title: Patterns and risk factors for deaths from external causes in rural Malawi over 10 years: a prospective population-based study.
abstract: BACKGROUND
  Little is known about the pattern or risk factors for deaths from external causes in sub-Saharan Africa: there is a lack of reliable data, and public health priorities have been focussed on other causes. This study assessed the prevalence and risk factor for deaths from external causes in rural Malawi.
  
  
  METHODS
  We analysed data from 2002-2012 from the Karonga demographic surveillance site which covers ~35,000 people in rural northern Malawi. Verbal autopsies with clinician coding are used to assign cause of death. Repeated annual surveys capture data on socio-economic factors. Using Poisson regression models we calculated age, sex and cause-specific rates and rate ratios of external deaths. We used a nested case-control study, matched on age, sex and time period, to investigate risk factors for these deaths, using conditional logistic regression.
  
  
  RESULTS
  In 315,580 person years at risk (pyar) there were 2673 deaths, including 143 from external causes. The mortality rate from external causes was 47.1/100,000 pyar (95 % CI 32.5-68.2) among under-fives; 20.1/100,000 pyar (95 % CI 13.1-32.2) among 5-14 year olds; 46.3/100,000 pyar (95 % CI 35.8-59.9) among 15-44 year olds; and 98.7/100,000 pyar (95 % CI 71.8-135.7) among those aged ≥45 years. Drowning (including four deaths in people with epilepsy), road injury and suicide were the leading external causes. Adult males had the highest rates (100.7/100,000 pyar), compared to 21.8/100,000pyar in adult females, and the rate continued to increase with increasing age in men. Alcohol contributed to 21 deaths, all in adult males. Children had high rates of drowning (9.2/100,000 pyar, 95 % CI 5.5-15.6) but low rates of road injury (2.6/100,000 pyar, 95 % CI 1.0-7.0). Among 5-14 year olds, attending school was associated with fewer deaths from external causes than among those who had never attended school (adjusted OR 0.15, 95 % CI 0.08-0.81). Fishermen had increased risks of death from drowning and suicide compared to farmers.
  
  
  CONCLUSIONS
  In this population the rate of deaths from external causes was lowest at age 5-14 years. Adult males had the highest rate of death from external causes, 5 times the rate in adult females. Drowning, road injury and suicide were the leading causes of death; alcohol consumption contributed to more than one quarter of the deaths in men
  
  
  CONCLUSIONS
  The high proportion of alcohol-related deaths in men, the predominance of drowning, deaths linked to uncontrolled epilepsy, and the possible protective effect of school attendance suggest areas for intervention.
authors.affiliation: Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, Keppel St, London, WC1E 7HT, UK. jdsteady@yahoo.co.uk.|Malawi National Cancer Registry, Blantyre, Malawi. jdsteady@yahoo.co.uk.
authors.forename: Steady
authors.initials: S
authors.lastname: Chasimpha
authors.affiliation: Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, Keppel St, London, WC1E 7HT, UK. Estelle.mclean@lshtm.ac.uk.
authors.forename: Estelle
authors.initials: E
authors.lastname: McLean
authors.affiliation: Karonga Prevention Study, Chilumba, Malawi. menard.chihana@kpsmw.org.
authors.forename: Menard
authors.initials: M
authors.lastname: Chihana
authors.affiliation: Karonga Prevention Study, Chilumba, Malawi. lackkachiwanda@gmail.com.
authors.forename: Lackson
authors.initials: L
authors.lastname: Kachiwanda
authors.affiliation: Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, Keppel St, London, WC1E 7HT, UK. Olivier.koole@lshtm.ac.uk.
authors.forename: Olivier
authors.initials: O
authors.lastname: Koole
authors.affiliation: Karonga Prevention Study, Chilumba, Malawi. ttafatatha@yahoo.com.
authors.forename: Terence
authors.initials: T
authors.lastname: Tafatatha
authors.affiliation: Karonga Prevention Study, Chilumba, Malawi. hazzie.mvula@kpsmw.org.
authors.forename: Hazzie
authors.initials: H
authors.lastname: Mvula
authors.affiliation: Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, Keppel St, London, WC1E 7HT, UK. moffat.nyirenda@lshtm.ac.uk.
authors.forename: Moffat
authors.initials: M
authors.lastname: Nyirenda
authors.affiliation: Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, Keppel St, London, WC1E 7HT, UK. mia.crampin@lshtm.ac.uk.|Karonga Prevention Study, Chilumba, Malawi. mia.crampin@lshtm.ac.uk.
authors.forename: Amelia C
authors.initials: AC
authors.lastname: Crampin
authors.affiliation: Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, Keppel St, London, WC1E 7HT, UK. judith.glynn@lshtm.ac.uk.
authors.forename: Judith R
authors.initials: JR
authors.lastname: Glynn
mesh_terms: D000328:Adult; D000367:Age Factors; D001344:Autopsy; D002423:Cause of Death / Q000639:trends*; D002648:Child; D004332:Drowning / Q000401:mortality; D005260:Female; D006801:Humans; D008295:Malawi / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D015995:Prevalence; D011446:Prospective Studies; D012307:Risk Factors; D012424:Rural Population / Q000706:statistics & numerical data*; D012737:Sex Factors; D013405:Suicide / Q000706:statistics & numerical data; D016019:Survival Analysis; D014947:Wounds and Injuries / Q000401:mortality*