Tekebash Araya, BSc.N., MPH Lecturer, AAU Manager, AAMSP

1. The 2nd Global HIV/AIDS Surveillance Meeting New Strategies in HIV Surveillance in Resource-Constrained Settings II: A Global HIV Surveillance Forum Bangkok, Thailand March 2-5, 2009 Mortality Surveillance in Ethiopia: Experience from Burial Surveillance in Addis Abababy the Addis Ababa Mortality Surveillance Program (AAMSP) Tekebash Araya, BSc.N., MPH Lecturer, AAU Manager, AAMSP

2. Outline of presentation • Introduction: an overview of AAMSP • Objectives • Methodology • Results • Recommendation • Acknowledgments

3. Ethiopia Haiti Vietnam Nigeria Ethiopia Guyana Cote d'Ivoire Uganda Kenya Rwanda Tanzania Zambia Namibia Botswana Mozambique South Africa

4. Introduction • Assessing HIV/AIDS mortality is important to develop programs to mitigate the effect of the HIV/AIDS epidemic in Ethiopia. • Cremation is not practiced in Ethiopia • Hospital deaths < 20 % • Prospective surveillance of burials established in Addis Ababa (AA) in 2001 to describe: • Overall magnitude of deaths • HIV- related deaths • Specific causes of deaths, • With the expansion of ART (since 2005), evaluates the impact of ART on mortality.

5. Objectives of AAMSP • Monitor the population level impact of HIV/AIDS on mortality in AA. • Evaluate the population level impact of ART on mortality in AA. • Provide an observatory information for other important causes of death as well (e.g., TB and STI; emerging diseases like diabetes mellitus, cardiovascular disorders, carcinomas; external injuries, etc).

6. Methods • Four components in AAMSP: • Burial Surveillance: • Retrospective assessment of five burial sites (three months before initiating the prospective BS); • Prospective burial surveillance at all burial sites within the AA city limit; • Verbal autopsies on sample of BS data (2001, 2003/2004, & 2007on continuous basis): • 1200 VA were administered since 2007; • Three round VA’s are reviewed by physicians & is on-ongoing; • Hospital surveillance: • Retrospective and prospective for validation study • “Iddir” surveillance: On establishment • Retrospective and prospective surveillance on a sample of 100 “idirs” for evaluating the completeness of death registration. >“Iddir” is a social indigenous organization with the main objective of assisting family members of the deceased before and after the funeral ceremony. • Ethical clearance: Faculty of Medicine, Addis Ababa University; Ethiopian Science and Technology Agency (ESTA) & renewed at yearly basis; and CDC.

7. Burial Sites in Addis Ababa

8. Field Work: Burial Surveillance at all cemeteries (N=88, with average 20,000 burials/yr) (Data Collectors, supervisors and field coordinator) Office Work: Data Entry Data Cleaning 10% Sample Drawing for verbal autopsy (VA) VA activities: Field (HH) coordination VA Interviews Physician VA Q. reviews VA data entry & cleaning Hospital Surveillance: (Death records /death certificates – registry match) Operational Structure of the Addis Ababa Mortality Surveillance Program (AAMSP) Scientific Reports (Cause of death analysis, Validity study)

9. Selected Questions on VA • Socio-demographic characteristics • All signs and symptoms- related to HIV/AIDS & other diseases • Health care seeking behavior/status • ART and related-treatment • Prescription medicines • Terminal-illness care provider relationship • Location and date of death • Death certificate if available • Date and place of burial • Etc.

10. Result (1) Before ART After ART

11. Result (2) Before ART After ART

12. Future directions • Increase completeness of death surveillance: • Iddir surveillance in AA, • Pilot burial surveillance outside of AA, because of body repatriation • Evaluate feasibility of scaling up of burial surveillance to national level

13. Conclusion • AAMSP monitors the population level impact of HIV/AIDS and ART via analyses of age- and sex- specific trends in AIDS mortality. • It will be instrumental in informing public health policy strategies for the provision of ART and outreach programs. • The potential public health value of the burial surveillance extends beyond monitoring the AIDS epidemic. It can serve as an observatory for surveillance of other important causes of death as well (e.g., emerging infectious diseases, diabetes mellitus, cardiovascular disorders, external injuries, etc).

14. Staff of AAMSP (partially)

16. Acknowledgments • CDC • EPHA • WHO • EHNRI/ENARP • School of Nursing, Department of Community Health (now SPH), & FOM of AAU. • Population Studies Center of the University of Pennsylvania. • Religious leaders and the Addis Ababa Labor and Social Affairs Bureau (now S, B & P Agency) facilitated our access to the burial sites. • Addis Ababa community for its participation in the BS and VA interviews.

17. Published papers • F. Tekolla, G. Reniers, T. Araya, D. Haile Mariam, G. Davey. The economic impact of HIV/AIDS morbidity and mortality on households in Addis Ababa, Ethiopia, AIDS Care 2008; 20 (8):995-1001. • Reniers G, Araya T, Sanders EJ; Life table estimates of adult HIV/AIDS mortality in Addis Ababa (2005), Ethiop.J.Health Dev. 2006; 20 (1): 3-9. • Reniers G, Araya T, Schaap A, Kumie A, Kebede D, Nagelkerke N, Coutinho R, Sanders EJ; Monitoring cause specific adult mortality in developing countries. A comparison of different data sources for Addis Ababa and their implications for policy and research. Social Science and Medicine (2005), 61: 1952-1957. • Araya T, Schaap A, Kebede D, Kumie A, Nagelkerke N, Coutinho R, Sanders EJ; Lay Diagnoses of causes of death for monitoring AIDS mortality in Addis Ababa, Ethiopia. Tropical Medicine and International Health. January 2004, 9:177-186. • Sanders EJ, Araya T, Schaap A, Kebede D, Kumie A, Nagelkerke N, Coutinho R; Mortality impact of AIDS in Addis Ababa, Ethiopia. AIDS, 2003, 17:1209-1216.

18. Thank you!