengthened by findings from CHAMPS. This approach adds specificity and provides a more complete overview of the chain of events leading to death, highlighting multiple potential interventions to prevent under-5 mortality and stillbirths. Full-Text PDF Open Access

Background: Alcohol and other drug (AOD) abuse is a major public health challenge disproportionately affecting marginalised communities. Involving communities in the development of responses can contribute to acceptable solutions.Objectives: To: (1) document forms, processes, and contexts of engaging communities to nominate health concerns and generate new knowledge for action; (2) further build participation in the local health system by reflecting on and adapting the process.Methods: PAR was progressed with 48 community stakeholders across three rural villages in the MRC/Wits Agincourt Health and Socio Demographic Surveillance System (HDSS) in Mpumalanga, South Africa. A series of workshops explored community-nominated topics, systematised lived experience into shared accounts and considered actions to address problems identified. Photovoice was also used to generate visual evidence. Narrative and visual data were thematically analysed, situated within practice frameworks, and learning and adaption elicited.Results: AOD abuse was identified as a topic of high priority. It was understood as an entrenched social problem with destructive effects. Biopsychosocial impacts were mapped and related to unemployment, poverty, stress, peer pressure, criminal activity, corruption, and a proliferating number of taverns. Integrated action agendas were developed focussed on demand, supply, and harm reduction underpinned by shared responsibility among community, state, and non-state actors. Community stakeholders appreciated systematising and sharing knowledge, taking active roles, developing new skills in planning and public speaking, and progressing shared accountability processes. Expectations required sensitive management, however.Conclusion: There is significant willingness and capacity among community stakeholders to work in partnership with authorities to address priority health concerns. As a process, participation can help to raise and frame issues, which may help to better inform action and encourage shared responsibility. Broader understandings of participation require reference to, and ultimately transfer of power towards, those most directly affected, developing community voice as continuous processes within social and political environments.

NAME INDEX Note: Page numbers followed by “n” Aaltonen, P. Abazi, A., 89 Abbas, M., 148, 149 Abell, P. Ackerman, JD, 86 Adams, RJ, 129 Adger, WN, 148, 149 Adomssent, M., 34 Agnolucci, P., 148, 149 Akanji, AA, 15 Akinlo, EA Akinyemi, AI Albareda-Tiana, S., 101 Albrecht, J., 82 Ali, AD Allen, A., 148, 149 Altan, H., 84, 94 Amann, M., 148, 149 Antonescu, NN, 35 Aransola, JA Arnell, N., 149 Association for Advancement of Sustainability in Higher Education (AASHE), 68–69, 72, 76 Avila, LV, 101 Axeiteiro, U., 101 Aydın, C., 136 Ayeb-Karlsson, S., 149 Azeiteiro, U., 84 Ball, S., 148, 149 Barlett, P., 160 Beale, DJ, 135 Beaudoin … 186 NAME INDEX Cohen, R., 125 Coloja, M., 35 Corcoran, PB, 34 Cortese, AD, 136 Costello, A., 148, 149 Cote, N., Council for Ontario Universities, 131n3 Cross, M., 129 Daddi, T., 83 Davies, C., 54, 150, 152 Davim, JP, De Geest, S., 148 Delclos, G., 94 Dhamani, K., 126, 129 Dike, VE …

BackgroundTime-critical conditions (TCC) are estimated to cause substantial mortality in low and middle-income countries. However, quantification of deaths and identification of contributing factors to those deaths are challenging in settings with poor health records.AimTo use verbal autopsy (VA) data from the Agincourt health and sociodemographic surveillance system in rural South Africa to quantify the burden of deaths from TCC and to evaluate the barriers in seeking, reaching and receiving quality care for TCC leading to death.MethodologyDeaths from 1993 to 2015 were analysed to identify causality from TCC. Deaths due to TCC were categorised as communicable, non-communicable, maternal, neonatal or injury-related. Proportion of deaths from TCC by age, sex, condition type and temporal trends was described. Deaths due to TCC from 2012 to 2015 were further examined by circumstances of mortality (CoM) indicators embedded in VA. Healthcare access, at illness onset and during the final day of life, as well as place of death, was extracted from free text summaries. Summaries were also analysed qualitatively using a Three Delays framework to identify barriers to healthcare.ResultsOf 15 305 deaths, 5885 (38.45%) were due to TCC. Non-communicable diseases were the most prevalent cause of death from TCC (2961/5885 cases, 50.31%). CoM indicators highlighted delays in a quarter of deaths due to TCC, most frequently in seeking care. The most common pattern of healthcare access was to die outwith a facility, having sought no healthcare (409/1324 cases, 30.89%). Issues in receipt of quality care were identified by qualitative analysis.ConclusionTCCs are responsible for a substantial burden of deaths in this rural South African population. Delays in seeking and receiving quality care were more prominent than those in reaching care, and thus further research and solution development should focus on healthcare-seeking behaviour and quality care provision.

Background: The outbreak of COVID-19 in China in early 2020 provides a rich data source for exploring the ecological determinants of this new infection, which may be of relevance as the pandemic develops. Objectives: Assessing the spread of the COVID-19 across China, in relation to associations between cases and ecological factors including population density, temperature, solar radiation and precipitation. Methods: Open-access COVID-19 case data include 18,069 geo-located cases in China during January and February 2020, which were mapped onto a 0.25 degrees latitude/longitude grid together with population and weather data (temperature, solar radiation and precipitation). Of 15,539 grid cells, 559 (3.6%) contained at least one case, and these were used to construct a Poisson regression model of cell-weeks. Weather parameters were taken for the preceding week given the established 5-7 day incubation period for COVID-19. The dependent variable in the Poisson model was incident cases per cell-week and exposure was cell population, allowing for clustering of cells over weeks, to give incidence rate ratios. Results: The overall COVID-19 incidence rate in cells with confirmed cases was 0.12 per 1,000. There was a single confirmed case in 113/559 (20.2%) of cells, while two grid cells recorded over 1,000 confirmed cases. Weekly means of maximum daily temperature varied from -28.0 degrees C to 30.1 degrees C, minimum daily temperature from -42.4 degrees C to 23.0 degrees C, maximum solar radiation from 0.04 to 2.74 MJm(-2) and total precipitation from 0 to 72.6 mm. Adjusted incidence rate ratios suggested brighter, warmer and drier conditions were associated with lower incidence. Conclusion: Though not demonstrating cause and effect, there were appreciable associations between weather and COVID-19 incidence during the epidemic in China. This does not mean the pandemic will go away with summer weather but demonstrates the importance of using weather conditions in understanding and forecasting the spread of COVID-19.

TranslationsFor the Chinese, French, German, and Spanish translations of the abstract see Supplementary Materials section.

Background Under-five and maternal mortality were halved in the Millennium Development Goals (MDG) era, with slower reductions for 2.6 million neonatal deaths and 2.6 million stillbirths. The Every Newborn Action Plan aims to accelerate progress towards national targets, and includes an ambitious Measurement Improvement Roadmap. Population-based household surveys, notably Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys, are major sources of population-level data on child mortality in countries with weaker civil registration and vital statistics systems, where over two-thirds of global child deaths occur. To estimate neonatal/child mortality and pregnancy outcomes (stillbirths, miscarriages, birthweight, gestational age) the most common direct methods are: (1) the standard DHS-7 with Full Birth History with additional questions on pregnancy losses in the past 5 years (FBH+) or (2) a Full Pregnancy History (FPH). No direct comparison of these two methods has been undertaken, although descriptive analyses suggest that the FBH+ may underestimate mortality rates particularly for stillbirths. Methods This is the protocol paper for the Every Newborn-INDEPTH study (INDEPTH Network, international Network for the Demographic Evaluation of Populations and their Health Every Newborn, Every Newborn Action Plan), aiming to undertake a randomised comparison of FBH+ and FPH, to measure pregnancy outcomes in a household survey in five selected INDEPTH Network sites in Africa and South Asia (Bandim in urban and rural Guinea-Bissau; Dabat in Ethiopia; IgangaMayuge in Uganda; Kintampo in Ghana; Matlab in Bangladesh). The survey will reach >68000 pregnancies to assess if there is >= 15% difference in stillbirth rates. Additional questions will capture birthweight, gestational age, birth/death certification, termination of pregnancy and fertility intentions. The World Bank's Survey Solutions platform will be tailored for data collection, including recording paradata to evaluate timing. A mixed methods assessment of barriers and enablers to reporting of pregnancy and adverse pregnancy outcomes will be undertaken. Conclusions This large-scale study is the first randomised comparison of these two methods to capture pregnancy outcomes. Results are expected to inform the evidence base for survey methodology, especially in DHS, regarding capture of stillbirths and other outcomes, notably neonatal deaths, abortions (spontaneous and induced), birthweight and gestational age. In addition, this study will inform strategies to improve health and demographic surveillance capture of neonatal/child mortality and pregnancy outcomes.

Half of the world?s deaths and their causes pass unrecorded by routine registration systems, particularly in low- and middle-income countries. Verbal autopsy (VA) collects information on medical signs, symptoms and circumstances from witnesses of a death that is used to assign likely medical causes. To further contextualise information on mortality, understanding underlying determinants, such as logistics, barriers to service utilisation and health systems responses, is important for health planning. Adding systematic methods for categorising circumstantial determinants of death to conventional VA tools is therefore important. In this context, the World Health Organization (WHO) leads the development of international standards for VA, and added questions on the social and health systems circumstances of death in 2012. This paper introduces a pragmatic and scalable approach for assigning relevant Circumstances Of Mortality CATegories (COMCATs) within VA tools, and examines their consistency, reproducibility and plausibility for health policy making, as well as assessing additional effort and cost to the routine VA process. This innovative COMCAT model is integrated with InterVA-5 software (which processes WHO-2016 VA data), for assigning numeric likelihoods to six circumstantial categories for each death. VA data from 4,116 deaths in the Agincourt Health and Socio-Demographic Surveillance System in South Africa from 2012 to 2016 were used to demonstrate proof of principle for COMCATs. Lack of resources to access health care, poor recognition of diseases and inadequate health systems responses ranked highest among COMCATs in the demonstration dataset. COMCATs correlated plausibly with age, sex, causes of death and local knowledge of the demonstration population. The COMCAT approach appears to be plausible, feasible and enhances the functionality of routine VA to account for critical limiting circumstances at and around the time of death. It is a promising tool for evaluating progress towards the Sustainable Development Goals and the roll-out of Universal Health Coverage.

Objective To investigate whether the key metric for monitoring progress towards sustainable development goal target 3.4 that is measuring premature noncommunicable disease mortality (deaths among people aged 30-69 years), is ageist. Methods To examine the relationship between premature noncommunicable disease mortality and noncommunicable disease mortality in older people, a database of mortality rates for cardiovascular disease, cancer, chronic obstructive pulmonary disease and diabetes in people aged 30 to 69 years and 70 to 89 years was compiled using estimates from the Global Burden of Disease Study 2017. The data covered 195 countries, six time-points and both sexes, giving 2340 instances. The World Health Organization's (WHO's) life-table method for the premature noncommunicable disease mortality metric was applied to the data. Findings There was a strong correlation between noncommunicable disease mortality patterns in the premature and older age groups, which suggests that measuring premature noncommunicable disease mortality is informative about such mortality in later life. Neither time nor geographical location had a substantial effect on this correlation. However, there were female-to-male differences in age-specific probabilities of death due to noncommunicable disease, implying that noncommunicable disease mortality should be assessed using a sex-disaggregated approach. Conclusion As the established WHO metric for premature noncommunicable disease mortality was predictive of noncommunicable disease mortality in older people, the metric should not be construed as ageist Focusing resources on measuring premature noncommunicable disease mortality will be appropriate, particularly in settings without universal civil death registration. This approach should not prejudice the provision of health services throughout the life-course.

Background: Understanding socioeconomic disparities in all-cause and cause-specific mortality can help inform prevention and treatment strategies. Objectives: To quantify cause-specific mortality rates by socioeconomic status across seven health and demographic surveillance systems (HDSS) in five countries (Ethiopia, Kenya, Malawi, Mozambique, and Nigeria) in the INDEPTH Network in sub-Saharan Africa. Methods: We linked demographic residence data with household survey data containing living standards and education information we used to create a poverty index. Person-years lived and deaths between 2003 and 2016 (periods varied by HDSS) were stratified in each HDSS by age, sex, year, and number of deprivations on the poverty index (0-8). Causes of death were assigned to each death using the InterVA-4 model based on responses to verbal autopsy questionnaires. We estimated rate ratios between socioeconomic groups (2-4 and 5-8 deprivations on our poverty index compared to 0-2 deprivations) for specific causes of death and calculated life expectancy for the deprivation groups. Results: Our pooled data contained almost 3.5 million person-years of observation and 25,038 deaths. All-cause mortality rates were higher among people in households with 5-8 deprivations on our poverty index compared to 0-2 deprivations, controlling for age, sex, and year (rate ratios ranged 1.42 to 2.06 across HDSS sites). The poorest group had consistently higher death rates in communicable, maternal, neonatal, and nutritional conditions (rate ratios ranged 1.34-4.05) and for non-communicable diseases in several sites (1.14-1.93). The disparities in mortality between 5-8 deprivation groups and 0-2 deprivation groups led to lower life expectancy in the higher-deprivation groups by six years in all sites and more than 10 years in five sites. Conclusions: We show large disparities in mortality on the basis of socioeconomic status across seven HDSS in sub-Saharan Africa due to disparities in communicable disease mortality and from non-communicable diseases in some sites. Life expectancy gaps between socioeconomic groups within sites were similar to the gaps between high-income and lower-middle-income countries. Prevention and treatment efforts can benefit from understanding subpopulations facing higher mortality from specific conditions.

The burden of disease is fundamental to understanding, prioritizing, and monitoring public health interventions. Cause of death is required to calculate the burden of disease, but in many parts of the developing world deaths are neither detected nor given a cause. Verbal autopsy is a feasible way of assigning a cause to a death based on an interview with those who cared for the person who died. As civil registration and vital statistics systems improve in the developing world, verbal autopsy is playing and increasingly important role in providing information about cause of death and the burden of disease. This note motivates the creation of a global symptom-cause archive containing reference deaths with both a verbal autopsy and a cause assigned through an independent mechanism. This archive could provide training and validation data for refining, developing, and testing machine-based algorithms to automate cause assignment from verbal autopsy data. This, in turn, would improve the comparability of machine-assigned causes and provide a means to fine-tune individual cause assignment within specific contexts.

Background: Verbal autopsy is an increasingly important methodology for assigning causes to otherwise uncertified deaths, which amount to around 50% of global mortality and cause much uncertainty for health planning. The World Health Organization sets international standards for the structure of verbal autopsy interviews and for cause categories that can reasonably be derived from verbal autopsy data. In addition, computer models are needed to efficiently process large quantities of verbal autopsy interviews to assign causes of death in a standardised manner. Here, we present the InterVA-5 model, developed to align with the WHO-2016 verbal autopsy standard. This is a harmonising model that can process input data from WHO-2016, as well as earlier WHO-2012 and Tariff-2 formats, to generate standardised cause-specific mortality profiles for diverse contexts. The software development involved building on the earlier InterVA-4 model, and the expanded knowledge base required for InterVA-5 was informed by analyses from a training dataset drawn from the Population Health Metrics Research Collaboration verbal autopsy reference dataset, as well as expert input. Results: The new model was evaluated against a test dataset of 6130 cases from the Population Health Metrics Research Collaboration and 4009 cases from the Afghanistan National Mortality Survey dataset. Both of these sources contained around three quarters of the input items from the WHO-2016, WHO-2012 and Tariff-2 formats. Cause-specific mortality fractions across all applicable WHO cause categories were compared between causes assigned in participating tertiary hospitals and InterVA-5 in the test dataset, with concordance correlation coefficients of 0.92 for children and 0.86 for adults. The InterVA-5 model's capacity to handle different input formats was evaluated in the Afghanistan dataset, with concordance correlation coefficients of 0.97 and 0.96 between the WHO-2016 and the WHO-2012 format for children and adults respectively, and 0.92 and 0.87 between the WHO-2016 and the Tariff-2 format respectively. Conclusions: Despite the inherent difficulties of determining "truth" in assigning cause of death, these findings suggest that the InterVA-5 model performs well and succeeds in harmonising across a range of input formats. As more primary data collected under WHO-2016 become available, it is likely that InterVA-5 will undergo minor re-versioning in the light of practical experience. The model is an important resource for measuring and evaluating cause-specific mortality globally.