We read with great interest, the article by Nabukalu D et al ⁽¹⁾, where they described how the verbal autopsy (VA) conducted by Community Health Workers (CHWs) faired against the existing passive surveillance in the Sub-County of Bugoye in Uganda. We present a few observations here.
There appears to be a mismatch between the title and objective of this paper. The title asserts that the CHW led VA to provide a better mortality measure than the existing surveillance mechanism; this implies to the reader to expect a presentation of comparison between two surveillance methods. However, upon reading the paper, with the title as the aim, the paper would be considered to have missed the following attributes of assessment of a public health surveillance system - predictive value, timeliness, stability, simplicity, flexibility, interoperability and cost of the new system, compared to the existing passive surveillance. ⁽²⁾
The mismatch is evident upon reading the objective which is focused to assess the feasibility of a new strategy i.e. leveraging CHWs for the ascertainment of cause of death in the community. In the context of the objective, the attributes for assessing feasibility might have the following indicators: whether employing CHWs to conduct VA is acceptable – from the perspectives of study respondents, community representatives and stakeholders; whether there is a demand for this new strategy e.g. demonstrated felt need of this data element by the policy maker; whether this strategy is implementable under given setting- e.g. time required to interview, local adaptations required; what were the other practicalities- e.g. human and material resources, cost incurred, obstacles faced by respondents, difficulty faced by the interviewers; what adaptations were required in the existing health system to accommodate the new strategy; what are the plausible elements that (dis)favor integration- e.g. features common between the proposed strategy and existing system; what were the outcomes- e.g. a description of the outcome measures which would be causes of death, in this context. ⁽³⁾ Most of the attributes were covered by the authors, however, the same might not have been mentioned in the methods section explicitly- e.g. implementation (training of VHTs, method of selection of deaths & respondents) and practicality (quality assessment of interviews performed). Similarly, possibilities for adaptation (role of new InterVA-5 tool to ease analysis), integration to existing health system and expansion (opportunity for expansion of VHTs’ activity to vital statistics and community disease surveillance) were discussed by the authors, however without referring to any baseline information on how these attributes were collected or mentioning them in the results section. A few attributes e.g. acceptability, which is a cardinal feature of feasibility, was found missing; a concern could be raised about feasibility, if conducting VA was not approved by the community people or, the VHT themselves. Moreover, use of specific indicators as outcome measures (such as cost incurred in the study for every death interviewed & participation refusal rate) in these focus areas of feasibility assessment could have objectively strengthened the conclusion. Nonetheless, we congratulate the authors for this important piece of work.

References:
1. Nabukalu D, Ntaro M, Seviiri M, Reyes R, Wiens M, Sundararajan R, et al. (2019) Community health workers trained to conduct verbal autopsies provide better mortality measures than existing surveillance: Results from a cross-sectional study in rural western Uganda. PLoS ONE 14(2):e0211482. https://doi.org/10.1371/j...
2. German RR, Lee LM, Horan JM, Milstein RL, Pertowski CA, Waller MN. Updated guidelines for evaluating public health surveillance systems: recommendations from the Guidelines Working Group. MMWR Recomm Rep. 2001 Jul 27;50(RR-13):1-35; quiz CE1-7.
3. Bowen DJ, Kreuter M, Spring B, Cofta-Woerpel L, Linnan L, Weiner D, et al. How We Design Feasibility Studies. American Journal of Preventive Medicine [Internet]. 2009 May;36(5):452–7.
Available from: http://dx.doi.org/10.1016...

Authors of the comment:
Dr. Vignesh L. (Junior Resident, Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, India) &
Dr. Partha Haldar (Assistant Professor, Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, India)