Minimally invasive autopsy reliably determined cause of death in Mozambique

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autopsyThe simplified minimally invasive autopsy (MIA) is a feasible and valid method in developing countries to allow reliable estimates of cause of death, find two studies, including one across five settings in Gabon, Kenya, Mali, Mozambique, and Pakistan, from the University Eduardo Mondlane, Maputo.

High concordance rates were observed between diagnoses obtained using a simplified minimally invasive autopsy method and those determined from complete autopsies in a series of deceased adult patients in Mozambique, according to research published by Jaume Ordi and colleagues from ISGlobal, Universitat de Barcelona, Barcelona, Spain.

In a linked research article, Khátia Munguambe and colleagues from the Centro de Investigação em Saúde da Manhiça, Universidade Eduardo Mondlane, Maputo, Mozambique, observed that the hypothetical acceptability of the minimally invasive autopsy and willingness to know the cause of death were high across five settings in Gabon, Kenya, Mali, Mozambique, and Pakistan.

While complete autopsies are considered the gold standard for the determination of cause of death, they are poorly accepted and difficult to perform in low- and middle- income countries. The simplified minimally invasive autopsy, which consists of histological and microbiological analyses of blood samples, cerebrospinal fluid samples, and tissue samples from solid organs using biopsy needles, could be an alternative method to the complete autopsy. In the first study, the researchers compared the cause of death identified in 112 deceased adult patients using a minimally invasive method with the cause of death identified from a complete autopsy. They observed 75.9% concordance rates between the diagnosis obtained with the minimally invasive autopsy and the gold standard diagnosis, with a particularly high agreement for infectious diseases.

In the second study, a mixed-methods approach was used to conduct 504 interviews with different informants, including those who had recently lost a family member, in five different countries. They found that 75% of the participants would be willing to know the cause death of a relative and that the overall hypothetical acceptability of minimally invasive autopsy on a relative was 73%.

Overall, these two studies provide support for the feasibility and validity of the minimally invasive autopsy method to be used in low-and middle-income settings to allow reliable estimates of cause of death.

In a linked perspective, Peter Byass of Umeå University, Umeå, Sweden reflects on the potential challenges for minimally invasive autopsies to become routinely used for determining cause of death in low- and middle-income countries. He says “MIA shows signs of being an important addition to the world’s available range of cause-of-death assignment methods.”

Background: There is an urgent need to identify tools able to provide reliable information on the cause of death in low-income regions, since current methods (verbal autopsy, clinical records, and complete autopsies) are either inaccurate, not feasible, or poorly accepted. We aimed to compare the performance of a standardized minimally invasive autopsy (MIA) approach with that of the gold standard, the complete diagnostic autopsy (CDA), in a series of adults who died at Maputo Central Hospital in Mozambique.
Methods and Findings: In this observational study, coupled MIAs and CDAs were performed in 112 deceased patients. The MIA analyses were done blindly, without knowledge of the clinical data or the results of the CDA. We compared the MIA diagnosis with the CDA diagnosis of cause of death.
CDA diagnoses comprised infectious diseases (80; 71.4%), malignant tumors (16; 14.3%), and other diseases, including non-infectious cardiovascular, gastrointestinal, kidney, and lung diseases (16; 14.3%). A MIA diagnosis was obtained in 100/112 (89.2%) cases. The overall concordance between the MIA diagnosis and CDA diagnosis was 75.9% (85/112). The concordance was higher for infectious diseases and malignant tumors (63/80 [78.8%] and 13/16 [81.3%], respectively) than for other diseases (9/16; 56.2%). The specific microorganisms causing death were identified in the MIA in 62/74 (83.8%) of the infectious disease deaths with a recognized cause.
The main limitation of the analysis is that both the MIA and the CDA include some degree of expert subjective interpretation.
Conclusions: A simple MIA procedure can identify the cause of death in many adult deaths in Mozambique. This tool could have a major role in improving the understanding and surveillance of causes of death in areas where infectious diseases are a common cause of mortality.

Paola Castillo, Miguel J Martínez, Esperança Ussene, Dercio Jordao, Lucilia Lovane, Mamudo R. Ismail, Carla Carrilho, Cesaltina Lorenzoni, Fabiola Fernandes, Rosa Bene, Antonio Palhares, Luiz Ferreira, Marcus Lacerda, Inacio Mandomando, Jordi Vila, Juan Carlos Hurtado, Khátia Munguambe, Maria Maixenchs, Ariadna Sanz, Llorenç Quintó, Eusebio Macete, Pedro Alonso, Quique Bassat, Clara Menéndez, Jaume Ordi

Abstract 2
Background: The minimally invasive autopsy (MIA) is being investigated as an alternative to complete diagnostic autopsies for cause of death (CoD) investigation. Before potential implementation of the MIA in settings where post-mortem procedures are unusual, a thorough assessment of its feasibility and acceptability is essential.
Methods and Findings: We conducted a socio-behavioural study at the community level to understand local attitudes and perceptions related to death and the hypothetical feasibility and acceptability of conducting MIAs in six distinct settings in Gabon, Kenya, Mali, Mozambique, and Pakistan. A total of 504 interviews (135 key informants, 175 health providers [including formal health professionals and traditional or informal health providers], and 194 relatives of deceased people) were conducted. The constructs “willingness to know the CoD” and “hypothetical acceptability of MIAs” were quantified and analysed using the framework analysis approach to compare the occurrence of themes related to acceptability across participants.
Overall, 75% (379/504) of the participants would be willing to know the CoD of a relative. The overall hypothetical acceptability of MIA on a relative was 73% (366/504). The idea of the MIA was acceptable because of its perceived simplicity and rapidity and particularly for not “mutilating” the body. Further, MIAs were believed to help prevent infectious diseases, address hereditary diseases, clarify the CoD, and avoid witchcraft accusations and conflicts within families. The main concerns regarding the procedure included the potential breach of confidentiality on the CoD, the misperception of organ removal, and the incompatibility with some religious beliefs. Formal health professionals were concerned about possible contradictions between the MIA findings and the clinical pre-mortem diagnoses. Acceptability of the MIA was equally high among Christian and Islamic communities. However, in the two predominantly Muslim countries, MIA acceptability was higher in Mali than in Pakistan.
While the results of the study are encouraging for the potential use of the MIA for CoD investigation in low-income settings, they remain hypothetical, with a need for confirmation with real-life MIA implementation and in populations beyond Health and Demographic Surveillance System areas.
Conclusions: This study showed a high level of interest in knowing the CoD of a relative and a high hypothetical acceptability of MIAs as a tool for CoD investigation across six distinct settings. These findings anticipate potential barriers and facilitators, both at the health facility and community level, essential for local tailoring of recommendations for future MIA implementation.

Maria Maixenchs, Rui Anselmo, Emily Zielinski-Gutiérrez, Frank O. Odhiambo, Clarah Akello, Maureen Ondire, S Shujaat H Zaidi, Sajid Bashir Soofi, Zulfiqar A Bhutta, Kounandji Diarra, Mahamane Djitèye, Roukiatou Dembélé, Samba Sow, Pamela Cathérine Angoissa Minsoko, Selidji Todagbe Agnandji, Bertrand Lell, Mamudo R Ismail, Carla Carrilho, Jaume Ordi, Clara Menéndez, Quique Bassat, Khátia Munguambe

PLOS One material
PLOS Medicine abstract 1
PLOS Medicine abstract 2
PLOS Medicine perspective

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