International Statistics Program Takes a Global View of Health

At the National Center for Health Statistics’s offices in Hyattsville, Md., one of the busiest and most collaborative programs has a distinctly global mission.

The International Statistics Program (ISP), under director Dr. Sam Notzon, gives NCHS a presence beyond our national borders, actively supporting NCHS programs and working with international organizations to improve the collection and quality of public health data.

ISP activities include working with the Division of Vital Statistics on an international collaboration to promote the use of automated systems for coding causes of death. The collaboration shares information on the Mortality Medical Data System (MMDS), the NCHS automated coding system, other automated systems, and related activities with the 10 member countries. The MMDS is considered the gold standard for the automated coding of mortality data. It is used by virtually every English-speaking country in the world, plus a few non-English-speaking countries, and has been responsible for improving the quality and comparability of international cause-of-death data. European members of this collaboration, working with ISP and DVS members, have adapted the MMDS to make it function in other languages, helping to spread the use of automated coding software around the world. The European version is known as IRIS.

ISP in the United States collaborates with colleagues from Australia, Canada, and New Zealand on the International Group for Indigenous Health Measurement. The group works with statistical agencies from the four countries to improve the accuracy of health data for American Indian, Alaska Native, and Native Hawaiian populations in the United States; First Nations, Inuit, and Métis populations in Canada; Aborigine and Torres Strait Islander populations in Australia; and the Maori population in New Zealand. Currently, the international group is promoting the use of linkage studies to improve the reporting of indigenous status on death certificates and various health records.

ISP is also working with the Office of Research and Methodology’s Questionnaire Design Research Laboratory on a verbal autopsy project in Kenya to improve the quality of information on cause of death in areas without physicians.

Among the many projects under way, Dr. Notzon identifies one that is pivotal to public health policy. At the direction of Dr. Thomas Frieden, director of the Centers for Disease Control and Prevention (CDC), Dr. Notzon is developing a global program for civil registration and vital statistics (CRVS) in developing countries.

Working with a small budget and a small staff–but with many collaborators—Dr. Notzon and staff have developed improvement projects in Morocco and Malawi, and a third project is planned for Kenya. The program also has provided training and technical assistance on vital statistics to Statistics South Africa. In addition, ISP has developed a training program on CRVS, designed to be incorporated into the Field Epidemiology Training Program that the CDC operates in 35 countries. Interest in the CRVS curriculum outside of CDC led to a regional course for Africa and the Middle East, undertaken in Morocco in September 2012. The program has also drawn the interest of the U.N. Economic Commission for Africa, which has invited ISP to train civil registration experts in Africa, and the World Health Organization (WHO), which has requested a training program for their Eastern Mediterranean regional office.

With the assistance of NCHS’s Division of Vital Statistics, ISP enlisted the National Association for Public Health Statistics and Information Systems (NAPHSIS), the national association of state registrars, to provide technical expertise to the project. NAPHSIS members have been key contributors to the development of all of the improvement projects to date. As experts in registration, and particularly on maintaining a civil registration office, their contribution is essential in providing expert advice on central office functions of civil registration systems and in addressing the lack of management skills that can plague civil registration systems in developing countries.

For its own use and the use of others, including CRVS systems staff in developing countries, ISP is developing a resource center containing reports, documents, and other materials useful for improving civil registration and vital statistics systems. The contents will include the more than 100 publications of the International Institute for Vital Registration and Statistics, a nongovernmental organization founded by the first director of NCHS, Dr. Forrest Linder. The materials will be available soon on the ISP section of the NCHS website.

Another major international collaboration involves working with the Organization for Economic Cooperation and Development (OECD). ISP supplies all U.S. nonexpenditure health data to OECD for inclusion in their globally accessible database. This 34-member organization of industrialized countries has also enlisted ISP to help select appropriate measures that can be used to compare health care quality across countries, ensuring comparability of the data.

ISP also participates in activities of WHO’s collaborating center on the Family of International Classifications, housed in another NCHS program. WHO’s many partners, including NCHS, are in the midst of what is generally regarded as a huge undertaking: the 11th revision of the International Classification of Diseases, or ICD–11. Two staff members from NCHS, including one from ISP, chair groups of crosscutting teams that use the work of the 20-plus chapter teams to develop the classifications of mortality and morbidity for ICD–11. Dr. Notzon notes that one of the big tasks in ICD–11 is developing definitions for every one of the disease entities. In its previous 10 editions, diseases were identified by name only. Supplying internationally agreed-upon definitions will help ensure comparability of data.

In an age of global health concerns, from HIV in Africa to H7N9 avian flu in China, Dr. Notzon sees all ISP projects dedicated to improving the quality of health data as integral to addressing important public health issues head-on. “In order to obtain funding to address health problems, you have to document the problems,” he says. “You can’t document them if you don’t have the data. And if you don’t have good data … you’re stuck.”