1. Mortality Information System
Fatima Marinho, MD, MPH, PhD
Health and Analysis (HSD/HA)
Pan American Health Organization (PAHO/WHO)

2. Topics
• Sources and data base
• Quality of death information in The Americas
% under-registration, % ill defined,
% garbage codes
• Distribution major causes of death
• Examples of data quality problems
• Challenges

3. Sources
• National Offices of Statistics
• Mexico, Ecuador, El Salvador, Peru
• Civil Registration offices
• Costa Rica, Argentina, Chile
• Ministry of Health
• Republica Dominicana, Brazil, Colombia

4. Main Variables/Annual data request to
the countries *
•Deaths: Individual data on each *Since 2009 this extensive set
death, with the following specifications: has been requested
•Sex
•Underlying cause of death Major civil division of
•Age (in hours for the first day, in days residence of the decedent
for the first month, in months for the •Certification of the cause (s)
first year, and complete years after one of death: physician or
nonmedical
year of age)
•Educational attainment of
•Other available causes decedent (instruction or
education level)
•Ethnicity of the decedent
•Place of occurrence of the
death (hospital, residence,
public thoroughfare, etc)
•Date of death

5. Seasonality of Respiratory Deaths

6. Why evaluate data quality?
• Accuracy of the information for policy
• Availability of the data doesn’t guarantee
quality
• The source per se is not a guarantee of
quality, for example, hospital statistics
• Poor quality of the data  poor decision 
lost of opportunity to identify problems and
intervention in order to improve the
population health

7. Challenges for using mortality
data
• Incomplete series of data registries
• Poor certification of cause of death
• Poor availability and opportunity of the data
• Poor use of the data
• Poor value of cause of death codification
• There is a tendency to codify the cause of death
according what is expected to be more frequent
• Late registration of death

8. Total defunciones
• En 2007 hubo un total de 5 736 164*
defunciones en los 32 países de la Región de
las Américas con datos para ese año (53,1%
hombres y 46,9% mujeres).
• La tasa de mortalidad ajustada por edad para la
población total fue 5,8 por 1 000 habitantes (7,1
por 1 000 en hombres y 4,7 por 1 000 en
mujeres).
*Dato corregido para subregistro
La mortalidad captada fue de 5 085 260
USA responde por mitad de las defunciones captadas

9. Timeliness
1950-2010
Bolivia
Haiti
Aruba
Number of countries in The Region with
Netherlands Antilles
Martinique
mortality data by cause, 1950-2010
Virgin Islands (USA)
50
Guadeloupe
French Guiana
Honduras
Grenada
Anguilla 45 CIE-7 CIE-8
Montserrat
Jamaica CIE-9 CIE-10
Guyana
Cayman Islands 40
Turks and Caicos Islands
Saint Vincent and
Bahamas
Brazil 35
British Virgin Islands
Peru
Nicaragua
Saint Lucia 30
Antigua and Barbuda
Argentina
Suriname
Bermuda 25
Belize
Cuba
Saint Kitts and Nevis
Paraguay 20
Dominican Republic
Dominica
Uruguay
Guatemala 15
El Salvador
Ecuador
Panama
Colombia
10
Venezuela
Puerto Rico
Barbados
Costa Rica
5
Trinidad and Tobago
Mexico
Chile
United States of America
Canada 0
1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010
0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 100.0
Percentage of years
Source: PAHO/WHO. Mortality Information System; Washington DC:2011

10. 45/48 Countries and
Under- registration % Territories in the
completeness Americas have a Vital
Statistics System working
Source: PAHO/WHO. Mortality Information System; Washington DC:2011

11. % ill-defined causes of death
Subregion
circa 2009
Source: PAHO/WHO. Mortality Information System; Washington DC:2011

12. % ill-defined
causes of death
by country
circa 2009
Source: PAHO/WHO. Mortality Information System; Washington DC:2011

13. % ill-defined causes of death
Selected countries, 2000-2009
25.0
20.0
Cuba
Estados Unidos de América
México
15.0
Colombia
Chile
Nicaragua
Panamá
10.0
Brasil
Paraguay
El Salvador
5.0
0.0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Source: PAHO/WHO. Mortality Information System; Washington DC:2011

14. % ill-defined causes
of death
Americas 2005-2009
2005 2006 2007 2008 2009
% % % % %
Other ill-defined and unspecified causes of 40.4 41.6 42.5 45.3 46.5
mortality (R99)
Unattended death (R98) 26.5 20.7 17.9 21.8 20.3
Senility (R54) 9.3 10.7 10.3 9.6 8.5
Other symptoms and signs involving the 8.2 7.1 7.1 6.9 7.6
circulatory and respiratory systems (R09)
Other sudden death, cause unknown 2.7 2.6 3.3 3.8 4.2
(R96)
Remainder 11.2 15.3 16.9 12.6 12.3
Number of deaths 196919 175695 179553 143577 137622
Source: PAHO/WHO. Mortality Information System; Washington DC:2011

15. % ill-defined causes
of death
Brazil 2005-2009
2005 2006 2007 2008 2009
% % % % %
Other ill-defined and unspecified causes of 35.9 41.6 42.0 44.1 43.8
mortality (R99)
Unattended death (R98) 46.1 38.2 35.1 34.9 33.1
Other symptoms and signs involving the 9.4 8.7 8.8 7.5 8.9
circulatory and respiratory systems (R09)
Senility (R54) 2.6 4.1 4.3 4.3 4.7
Other general symptoms and signs 1.7 3.3 3.7 3.3 3.3
(R68)
Remainder 2.2 3.3 3.5 3.5 3.6
Number of deaths 104455 85543 80244 79784 78994
Source: PAHO/WHO. Mortality Information System; Washington DC:2011

16. % ill-defined causes
of death
Cuba 2005-2009
2005 2006 2007 2008 2009
% % % % %
Other ill-defined and unspecified causes of 45.8 54.0 49.8 44.2 40.6
mortality (R99)
Senility (R54) 18.2 17.6 19.3 24.1 23.1
Other sudden death, cause unknown 19.2 15.2 14.2 13.5 16.8
(R96)
Unattended death (R98) 3.6 0.9 4.5 3.7 4.4
Other general symptoms and signs 4.6 4.7 3.9 3.5 3.0
(R68)
Remainder 6.4 4.7 4.7 5.9 8.1
Number of deaths 637 635 643 764 794
Source: PAHO/WHO. Mortality Information System; Washington DC:2011

17. % ill-defined causes
of death
Peru 2003-2007
2005 2006 2007 2008 2009
% % % % %
Other ill-defined and unspecified causes of 27.6 44.6 77.8 78.1 74.6
mortality (R99)
Senility (R54) 18.3 8.9 0.0 0.0 0.0
Other symptoms and signs involving the 11.4 19.5 0.0 0.0 0.0
circulatory and respiratory systems (R09)
Shock, not elsewhere classified (R57) 10.8 5.1 0.0 0.0 1.6
Unattended death (R98) 4.4 7.9 0.0 8.3 11.6
Remainder 27.5 14.0 22.2 13.7 12.2
Number of deaths 2149 1814 18 630 189
Source: PAHO/WHO. Mortality Information System; Washington DC:2011

18. % under-registration and % ill-defined causes
of death
Americas, 2007-2009
Nicaragua
Jamaica
Cayman Islands
Americas
Source: Health situation in the Americas – Basic Indicators 2011

19. Causes of death?
In the Second Annual Report of the Registrar General of Great Britain in 1840, William
Farr presented the statistics of causes of death (CoD), defined as:
“diseases, which terminate in the extinction of existence,” but Farr highlighted the
concern that “…the attention of the observer was less attracted to this class of
facts, and overlooking the proximate cause, that is, the internal morbid
process…”
In that report, he also criticized the use of vague categories like
“sudden death,”
“natural death,”
“visitation of God,” and
“old age,”
but he admitted that in some cases, no particular cause of death could be identified
All these criticisms remain relevant today

20. Underlying cause of death (ICD)
a) the disease or injury which initiated the train of morbid events
leading directly to death or
c) b) the circumstances of the accident or violence which
produced the fatal injury”
The most effective public health objective is to prevent the precipitating from
operating
From the stand point of prevention of death is necessary to break the chain of
events or to effect a cure at some point
Even with a physician-completed death certificate, assignment
of the underlying cause of death can be problematic

21. many deaths assigned to causes that
cannot or should not be considered
underlying causes of death
“often called garbage codes (GCs)”
In 1996, Murray and Lopez introduced the
term “garbage coding” for the practice
of assigning deaths to causes that are
not useful for public health analysis of
cause-of-death
data as part of the assessment of the Global
Burden of Disease (GBD)

22. Typology of Garbage Codes
Four categories were identified:
3.Causes that cannot or should not be considered as underlying causes of death
(Type 1)
chapter 18 of ICD-10 or R codes
essential primary hypertension and atherosclerosis.
causes that are described as the long-term sequelae of disease, such as
paraplegia and tetraplegia
2. Intermediate causes of death (Type 2):
heart failure, septicemia, peritonitis, osteomyelitis, or pulmonary embolism.
3. Immediate causes of death (Type 3):
final steps in a disease pathway leading to death.
disseminated intravascular coagulation or defibrination syndrome .
Cardiac arrest and respiratory failure
4. Unspecified causes (Type 4):
injuries are coded to unspecified factors or intent
Source: Algorithms for enhancing public health utility of national
causes of death data IHME

23. This typology has been developed
taking into consideration the
following:
•the likelihood that a condition can be an underlying
cause of death
•the need for codes that provide a location for
unspecified or ambiguous causes of death
•the need for codes that represent causes that are
not underlying but intermediate or final events in
the chain leading to death
Source: Algorithms for enhancing public health utility of national
causes of death data IHME

24. Garbage Codes
Subregion and country ARG
VGB
circa 2009 GTM
VCT
MSR
SLV
GRD
LCA
ABW
BRB
ATG
CYM
URY
DOM
PRI
ECU
AIA
GUY
PAN
PRY
BHS
TCA
NIC
BLZ
BRA
KNA
USA
VEN
BMU
MEX
JAM
TTO
SUR
CHL
COL
CRI
CUB
VIR
0.0% 5.0% 10.0% 15.0% 20.0% 25.0% 30.0% 35.0%
Source: PAHO/WHO. Mortality Information System; Washington DC:2011
Source: PAHO/WHO. Mortality Information System; Washington DC:2011 Source: Algorithms for enhancing public health utility of national
causes of death data IHME

25. • Intermediate causes
Causes %
are the most important gc
(60%)
Heart failure (I50) 19.0
Other sepsis (A41) 9.6
12%
23%
6% Essential (primary) hypertension 6.7
(I10)
Chronic kidney disease (N18) 6.0
Malignant neoplasm, without 5.7
specification of site (C80)
Exposure to unspecified factor 3.7
59%
(X59)
Type 1 Causes that cannot or should not be considered as ucd Unspecified kidney failure (N19) 3.5
Type 3 Immediate Pneumonitis due to solids and 3.1
Type 2 Intermediate liquids (J69)
Type 4 Unspecified causes
Other diseases of digestive 2.9
system (K92)
Cardiac arrest (I46) 2.7
Remainder 39.3
Source: PAHO/WHO. Mortality Information System; Washington DC:2011

26. Type 1 Causes that cannot % Type 2 Intermediate causes %
or should not be considered
as ucd
Heart failure (I50) 31.9
Essential (primary) 57.7
hypertension (I10) Other sepsis (A41) 16.1
Atherosclerosis (I70) 15.9 Chronic kidney disease (N18) 10.1
Cerebral palsy (G80) 5.3 Unspecified kidney failure 5.8
Hyperplasia of prostate (N40) 2.8 (N19)
Remainder 18.3 Remainder 36.1
Source: PAHO/WHO. Mortality Information System; Washington DC:2011

27. Type 3 Immediate causes % Type 4 Unspecified causes %
of death
Respiratory failure, not 50.1 Malignant neoplasm, without 24.9
elsewhere classified (J96) specification of site (C80)
Cardiac arrest (I46) 45.1 Exposure to unspecified factor 16.2
(X59)
Complications and ill-defined 12.8
Disseminated intravascular 2.8 descriptions of heart disease
coagulation [defibrination (I51)
syndrome] (D65)
Unspecified event, undetermined 6.9
intent (Y34)
Remainder 1.9
Remainder 39.3
Source: PAHO/WHO. Mortality Information System; Washington DC:2011

29. Cause of death and
Epidemiologic transition in the
Region

30. Transición Epidemiológica en EU
Estados Unidos
100.00%
90.00%
80.00%
70.00%
60.00%
50.00%
40.00%
30.00%
20.00%
10.00%
0.00%
50
52
54
58
60
64
66
68
70
72
74
76
78
80
82
84
86
88
90
92
94
96
98
00
02
04
56
62
19
19
19
19
19
19
19
19
19
19
19
19
20
20
19
19
19
19
19
19
19
19
19
19
19
19
19
20
Group I Communicable Group II Non communicable Group III Injuries Ill defined
Fuente: Sistema de inforamción de Mortaldiad HA/HSD/OPS

31. Transición Epidemiológica en Brasil
100
90
80
70
60
50
40
30
20
10
0
1930 1940 1950 1960 1970 1980 1990 2000 2009
Group I Communicable Group II No Communicable Group III Injuries Group IV Ill Defined
Fuente: Sistema de inforamción de Mortaldiad HA/HSD/OPS

32. Transición Epidemiológica en México
México
100.00%
90.00%
80.00%
70.00%
60.00%
50.00%
40.00%
30.00%
20.00%
10.00%
0.00%
59
67
83
85
91
99
07
55
57
61
63
65
69
71
73
75
77
79
81
87
89
93
95
97
01
03
05
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
20
20
19
19
19
19
20
20
Group I Communicable Group II Non communicable Group III Injuries Ill defined
Fuente: Sistema de inforamción de Mortaldiad HA/HSD/OPS

33. Transición Epidemiológica en Guatemala
Guatemala
100.00%
90.00%
80.00%
70.00%
60.00%
50.00%
40.00%
30.00%
20.00%
10.00%
0.00%
63
65
69
71
75
81
86
88
92
94
96
98
00
02
06
67
77
79
90
04
19
19
19
19
19
19
19
19
20
20
19
19
19
19
19
19
19
19
20
20
Group I Communicable Group II Non communicable Group III Injuries Ill defined
Fuente: Sistema de inforamción de Mortaldiad HA/HSD/OPS

34. The three leading causes of death in the Americas
Rango 1 2 3
Países Año
Argentina 2009 Enfermedades isquémicas Enfermedades
Influenza y neumonía del corazón cerebrovasculares
Belice 2008 Enfermedades isquémicas Eventos de intención no
Diabetes mellitus del corazón determinada
Brasil 2009 Enfermedades Enfermedades isquémicas
cerebrovasculares del corazón Influenza y neumonía
Canadá 2007 Neoplasia maligna de la
Enfermedades tráquea, de los bronquios Demencia y enfermedad
isquémicas del corazón y del pulmón de Alzheimer
Chile 2008 Enfermedades Enfermedades isquémicas Cirrosis y otras
cerebrovasculares del corazón enfermedades del hígado
Colombia 2008 Enfermedades Enfermedades
isquémicas del corazón Agresiones/homicidios cerebrovasculares
Costa Rica 2009 Enfermedades Enfermedades Enfermedades
isquémicas del corazón cerebrovasculares hipertensivas
Cuba Neoplasia maligna de la
Enfermedades Enfermedades tráquea, de los bronquios
2009 isquémicas del corazón cerebrovasculares y del pulmón
Ecuador 2009 Enfermedades
Diabetes mellitus cerebrovasculares Influenza y neumonía
El Salvador 2008 Enfermedades del sistema Enfermedades isquémicas
Agresiones/homicidios urinario del corazón
Estados 2007 Neoplasia maligna de la
Unidos de Enfermedades tráquea, de los bronquios Demencia y enfermedad
América isquémicas del corazón y del pulmón de Alzheimer
Guatemala 2008 Ciertas afecciones
originadas en el período
Influenza y neumonía Agresiones/homicidios perinatal
Enfermedades Enfermedades
Américas 2007 isquémicas del corazón cerebrovasculares Diabetes mellitus
Source: Mortality Information System - PAHO

35. The three leading cause of death in the Americas
Rango 1 2 3
Países Año
Guyana 2006 Enfermedades Enfermedades
isquémicas del corazón cerebrovasculares Diabetes mellitus
Islas del 2008
Caribe No- Enfermedades Enfermedades
Latino isquémicas del corazón cerebrovasculares Diabetes mellitus
México 2009 Enfermedades isquémicas Cirrosis y otras enfermedades del
Diabetes mellitus del corazón hígado
Nicaragua 2009 Enfermedades isquémicas Cirrosis y otras enfermedades del
Diabetes mellitus del corazón hígado
Panamá 2009 Enfermedades Enfermedades
isquémicas del corazón cerebrovasculares Diabetes mellitus
Paraguay 2009 Enfermedades Enfermedades isquémicas Ciertas afecciones originadas en el
cerebrovasculares del corazón período perinatal
Perú 2007 Enfermedades isquémicas
Influenza y neumonía del corazón Enfermedades cerebrovasculares
Puerto Rico 2007 Enfermedades Demencia y enfermedad de
isquémicas del corazón Diabetes mellitus Alzheimer
República 2004 Enfermedades Enfermedades Ciertas afecciones originadas en el
Dominicana isquémicas del corazón cerebrovasculares período perinatal
Suriname 2007 Enfermedades Enfermedades isquémicas
cerebrovasculares del corazón Diabetes mellitus
Territorios 2005 Enfermedades
franceses cerebrovasculares Diabetes mellitus Neoplasia maligna de la próstata
Trinidad y 2007 Enfermedades
Tobago isquémicas del corazón Diabetes mellitus Enfermedades cerebrovasculares
Uruguay 2004 Enfermedades Enfermedades isquémicas Neoplasia maligna de la tráquea,
cerebrovasculares del corazón de los bronquios y del pulmón
Venezuela 2007 Enfermedades Enfermedades
isquémicas del corazón cerebrovasculares Agresiones/homicidios
Enfermedades Enfermedades
Américas 2007 isquémicas del corazón cerebrovasculares Diabetes mellitus

36. Diabetes Mellitus
Americas, 2000-2009
100.00%
80.00%
60.00%
%
40.00%
20.00%
0.00%
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Insulin-dependent diabetes mellitus E10 Non-insulin-dependent diabetes mellitus E11
Malnutrition-related diabetes mellitus E12 Other specified diabetes mellitus E13
Unspecified diabetes mellitus E14
Source: PAHO/WHO. Mortality Information System; Washington DC:2011

37. Diabetes Mellitus
Brazil, 2000-2009
100.00%
80.00%
60.00%
%
40.00%
20.00%
0.00%
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Insulin-dependent diabetes mellitus E10 Non-insulin-dependent diabetes mellitus E11
Malnutrition-related diabetes mellitus E12 Other specified diabetes mellitus E13
Unspecified diabetes mellitus E14
Source: PAHO/WHO. Mortality Information System; Washington DC:2011

38. Diabetes Mellitus
Mexico, 2000-2009
100.00%
80.00%
60.00%
%
40.00%
20.00%
0.00%
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Insulin-dependent diabetes mellitus E10 Non-insulin-dependent diabetes mellitus E11
Malnutrition-related diabetes mellitus E12 Other specified diabetes mellitus E13
Unspecified diabetes mellitus E14
Source: PAHO/WHO. Mortality Information System; Washington DC:2011

39. Diabetes Mellitus
Cuba, 2000-2009
100.00%
80.00%
60.00%
%
40.00%
20.00%
0.00%
2001 2002 2003 2004 2005 2006 2007 2008 2009
Insulin-dependent diabetes mellitus E10 Non-insulin-dependent diabetes mellitus E11
Malnutrition-related diabetes mellitus E12 Unspecified diabetes mellitus E14
Source: PAHO/WHO. Mortality Information System; Washington DC:2011

40. Mortality total and due to
cardiovascular diseases
Belize, 2000-2007
Adjusted mortality rates due to CVD dropped 43.7% from 2000 to 2007, very higher than the
average of the Region. The CVD mortality trend for Belize wasn’t showed individually in the
Americas profile.
Source: PAHO/WHO. Mortality Information System; Washington DC:2011

41. Mortality due to cardiovascular diseases
by major group of causes
Limitations to compare Argentina mortality rates due to Ischaemic heart disease to other countries
Source: PAHO/WHO. Mortality Information System; Washington DC:2011

42. Mortality due to cardiovascular
diseases by major group of causes
Americas 43 22 9 12 14
Guatemala 42 22 29 52 10
Ecuador 27 44 37 26 17
Canada 57 21 3 7 19
Argentina 35 35 10 53 31
0% 20% 40% 60% 80% 100%
Ischaemic (I20-I25) Cerebrovascular (I60-I69)
Hypertensive (I10-I15) Cardiac Arrest (I46)+Heart faillure (I50)
Other
Source: PAHO/WHO. Mortality Information System; Washington DC:2011

43. Cardiovascular diseases mortality
Selected countries
Source: PAHO/WHO. Mortality Information System; Washington DC:2011

44. Diabetes mellitus mortality
Selected countries
Source: PAHO/WHO. Mortality Information System; Washington DC:2011

45. What do we need?
• Unify criteria for measuring quality (definitions, standards)
• Encourage the development and consolidation of a critical mass of
research on causes of death …..
Evaluation in The Region
• Policy focused on countries with major needs
• Promote the use of standards to improve the quality of information
• Use and dissemination of statistics locally corrected