Misclassification of Infant Deaths -- Alaska, 1990-1991

In June 1991, the Alaska Section of Vital Statistics reported that nine deaths of Alaskan Native infants occurred in seven villages in southwestern Alaska from January 1990 through June 1991. In comparison, seven Alaskan Native infant deaths occurred in these villages during 1986-1989. Two of the deaths during 1990-1991 had been attributed to acute viral myocarditis (International Classification of Diseases, Ninth Revision (ICD-9), code 422.9) and three to viral or unspecified pneumonitis (ICD-9 codes 480.9 and 486), while from 1985 through 1989, one infant death in these villages had been attributed to either of these causes. An examination of the clinical histories of these nine infants by the Alaska Division of Public Health (ADPH) suggested some of the diagnoses might be inaccurate. This report summarizes an investigation by the ADPH to assess the accuracy of the immediate cause of death recorded on the death certificates for the nine infants.

The nine infants who died ranged in age from 26 days to 8 months and were unrelated. Six had been found dead by caretakers, two died while receiving care at the regional hospital, and one had a respiratory arrest at a village clinic after presenting with cyanosis and periodic apnea. For eight of the infants, a pathologist determined cause of death after postmortem examination; no autopsy was performed on the ninth infant, and cause of death was determined by a physician familiar with the case history.

The ADPH formed an infant death review team consisting of a medical epidemiologist, pediatricians, a consulting pediatric pathologist, other physicians, and public health nurses who reviewed clinical records and pathologic specimens for each death. For two of the infants, there was no information about the scene of death and limited clinical information.

The review team offered a consensus cause of death for each infant. This was compared to the cause of death listed on the death certificate for each of the nine infants (Table 1). The review team reported that for the two infants with acute viral myocarditis listed as the cause of death on the death certificate, the cause was sudden infant death syndrome (SIDS) for one and unknown for the other (Table 1). Similarly, for two infants with pneumonitis listed as cause of death on the death certificate, the review team reported the cause as SIDS for one and unknown for the other. Overall, five deaths had been inappropriately attributed to myocarditis or pneumonitis and at least two were due to SIDS. Both deaths that had been attributed on the death certificates to SIDS were considered accurate by the review team (Table 1) (1).

Reported by: JP Middaugh, MD, State Epidemiologist, Alaska Dept of Health and Social Svcs. Div of Field Epidemiology, Epidemiology Program Office, CDC.

Editorial Note

Editorial Note: The findings of this investigation revealed that the cause of death listed on the death certificates for five of the nine infants was inaccurate. In particular, the underdiagnosis of SIDS indicated in this investigation suggests the possibility that the SIDS rate for Alaska (2.7 per 1000 live births) (2,3) -- approximately twice the overall rate for the United States (U.S. rate: 1.4 per 1000 live births (CDC, unpublished data, 1979-1988)) -- may be higher than previously considered.

A variety of determinants may influence the accuracy and quality of data derived from death certificates. These include 1) differences in the interpretation of the causes of death by those entering this information on death certificates (e.g., understanding definitions of underlying, intermediate, and immediate cause of death), 2) incomplete clinical and laboratory information available at the time death certificates are completed, 3) variations in coding the underlying cause of death, and 4) the level of training and experience of those determining cause of death (4,5). Misclassification of cause of death on death certificates may bias epidemiologic studies, misdirect prevention efforts and services, and prompt inappropriate action within the justice system.

Although reports have suggested that use of autopsy information will improve the accuracy of vital statistics data (4-7), findings from this investigation indicate that autopsies alone may not improve the accuracy of such data for infant deaths. The findings in this report suggest that infant death review teams may improve the accuracy of causes of death for infants (8). Since this investigation, the ADPH, in cooperation with the Alaska Area Native Health Service, plans to investigate and review all infant deaths that occur in Alaska. An infant death review committee similar to the one assembled to conduct this investigation in Alaska should be considered in other locales to periodically review infant deaths, including parental interviews and death scene investigations, to improve cause-of-death reporting for infants (8).

References

1. Willinger M, James LS, Catz C. Defining the sudden infant death syndrome (SIDS): deliberations of an expert panel convened by the National Institute of Child Health and Human Development. Pediatr Pathol 1991;11:677-84.

2. Adams MM. The descriptive epidemiology of sudden infant deaths among natives and whites in Alaska. Am J Epidemiol 1985;122:637-43.

3. Fleshman JK, Peterson DR. The sudden infant death syndrome among Alaska Natives. Am J Epidemiol 1977;105:555-8.

4. Ruzicka LT, Lopez AD. The use of cause-of-death statistics for health situation assessment: national and international experiences. World Health Stat Q 1990;43:249-58.

5. Kircher T. The autopsy and vital statistics. Hum Pathol 1990;21:166-73.

6. NCHS. Annotated bibliography of cause-of-death validation studies: 1958-1980 -- data evaluation and methods research. Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, CDC, 1982. (Vital and health statistics; series 2, no. 89).

7. Engel LW, Strauchen JA, Chiazze L, Heid M. Accuracy of death certification in an autopsied population with specific attention to malignant neoplasms and vascular diseases. Am J Epidemiol 1980;111:99-112.

8. Durfee MJ, Gellert GA, Tilton-Durfee D. Origins and clinical relevance of child death review teams. JAMA 1992;267:3172-5.

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