Karat Aaron S, Tlali Mpho, Fielding Katherine L, Charalambous Salome, Chihota Violet N, Churchyard Gavin J, Hanifa Yasmeen, Johnson Suzanne, McCarthy Kerrigan, Martinson Neil A, Omar Tanvier, Kahn Kathleen, Chandramohan Daniel, Grant Alison D
Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, United Kingdom.
The Aurum Institute, Johannesburg, South Africa.
PLoS One. 2017 Mar 23;12(3):e0174097. doi: 10.1371/journal.pone.0174097. eCollection 2017.
The World Health Organization (WHO) aims to reduce tuberculosis (TB) deaths by 95% by 2035; tracking progress requires accurate measurement of TB mortality. International Classification of Diseases (ICD) codes do not differentiate between HIV-associated TB and HIV more generally. Verbal autopsy (VA) is used to estimate cause of death (CoD) patterns but has mostly been validated against a suboptimal gold standard for HIV and TB. This study, conducted among HIV-positive adults, aimed to estimate the accuracy of VA in ascertaining TB and HIV CoD when compared to a reference standard derived from a variety of clinical sources including, in some, minimally-invasive autopsy (MIA).
Decedents were enrolled into a trial of empirical TB treatment or a cohort exploring diagnostic algorithms for TB in South Africa. The WHO 2012 instrument was used; VA CoD were assigned using physician-certified VA (PCVA), InterVA-4, and SmartVA-Analyze. Reference CoD were assigned using MIA, research, and health facility data, as available. 259 VAs were completed: 147 (57%) decedents were female; median age was 39 (interquartile range [IQR] 33-47) years and CD4 count 51 (IQR 22-102) cells/μL. Compared to reference CoD that included MIA (n = 34), VA underestimated mortality due to HIV/AIDS (94% reference, 74% PCVA, 47% InterVA-4, and 41% SmartVA-Analyze; chance-corrected concordance [CCC] 0.71, 0.42, and 0.31, respectively) and HIV-associated TB (41% reference, 32% PCVA; CCC 0.23). For individual decedents, all VA methods agreed poorly with reference CoD that did not include MIA (n = 259; overall CCC 0.14, 0.06, and 0.15 for PCVA, InterVA-4, and SmartVA-Analyze); agreement was better at population level (cause-specific mortality fraction accuracy 0.78, 0.61, and 0.57, for the three methods, respectively).
Current VA methods underestimate mortality due to HIV-associated TB. ICD and VA methods need modifications that allow for more specific evaluation of HIV-related deaths and direct estimation of mortality due to HIV-associated TB.
世界卫生组织（WHO）旨在到2035年将结核病（TB）死亡人数减少95%；追踪进展需要准确测量TB死亡率。国际疾病分类（ICD）编码并未更普遍地区分与HIV相关的TB和HIV。口头尸检（VA）用于估计死亡原因（CoD）模式，但大多是对照HIV和TB的次优金标准进行验证的。这项针对HIV阳性成年人开展的研究旨在评估与源自包括某些情况下的微创尸检（MIA）在内的多种临床来源的参考标准相比，VA在确定TB和HIV CoD方面的准确性。
死者被纳入南非一项经验性TB治疗试验或一项探索TB诊断算法的队列研究。使用了WHO 2012工具；通过医生认证的VA（PCVA）、InterVA-4和SmartVA-Analyze来指定VA CoD。参考CoD根据可用的MIA、研究和医疗机构数据来指定。共完成了259份VA：147名（57%）死者为女性；中位年龄为39岁（四分位间距[IQR] 33 - 47），CD4细胞计数为51个/μL（IQR 22 - 102）。与包含MIA的参考CoD（n = 34）相比，VA低估了因HIV/AIDS导致的死亡率（参考值为94%，PCVA为74%，InterVA-4为47%，SmartVA-Analyze为41%；机遇校正一致性[CCC]分别为0.71、0.42和0.31）以及与HIV相关的TB导致的死亡率（参考值为41%，PCVA为32%；CCC为0.23）。对于个体死者，所有VA方法与不包含MIA的参考CoD（n = 259；PCVA、InterVA-4和SmartVA-Analyze的总体CCC分别为0.14、0.06和0.15）的一致性较差；在人群水平上一致性更好（三种方法的死因特异性死亡率分数准确性分别为0.78、0.61和0.57）。
当前的VA方法低估了与HIV相关的TB导致的死亡率。ICD和VA方法需要改进，以便能够更具体地评估与HIV相关的死亡，并直接估计与HIV相关的TB导致的死亡率。
Zotero 插件