Pattern of all-causes and cause-specific mortality in an area with progressively declining malaria burden in Korogwe district, north-eastern Tanzania

All-cause and cause-specific mortality data are useful for estimating the burden of disease as well as planning, monitoring and assessing effectiveness of different health interventions [1]. In order to generate such data, well-established, consistent, systematic, and active vital registration systems are needed [2]. Such systems are limited in most developing countries especially in sub-Saharan Africa (SSA) [3]. Unfortunately, in these countries, about 80% of deaths occur outside health facilities [4] and even the few deaths which occur at health facilities are usually not recorded or the records are inconsistent and unreliable [5]. To complement that, some of these countries adopted and introduced a health and demographic surveillance system (HDSS) which is routinely conducted at specific sites as the platform for generating supportive vital events, including mortality data [6]. Verbal autopsy (VA) method is applied to determine cause-specific mortality within these HDSS sites [7].

The VA is a tool for determining cause-specific mortality, based on responses collected from families and/or caregivers of the deceased from a series of structured questions on the signs and symptoms experienced by the deceased, and their duration [8]. This approach has increasingly become a useful alternative method for estimating cause-specific mortality in areas without vital registration systems [9], despite some technical limitations such as recall bias, questionnaire design, choice of interviewers and respondents, and mechanism for establishing causes of death [10]. The method has been extensively validated and adopted for estimating cause-specific mortality under different settings [11]. It has proved to be useful in estimating all causes, cause-specific as well as seasonal mortality in studies conducted under HDSS [12] and elsewhere [13].

In the majority of SSA countries most deaths in children aged 1–15 years are commonly associated with preventable communicable diseases, with malaria being the leading cause [14]. Other main causes of death in children include diarrhoea and acute respiratory tract infections [15]. For young adults (15–45 years), majority of deaths are due to HIV/AIDS, tuberculosis and malaria [12, 16, 17]. Also, there is a rising epidemic of non-communicable diseases (NCDs) in SSA, particularly chronic conditions such as cardiovascular diseases, diabetes, respiratory diseases and cancers, which contribute about 25% of all deaths [18]. Recent reports have indicated that the number of deaths in Tanzania caused by NCDs and injuries has been increasing, particularly in urban areas [19].

Reducing the burden of disease in developing countries is considered to be one of the most important global tasks, which will reduce poverty and improve general health of communities. Different interventions have been developed to reduce morbidity and mortality attributable to preventable diseases and other causes [20, 21]. However, monitoring such interventions particularly in poor communities is always limited by lack of reliable data to track the trend of morbidity and mortality and thus the impacts of such interventions. Recent studies have shown a dramatic decline of malaria burden in Tanzania and possibly malaria-related mortality due to enhanced malaria control over the past decade [22, 23]. Korogwe district has also experienced a decline of malaria transmission from 78.4% in 2003 in high transmission area [24] to 4.6% between 2011 and 2013 [25]. This has resulted in decrease in the number of patients attending health facilities [26‐28]. However, the impact of recent changes in malaria epidemiology on mortality attributable to malaria has received little attention. This study was conducted to determine the pattern of all-cause and cause-specific mortality in an area that has been developed for different malaria interventions [29].

This study assessed and summarized the trends and patterns of all-cause and cause-specific mortality in Korogwe HDSS. Few studies in Tanzania have been conducted to investigate cause-specific mortality with respect to different malaria transmission intensity and also document changes in malaria deaths, particularly following a progressive decline of malaria burden in recent years [36]. Over the 7-year period, the study observed significant number of deaths and cause-specific mortality. Overall, mortality rates in the area were lower compared to those previously reported in other parts of Tanzania [37, 38] and sub-Saharan Africa [39‐42]. The main reasons for declining trends in mortality, apart from the decline in malaria burden, could include socio-economic development, improved health services, such as the establishment of primary health care, provision of preventive services and immunization.

This study showed that the majority of deaths, even those involving infants and under-fives, occurred at home, which might be due to poor utilization of available health facilities in the study area. However the proportion of deaths which occurred out of health facilities in this site was lower (by approximately 10%) compared to the proportion previously reported in Nairobi HDSS, Kenya [4]. Similarly, a majority of deaths had occurred at home, as shown by other studies conducted in Muheza district (72.4%) [43] and in Kenya (87.0%) [17]. All villages involved in this study either have a dispensary or are within 5 km of the nearest health facility. The reason for failure of community members to utilize health services provided by these facilities, even in the terminal stages of a deceased’s illness, is not clearly known. However, other studies observed that place of residence, either urban or rural, contributed to home deaths [44].

The increase in all-cause mortality trends (overall and in under-fives mortality) and malaria-specific mortality between 2006 and 2007 could probably be due to abnormal and prolonged short rains towards the end of 2006. Previous malaria incidence studies conducted in the study area [26] showed an increase in malaria incidence during the same period as a result of high rainfall in 2006. This suggests that overall trends of mortality were highly correlated to malaria-specific mortality and the general level of malaria transmission in the area. Although this might need to be further assessed, the high correlation of malaria morbidity with the general trend of mortality in Korogwe indicates that a continued decline of malaria transmission will most likely lead to a significant decline of mortality in the population. According to WHO, the reduction of malaria mortality rates among under-fives in Africa has led to a rise in life expectancy at birth for 12% from 50.6 years in 2000 to 60 years in 2015 [23]. Another study showed that a decline in malaria incidence occurred together with that in invasive bacterial infections [45] and this could possibly account for the decline of all-cause mortality that occurred concurrently with malaria-specific deaths.

Although overall mortality rates showed a slight decline, the rates were higher among males compared to females. The difference in mortality among males and females has been described elsewhere as a mixture of biological difference, behavioural factors, such as more smoking in males and socio-economic roles whereby males tend to be employed in more dangerous, harmful, stressful, or difficult occupations than females [46, 47]. Vulnerability of non-immune individuals, including infants, to infectious diseases might be the reason for sustained high mortality in infants compared to under-fives. However, reasons for persistently high mortality among infants are not clearly known. Since mortality data are an important indicator of performance and quality of health services in a given country/region, more studies are needed to determine the reasons for the persistently high rate of deaths among infants.

Communicable diseases were responsible for the majority of deaths, whereby malaria was the leading cause in all age groups except for individuals aged 15–49 years. Findings from other sites in SSA with high malaria transmission intensity have reported high malaria mortality among infants and children up to 15 years of age and a significant contribution to adult deaths [13, 16, 24, 48]. Another main cause of both infant and under-fives mortality was pneumonia while sepsis contributed almost 10% of infant deaths, as observed in other sites [49]. However, different patterns have been reported in western African sites where diarrhoea and upper respiratory infections were among the main causes of mortality in children and other age groups [16, 50]. This study showed that HIV/AIDS caused a larger proportion of deaths among adults aged 15–59 years and this is consistent with findings reported from other sites in SSA [17, 51, 52]. Tuberculosis was also one of the main causes of deaths in adults above 15 years and this can be linked to its co-morbidity with HIV/AIDS [12, 53]. Unlike previous reports from other areas in SSA [12, 17], NCDs (stroke, hypertension, cancer, cardiac failure) caused more than one-third of all deaths in elderly (≥ 60 years old). This may indicate an increase in NCD-related mortality in rural and semi-urban villages, which is in line with that previously reported in urban and prosperous rural communities in Tanzania [54]. Further surveillance will be required to track the pattern and trends of NCD morbidity and mortality in order to devise and implement appropriate control interventions, particularly with the current pattern of declining burden of malaria and other infectious diseases.

Previous malaria epidemiological studies, both community and hospital based in Korogwe showed a decrease of malaria transmission in the area [24, 55‐57]. Entomological studies has also reported decline of populations of malaria vectors, which may have resulted into low malaria infection and hence the decline in malaria burden and deaths [58]. In general, the results showed the decrease in malaria mortality in the study area from 2006 to 2012, a similar pattern as reported in other areas of Tanzania [59] as well as other malaria-endemic areas [60].

Data generated using VA are usually faced with inherent limitations associated with methods that include recall bias, questionnaire design, choice of interviewers and respondents, and mechanism for establishing causes of death. However, the study managed to reduce the recall bias by conducting VA assessment within 2 weeks after death. The INDEPTH VA questionnaire was used to collect information on the possible causes of death to ensure that it captured standardized information which is commonly required for this type of analysis. A trained fieldworker collected the data by conducting interviews according to standard operating procedures and hence reduced the choice of interviewers’ variability and respondents’ limitations. Two physicians assessed the VA questionnaires to establish the causes of death and a third physician helped to resolve any discordant assignment, and this helped to minimize and reduce the chances of wrong assignment of causes of death. Despite these limitations, the data presents important information on the trends of deaths, cause-specific mortality and trends of malaria deaths in Korogwe HDSS. The interpretation and generalization of the findings might be limited to this site.

This study showed a significant decline of deaths in the Korogwe HDSS site and malaria was the main cause of death in all ages except individuals aged 15–59 years, with a declining trend over the study period. Most of the adult deaths (among those aged 15–59 years) were mainly caused by HIV/AIDS, while malaria and NCDs (stroke, hypertension, cancer, cardiac failure) caused the majority of deaths in elderly (aged 60 years and above). Although control interventions aiming at reducing the burden of communicable diseases in the study area need to be sustained, specific interventions targeting NCDs among adults and elderly are also urgently required.