Trends in Causes of Adult Deaths among the Urban Poor: Evidence from Nairobi Urban Health and Demographic Surveillance System, 2003-2012.

What kills people around the world and how it varies from place to place and over time is critical in mapping the global burden of disease and therefore, a relevant public health question, especially in developing countries. While more than two thirds of deaths worldwide are in developing countries, little is known about the causes of death in these nations. In many instances, vital registration systems are nonexistent or at best rudimentary, and even when deaths are registered, data on the cause of death in particular local contexts, which is an important step toward improving context-specific public health, are lacking. In this paper, we examine the trends in the causes of death among the urban poor in two informal settlements in Nairobi by applying the InterVA-4 software to verbal autopsy data. We examine cause of death data from 2646 verbal autopsies of deaths that occurred in the Nairobi Urban Health and Demographic Surveillance System (NUHDSS) between 1 January 2003 and 31 December 2012 among residents aged 15 years and above. The data is entered into the InterVA-4 computer program, which assigns cause of death using probabilistic modeling. The results are presented as annualized trends from 2003 to 2012 and disaggregated by gender and age. Over the 10-year period, the three major causes of death are tuberculosis (TB), injuries, and HIV/AIDS, accounting for 26.9, 20.9, and 17.3% of all deaths, respectively. In 2003, HIV/AIDS was the highest cause of death followed by TB and then injuries. However, by 2012, TB and injuries had overtaken HIV/AIDS as the major causes of death. When this is examined by gender, HIV/AIDS was consistently higher for women than men across all the years generally by a ratio of 2 to 1. In terms of TB, it was more evenly distributed across the years for both males and females. We find that there is significant gender variation in deaths linked to injuries, with male deaths being higher than female deaths by a ratio of about 4 to 1. We also find a fifteen percentage point increase in the incidences of male deaths due to injuries between 2003 and 2012. For women, the corresponding deaths due to injuries remain fairly stable throughout the period. We find cardiovascular diseases as a significant cause of death over the period, with overall mortality increasing steadily from 1.6% in 2003 to 8.1% in 2012, and peaking at 13.7% in 2005 and at 12.0% in 2009. These deaths were consistently higher among women. We identified substantial variations in causes of death by age, with TB, HIV/AIDS, and CVD deaths lowest among younger residents and increasing with age, while injury-related deaths are highest among the youngest adults 15-19 and steadily declined with age. Also, deaths related to neoplasms and respiratory tract infections (RTIs) were prominent among older adults 50 years and above, especially since 2005. Emerging at this stage is evidence that HIV/AIDS, TB, injuries, and cardiovascular disease are linked to approximately 73% of all adult deaths among the urban poor in Nairobi slums of Korogocho and Viwandani in the last 10 years. While mortality related to HIV/AIDS is generally declining, we see an increasing proportion of deaths due to TB, injuries, and cardiovascular diseases. In sum, substantial epidemiological transition is ongoing in this local context, with deaths linked to communicable diseases declining from 66% in 2003 to 53% in 2012, while deaths due to noncommunicable causes experienced a four-fold increase from 5% in 2003 to 21.3% in 2012, together with another two-fold increase in deaths due to external causes (injuries) from 11% in 2003 to 22% in 2012. It is important to also underscore the gender dimensions of the epidemiological transition clearly visible in the mix. Finally, the elevated levels of disadvantage of slum dwellers in our analysis relative to other population subgroups in Kenya continue to demonstrate appreciable deterioration of key urban health and social indicators, highlighting the need for a deliberate strategic focus on the health needs of the urban poor in policy and program efforts toward achieving international goals and national health and development targets.