What is verbal autopsy?
Verbal autopsy (VA) is a method used to determine the cause of death through interviews with the deceased person's next of kin or caregivers. These interviews involve a standardized questionnaire to gather details on symptoms, medical history, and the circumstances leading to death. Healthcare professionals or algorithms then analyze this information to identify the likely cause of death.
The primary goal of verbal autopsy is to describe the causes of death at the community level or population level in areas where there is no medical certification of deaths or it is not yet well-established. <p> Verbal autopsy serves as a valuable tool for countries to obtain the information needed on non-medically certified community deaths to strengthen civil registration and vital statistics (CRVS) systems and provide critical health data for evidence-based health policies and plans.
Verbal autopsy instrument 2022
The WHO verbal autopsy instrument is designed for electronic data collection capturing all age groups, including maternal and perinatal deaths, and also deaths caused by injuries. The 2022 WHO verbal autopsy (VA) instrument, suitable for routine use, is built upon the 2016 instrument version, incorporating findings from systematic reviews, expert consultations, and extensive field feedback from its use. Compared to the 2016 instrument, the number of questions has been reduced and the interview process has been simplified.
Supporting materials for the 2022 WHO verbal autopsy instrument
The WHO verbal autopsy training package offers a comprehensive set of resources designed to ensure training of interviewers and of supervisors/master trainers for standardized and effective data collection procedures. It includes the following key components:
- Verbal autopsy standards manual – provides background information on the application and implementation of the 2022 instrument, including how to adapt the standard questionnaire for local use. It also features the WHO target list of causes of death for verbal autopsy with correspondence to ICD-10 and ICD-11 codes.
- Training manuals - guidance for the trainers on class work, smartphone/tablet computer exercises and role-play training cases as well as field practice.
- Accompanying powerpoint slides for each session as a training delivery method for participants. The training slides are not a substitute for the training manuals, where guidance and instructions for the trainers can be found (including aspects for local adaptation).
- Training curriculums offer an overview of included training content, learning objectives and teaching methods used.
- Verbal autopsy field interviewer manual - describes the questions and possible responses to each question in detail. This manual should be provided to both trainers and all trainees.
- Demo/Training ODK Central server allows access to the WHO verbal autopsy instrument for demonstration and training purposes. By registering to the server, the user will be able to download the 2022 or 2016 instrument on tablets devices, test the instrument and send data to the server with the possibility of reviewing the data submitted. This will demo/training ODK central server will allow testing the full process of the verbal autopsy system, evaluating it and as well training fieldworkers on its use.
- Sample paper versions of the 2022 WHO verbal autopsy allows interviewers and data managers to become familiarised with the sequence and flow of the verbal autopsy instrument. These are not intended for data collection, the 2022 WHO verbal autopsy instrument information should be collected electronically.
- ODK verbal autopsy quick guide provides guidance on how to ensure that all necessary IT arrangements are in place before commencing the verbal autopsy implementation.
- Lastly, the verified translations for the verbal autopsy (VA) instrument soon to be available for Arabic, French, Portuguese, Spanish and Swahili.
Collectively, these resources play a crucial role in maintaining high-quality data collection and analysis in verbal autopsy methods.
27 July 2023
Supporting slides for verbal autopsy interviewers' training
27 July 2023
Supporting slides for verbal autopsy master trainers/supervisors' training
27 July 2023
2022 WHO verbal autopsy manual and training curriculum for supervisors
4 April 2022
Paper forms of 2022 WHO verbal autopsy instrument
Reporting of issues & inquiries with the WHO verbal autopsy instrument
To support the maintenance and update process of the WHO verbal autopsy standards and optimize the field experience for interviewers and respondents, it is important that users report issues encountered with the application of the verbal autopsy instrument.
Issues with the instrument should be submitted to the Public GitHub platform of the WHO verbal autopsy instrument— https://github.com/SwissTPH/WHO-VA/issues – which contains a list of submitted issues and related feedback. To report an issue via the Public GitHub platform, please send an email to who.va.issues@swisstph.ch.
To submit other input or inquiries, including issues involving private and confidential information, translations of the WHO verbal autopsy instrument, and other verbal autopsy implementation support materials, please email WHO directly at verbalautopsy@who.int.
Other versions of the WHO verbal autopsy instrument
The 2016 WHO verbal autopsy instrument
The 2016 WHO verbal autopsy (VA) instrument is fully compatible with publicly available analytical software for assigning the cause of death (SmartVA, InterVA, InSilicoVA). A conversion algorithm transforms the output of the WHO VA 2016 questionnaire in files that can be processed by SmartVA, InterVA, and InSilicoVA.
WHOVA2016 Implementation support pack (Guides for interviewers, trainers and planners)
Unofficial translations of the 2022 and 2016 verbal autopsy instrument, as well as supporting materials, have been shared by users and are available upon request. Please contact the verbal autopsy email address. Users are also encouraged to send any translations of WHO verbal autopsy materials to the same email address.
Contact email: verbalautopsy@who.int.
Use of verbal autopsy in the identification of COVID-19 deaths
Verbal autopsy can fill a critical gap in measuring the mortality from COVID-19 for deaths which occur outside of a healthcare setting.
A set of questions to identify COVID-19 deaths has been included in version 1.5.3 of the electronic (ODK) 2016 WHO verbal autopsy instrument. The questions have been added to the WHO verbal autopsy questionnaire upon request by countries and to standardize and align questions proposed by different initiatives with the WHO definition of death due to COVID-19, the underlying case definition for surveillance of COVID-19, including questions for rapid mortality surveillance purposes.
A brief technical note has been added to the WHO verbal autopsy standards manual that offers guidance for the use of verbal autopsy to identify COVID-19 deaths. Specific information on each of the new questions can be found in the updated sections of the question by question instructions (Appendices A-C) of the verbal autopsy field interviewer Manual for the 2016 WHO verbal autopsy Instrument.
The WHO Verbal Autopsy Reference Group (VARG)
A WHO verbal autopsy working group was established at the first meeting of the WHO reference group on global health statistics ( RGHS), 9–10 December 2013. The working group was then reorganized as a WHO verbal autopsy reference group (VARG). The VARG supports and advises WHO regarding:
- Development and maintenance of WHO verbal autopsy standards and respective verbal autopsy instrument with evidence from the field;
- Standards and recommendations for verbal autopsy training and implementation;
- Advancement of methods and tools for assigning causes of death from verbal autopsy interviews;
- Use of the causes of death data determined by verbal autopsy;
- Use of the verbal autopsy causes of death data as a complement to medically certified cause of death data;
- Quality assessment and assurance of verbal autopsy data;
- Methods for comparing and evaluating verbal autopsy results, including causes of death distribution estimated by different verbal autopsy instruments.
Cause of Death Assignment
openVA
- Purpose: openVA is a software that runs automated VA coding algorithms and is available as a package for the R statistical software. The primary motivation is to help users compare results across different algorithms using a single tool. The software is freely available and open source, so users have access to the code and can see exactly how the program works.
- Components: The available algorithms include InSilicoVA, InterVA4, InterVA5, and Naïve Bayes Classifier, and Tariff. Tariff2 will be available in the near future.
- Open VA URL
- GitHub URL
- R CRAN URL
openVA pipeline
- Purpose: The openVA pipeline is an open source software that automates the processing of VA data by downloading records, assigning a cause of death, and posting the results to a DHIS-2 server. Data and results are also stored locally on the computer in an encrypted SQLite database, referred to as the transfer database. The openVA pipeline can be set to run automatically and is particularly useful when a large amount of data is being collected on a continual basis.
- Data flow: The openVA pipeline performs 3 general tasks: (1) downloads new records from an ODK Aggregate server; (2) runs openVA to assign causes of death with an algorithm specified by the user; and (3) uploads the VA data with assigned causes and metadata to a DHIS server that has the VA module
- Software implementation: The openVA pipeline is written in the Python programming language and depends on several other programming languages and tools, including: ODK Briefcase, R, Java, and SQLite.
- GitHub URL
- Python Package Index (PyPI) URL
- Documentation URL
Algorithms for assigning causes of death to verbal autopsy data
The algorithms offer an opportunity of identifying the cause of death from the responses of the interview. It is know that all the current algorithms have strengths and weaknesses, depending on the setting and the target cause. At present there is no assessment existing that would allow to give preference to any algorithm.
The list below refers to algorithms that are maintained by different groups. Some algorithms disclose software algorithms and statistical weights, others don't. The list below does not imply any recommendation for any particular algorithm.
- The InterVA algorithms combine the reported symptoms with probabilities (produced by medical experts) of how likely the observed symptoms are if a particular cause is responsible for the death. The cause with the greatest propensity (above a given threshold) is assigned to the death – if none of the propensities exceed the threshold, then the death has an “indeterminate” cause. The distribution of deaths across the data serves as an estimate of the cause-specific mortality fraction (CSMF), or the percent of all deaths that are due to each cause.
- InSilicoVA algorithm combines both the presence and absence of each symptom with probabilities of how likely it is to observe each symptom if a particular cause is responsible for the death. This algorithm also includes a statistical model for the CSMF, which is linked to the causes assigned to each individual in the data to ensure the two estimates are consistent. InSilicoVA also provides estimates of uncertainty for all of the outputs, e.g., individual cause assignments and the CSMF.
- The Naïve Bayes Classifier algorithm combines both the presence and absence of each symptoms (similar to InSilicoVA), but uses the distribution of assigned causes in the data to estimate the CSMF (similar to InterVA).
- The Tariff algorithm starts by calculating tariffs that measure how informative each symptom is for each cause using the symptom-cause patterns observed in the PHMRC gold standard VA validation study dataset. Tariffs are then summed across all positive responses, and the cause with the highest ranked Tariff Score is assigned to the death. The distribution of deaths across the data is used to estimate the CSMF.
- Tariff2 is implemented in the SmartVA Analyze software and implements the Tariff algorithm with several modifications: (1) tariffs that are less reliable are removed; (2) the preparation of data from the open-ended narratives is standardized and the associated tariffs are validated by physician review; (3) implausible causes and unlikely symptom-cause associations in the PHMRC gold standard validation study dataset were adjusted or removed; and (4) deaths (in the PHMRC dataset) that lack enough information for assigning a cause of death are removed.
Implementation Support
- openVA Pipeline
- Integrating community-based verbal autopsy into civil registration and vital statistics (CRVS): system-level considerations
Don de Savigny, Ian Riley, Daniel Chandramohan, Frank Odhiambo, Erin Nichols, Sam Notzon, Carla AbouZahr, Raj Mitra, Daniel Cobos Muñoz, Sonja Firth, Nicolas Maire, Osman Sankoh, Gay Bronson, Philip Setel, Peter Byass, Robert Jakob, Ties Boerma & Alan D. Lopez. (2017) Global Health Action, 10:1, DOI: 10.1080/16549716.2017.1272882
- VA Costing and Budgeting Tool
The VA costing tool will help you estimate the resources required to implement VA as part of the routine CRVS system. It is a Microsoft Excel file that will guide the team during the data collection or analysis. It provides the total financial and economic cost of implementation as well as unit cost (e.g. cost per VA) relevant for policy making.
It is a flexible tool that can be adapted to different implementation scenarios. It also has a modelling function to project cost over time according to user specified assumptions. For more information contact daniel.cobos@swisstph.ch.
- VA Sample Size Calculator
The purpose of this package is to assist countries with scale up and rollout planning for the application of verbal autopsy (VA) as a function of a national Civil Registration and Vital Statistics (CRVS) system. Users will include those tasked with designing and managing the national CRVS VA system, supported by a governing body such as a National Mortality Committee of the National CRVS Committee.
In addition to discussing strategies and principles, this guidance package proposes approaches to conventional cluster sampling methods and provides the statistical rationale, logic, mathematical formulations, and a worked example, for: i) calculating the required number of clusters needed in a VA cluster sample design; and ii) drawing the needed clusters from a national sampling frame. The "package"consists of two items: The Guidance Document, and the Calculator Tool. For more information contact daniel.cobos@swisstph.ch and d.desavigny@swisstph.ch.
Use of Verbal Autopsy Data
- Guidelines for Interpreting Verbal Autopsy Data
Guidelines developed by a technical working group of the Bloomberg Philanthropies Data for Health (D4H) initiative that provide five steps for users of VA to follow to help them interpret and present their VA data, and thus improve the VA’s utility for public health decision-making.
- Guidance on the Analysis of Verbal Autopsy (VA) and Medical Certificate of Cause of Death (MCCD) Data (under review)
This document provides guidance on how to aggregate mortality data from multiple sources and to integrate the results into national statistical processes. While such guidance is expected to evolve as more countries gain additional experience in putting mortality data to use, this initial guidance aims to demonstrate the utility of VA data alongside MCCD data, moving countries towards using VA data now. The guidance was developed by a technical working group of the Bloomberg Philanthropies Data for Health (D4H) initiative and is currently under review by the WHO VA Reference Group.
Governance and Legal Aspects
- Principles and Recommendations for a Vital Statistics Systems, Revision 3
This document of the United Nations Statistics Division presents a set of principles and recommendations and provides guidance on establishing a functioning system for collecting, processing and disseminating vital statistics; improving sources of vital statistics, primarily the functioning of the civil registration system and its components; and the role of complementary sources of vital statistics, such as population censuses, household surveys and public-health records. The version referenced here includes highlights of points relevant to verbal autopsy implementation.
- Guidelines on the Legislative Framework for Civil Registration, Vital Statistics and Identity Management (draft available for review)
These Guidelines offer a tool for developing a strong rights-based legal framework for civil registration, vital statistics and identity management (CRVSID) systems. Prepared by the United Nations Statistics Division and Vital Strategies, with financial support and technical input from the Bloomberg Data for Health Initiative, these Guidelines complement the Principles and Recommendations for a Vital Statistics System, Revision 3 and the Handbooks on Civil Registration and Vital Statistics Systems. The version referenced here includes highlights of points relevant to verbal autopsy implementation.
Other reports
The report briefly summarizes the methods and results of the revision.
Meetings and workshops
Community of practice meetings
Organized by the WHO verbal autopsy reference group since March 2022, monthly virtual meetings are held with the community of verbal autopsy users to support those implementing verbal autopsy for estimating causes of death where medical certification is not yet feasible. Participation is open to all of those who are interested. Topics rotate around the following four themes: information technologies, implementation management, data analysis and use, and implementation research. The meetings are conducted in English with live translation for French, Spanish and Portuguese. If you wish to be added to the verbal autopsy community of practice emailing list, please send an email to verbalautopsy@who.int.
Verbal autopsy reference group (VARG) annual meeting 2022 Geneva, Switzerland
The WHO verbal autopsy reference group (VARG) convened virtually at the WHO Family of International Classifications (WHO-FIC) Network annual meeting on 17 October 2022. The WHO-FIC Network, a network of WHO Collaborating Centres, NGOs, and selected experts, was established in 1970 to support WHO’s work on international classifications. The principal role of the WHO-FIC Network is to promote the implementation, use, maintenance, development, and updating of the WHO reference health classifications. More information
Webinar for the launch of the 2022 WHO verbal autopsy instrument
On April 6 2022 and organized by the WHO Classifications and Terminologies Unit, the webinar included an introduction to verbal autopsy, to the development of WHO verbal autopsy instruments and to the application and implementation of verbal autopsy. Details the revision process and methodology of the 2016 WHO verbal autopsy instrument that led to the development of the 2022 WHO verbal autopsy instrument, as well as a demo of electronic tools for the 2022 WHO verbal autopsy instrument. More information
WHO verbal autopsy reference group workshop (VARG), Bangkok, Thailand
First face-to-face meeting since the COVID-19 pandemic. The workshop focused on the following key priorities of the VARG workplan: development of training manuals for the 2022 WHO verbal autopsy instrument; presentation of emerging results from existing research efforts in verbal autopsy; presentation of the assessment of the gap in resources and guidelines for the verbal autopsy community of users; review of feedback on use of the 2022 WHO verbal autopsy instrument; monitoring use and users of the WHO verbal autopsy instrument – development of user engagement surveys and maintenance of WHO verbal autopsy implementation map; review of VARG workplan 2021-2022 and planning for the 2022-2023 workplan. The applications of verbal autopsy in Thailand were also presented by the Thailand verbal autopsy team.
Verbal autopsy reference group (VARG) annual meeting, 2021
The WHO verbal autopsy reference group (VARG) convened virtually at the WHO Family of International Classifications (WHO-FIC) Network annual meeting on 18 October 2021. The WHO-FIC Network, a network of WHO Collaborating Centres, NGOs, and selected experts, was established in 1970 to support WHO’s work on international classifications. The principal role of the WHO-FIC Network is to promote the implementation, use, maintenance, development, and updating of the WHO reference health classifications. More information
Virtual workshop: Revision of the 2016 WHO Verbal Autopsy instrument – Final Phase
Part 1: 23-25 February 2021 and part 2: 3-4 May 2021
Workshop conducted to a) identify a list of questions for removal from the 2016 WHO verbal autopsy instrument that yields a verbal instrument that is as short and simplified as possible without drops in performance for algorithms and physician-coded verbal autopsy (PCVA) use; and b) finalize the resolution of issues identified with the 2016 WHO verbal instrument. Workshop convened members of the WHO verbal autopsy reference group (VARG) alongside a panel of physicians with experience in physician certified verbal autopsy.
Training Workshop – Item reduction for the 2016 WHO verbal autopsy Instrument
A virtual training with country teams was conducted on the item reduction process, methodologies and item response and importance analysis on October 26, 28, 30, 2020.
Verbal autopsy reference group (VARG) annual meeting, 2020
The WHO verbal autopsy reference group (VARG) convened virtually at the WHO Family of International Classifications (WHO-FIC) Network annual meeting on 21 October 2020. The WHO-FIC Network, a network of WHO Collaborating Centres, NGOs, and selected experts, was established in 1970 to support WHO’s work on international classifications. The principal role of the WHO-FIC Network is to promote the implementation, use, maintenance, development, and updating of the WHO reference health classifications. More information
Response pattern analysis for the revision of the 2016 WHO verbal autopsy instrument
The technical virtual workshop was structured in two parts, with the first taking place July 8-9, and the second on July 15-16. During the course of the workshop, the methodology and results of analyses with collected 2016 WHO verbal autopsy data were presented through quantitative and qualitative approaches for the item reduction of the WHO verbal autopsy instrument. The agreed process involves the data-driven review of the feasibility of questions and expert-led assessment about actions to be taken. The virtual workshop brought together 78 participants, including the members of the verbal autopsy reference group, officials of several low middle income countries that are using verbal autopsy, experts in the field and key partners.
Verbal autopsy reference group (VARG) annual meeting, 2019
The WHO verbal autopsy reference group (VARG) convened at the WHO Family of International Classifications (WHO-FIC) Network annual meeting in Banff, Canada on October 9, 2019. The WHO-FIC Network, a network of WHO Collaborating Centres, NGOs, and selected experts, was established in 1970 to support WHO’s work on international classifications. The principal role of the WHO-FIC Network is to promote the implementation, use, maintenance, development, and updating of the WHO reference health classifications.
WHO VARG meeting for the item reduction of the 2016 WHO verbal autopsy instrument, Lisbon
Two-day meeting convened with a technical group consisting of the developers of the algorithms and the coordination of the verbal autopsy reference group (VARG) to produce a draft methodology for the item reduction of the 2016 WHO verbal autopsy instrument.
Verbal autopsy data analysis workshop for Tanzania’s Ministry of Health, community development, gender, elderly and children.
This workshop was conducted on July 29-30, 2019, in Dar es Salaam, Tanzania. The workshop brought together stakeholders for the civil registration and vital statistics (CRVS)- verbal autopsy (VA) demonstration sites (over 200 wards across 4 Regions) and included staff from the Ministry of Health, National Bureau of Statistics, the Civil Registration Agency (RITA), Muhimbili National Hospital, Ifakara Health Institute, and the National Institute for Medical Research and facilitators from the Swiss Tropical and Public Health Institute and the University of Ohio. All WHO verbal autopsy data were run through Open VA and processed with Inter-VA and In Silico algorithms. Results were compared with physician coded verbal autopsy, sorted for discordance, and discussed, along with scenarios for going to national scale.
Verbal autopsy data analysis workshop for Ghana Health Service
The workshop was conducted in Accra, Ghana on February 6-7, 2018, with the VA implementation team of the Ghana Health Service Facilitators from Swiss Tropical and Public Health Institute with support from Vital Strategies assisted the processing of CRVS-VA Pre-Test data from WHO VAs for all deaths for one year from one District using OpenVA with Inter-VA and InSilico. Results were used to plan the extension of implementation to full regional scale.
WHO AFRO EMRO Workshop on ICD-10 Compliant Medical Certification of Causes of Death and Verbal Autopsy Methods.
This workshop was conducted with the support from Vital Strategies in Luxor, Egypt, 25-39 November 2018 with participants from Egypt, Uganda, Sudan, Morocco, Cameroon, Malawi, Liberia, Lesotho and Gambia. The workshop provided a full orientation to the requirements to establish and integrate verbal autopsy with WHO verbal autopsy instruments and methods into routine national civil registration and vital statistics systems.
Ohio 2018
As the collection of VA data is rapidly increasing, there is a need to develop further tools and guidance regarding the analysis of verbal autopsy raw data for the purpose of quality control. To meet this need the WHO verbal autopsy reference group hosted a workshop on 05 -16 November 2018 in Columbus, USA. More information and presentations for the training of trainers.
2018 WHO-FIC verbal autopsy reference group meeting
The WHO verbal autopsy reference group (formerly working group) convened for the first time at the WHO Family of International Classifications (WHO-FIC) Network annual meeting in Seoul, South Korea on October 24, 2018. The WHO-FIC Network, a network of WHO Collaborating Centres, NGOs, and selected experts, was established in 1970 to support WHO’s work on international classifications. The principal role of the WHO-FIC Network is to promote the implementation, use, maintenance, development, and updating of the WHO reference health classifications, which now officially includes verbal autopsy. More information
Technical Meeting on Mortality Data Analysis with Verbal Autopsy, Washington DC, 2018
A technical workshop on 12-14 September 2018 to generate a draft set of principles, considerations, and recommendations about how countries can: 1) yield high quality statistics from verbal autopsy data and 2) integrate verbal autopsy results and other sources of mortality data into their mortality data processes. Meeting materials and a summary of outcomes are available. More information
Singapore ODK and GitHub 2018
To share experiences and build global capacity in focus countries of the Bloomberg Philanthropies Data for Health Initiative and beyond on the use of the Open Data Kit (ODK) platform for electronic data collection for VA and the use of the GitHub platform for questionnaire management, the Initiative together with Swiss TPH organised two workshops on 28 May - 01 June and 11-15 June 2018 in Singapore. More information
Singapore openVA Pipeline 2018
To facilitate the automatic determination of the cause of death from verbal autopsy and to automate the processing of that data from the data collection platform (Open Data Kit) to DHIS2, the openVA Pipeline was developed. To gather developers and users, a meeting was organised on 23-25 May 2018 in Singapore. More information
Accra 2017
Implementing verbal autopsy within civil registration and vital statistics (CRVS) systems is a major undertaking, and global experience on how to achieve such integration and obtain cause of death data from community death as part of routine processes is rapidly accumulating in countries. To share experiences and discuss emerging international best practice, partners in the Initiative together with other relevant global stakeholders convened a meeting of global “verbal autopsy in civil registration and vital statistics” practitioners on 11-14 December 2017 in Accra, Ghana. More information