Trends in causes of death among children under 5 in Bangladesh, 1993-2004: an exercise applying a standardized computer algorithm to assign causes of death using verbal autopsy data

Trends and inequalities in neonatal mortality rate in Bangladesh: Evidence from cross-sectional surveys

Background and Aims

Given the significance of addressing neonatal mortality in pursuing the 2030 Sustainable Development Goal on child health, research focus on this area is crucial. Despite the persistent high rates of neonatal mortality rate (NMR) in Bangladesh, there remains a notable lack of robust evidence addressing inequalities in NMR in the country. Therefore, this study aims to fill the knowledge gap by comprehensively investigating inequalities in NMR in Bangladesh.

Methods

The Bangladesh Demographic and Health Survey (BDHS) data from 2000 to 2017 were analyzed. The equity stratifiers used to measure the inequalities were wealth status, mother's education, place of residence, and subnational region. Difference (D) and population attributable fraction (PAF) were absolute measures, whereas population attributable risk (PAR) and ratio (R) were relative measures of inequality. Statistical significance was considered by estimating 95% confidence intervals (CIs) for each estimate.

Results

A declining trend in NMR was found in Bangladesh, from 50.2 in 2000 to 31.9 deaths per 1000 live births in 2017. This study detected significant wealth-driven (PAF: -20.6, 95% CI: -24.9, -16.3; PAR: -6.6, 95% CI: -7.9, -5.2), education-related (PAF: -11.6, 95% CI: -13.4, -9.7; PAR: -3.7, 95% CI: -4.3, -3.1), and regional (PAF: -20.6, 95% CI: -27.0, -14.3; PAR: -6.6, 95% CI: -8.6, -4.6) disparities in NMR in all survey points. We also found a significant urban-rural inequality from 2000 to 2014, except in 2017. Both absolute and relative inequalities in NMR were observed; however, these inequalities decreased over time.

Conclusion

Significant variations in NMR across subgroups in Bangladesh highlight the need for comprehensive, and targeted interventions. Empowering women through improved access to economic resources and education may help address disparities in NMR in Bangladesh. Future research and policies should focus on developing strategies to address these disparities and promote equitable health outcomes for all newborns.

Comparison of causes of stillbirth and child deaths as determined by verbal autopsy and minimally invasive tissue sampling

In resource-limited settings where vital registration and medical death certificates are unavailable or incomplete, verbal autopsy (VA) is often used to attribute causes of death (CoD) and prioritize resource allocation and interventions. We aimed to determine the CoD concordance between InterVA and CHAMPS's method. The causes of death (CoDs) of children <5 were determined by two methods using data from seven low- and middle-income countries (LMICs) enrolled in the Child Health and Mortality Prevention Surveillance (CHAMPS) network. The first CoD method was from the DeCoDe panel using data from Minimally Invasive Tissue Sampling (MITS), whereas the second method used Verbal Autopsy (VA), which utilizes the InterVA software. This analysis evaluated the agreement between the two using Lin's concordance correlation coefficient. The overall concordance of InterVA4 and DeCoDe in assigning causes of death across surveillance sites, age groups, and causes of death was poor (0.75 with 95% CI: 0.73-0.76) and lacked precision. We found substantial differences in agreement by surveillance site, with Mali showing the lowest and Mozambique and Ethiopia the highest concordance. The InterVA4 assigned CoD agrees poorly in assigning causes of death for U5s and stillbirths. Because VA methods are relatively easy to implement, such systems could be more useful if algorithms were improved to more accurately reflect causes of death, for example, by calibrating algorithms to information from programs that used detailed diagnostic testing to improve the accuracy of COD determination.

Incidence of Acute Diarrhea-Associated Death among Children < 5 Years of Age in Bangladesh, 2010-12

Although acute diarrheal deaths have declined globally among children < 5 years, it may still contribute to childhood mortality as an underlying or contributing cause. The aim of this project was to estimate the incidence of acute diarrhea-associated deaths, regardless of primary cause, among children < 5 years in Bangladesh during 2010-12. We conducted a survey in 20 unions (administrative units) within the catchment areas of 10 tertiary hospitals in Bangladesh. Through social networks, our field team identified households where children < 5 years were reported to have died during 2010-12. Trained data collectors interviewed caregivers of the deceased children and recorded illness symptoms, health care seeking, and other information using an abbreviated international verbal autopsy questionnaire. We classified the deceased based upon the presence of diarrhea before death. We identified 880 deaths, of which 36 (4%) died after the development of acute diarrhea, 17 (2%) had diarrhea-only in the illness preceding death, and 19 (53%) had cough or difficulty breathing in addition to diarrhea. The estimated annual incidence of all-cause mortality in the unions < 13.6 km of the tertiary hospitals was 26 (95% confidence interval [CI] 16-37) per 1,000 live births compared with the mortality rate of 37 (95% CI 26-49) per 1,000 live births in the unions located ≥ 13.6 km. Diarrhea contributes to childhood death at a higher proportion than when considering it only as the sole underlying cause of death. These data support the use of interventions aimed at preventing acute diarrhea, especially available vaccinations for common etiologies, such as rotavirus.

Behavioral antecedents for handwashing in a low-income urban setting in Bangladesh: an exploratory study

BACKGROUND

Health programs commonly promote handwashing by drawing attention to potential fecal contamination in the environment. The underlying assumption is that the thought of fecal contamination will result in disgust, and motivate people to wash their hands with soap. However, this has not proven sufficient to achieve high rates of handwashing with soap at key times. We argue that handwashing with soap is influenced by broader range of antecedents, many unrelated to fecal contamination, that indicate to people when and where to wash their hands. This exploratory study aimed to identify and characterize this broader range of handwashing antecedents for use in future handwashing promotion efforts.

METHODS

First, an initial list of behavioral antecedents was elicited through unstructured interviews, focus group discussions and observation with residents, from a low-income community in Dhaka, Bangladesh, who were also recipients of a handwashing intervention. Then, photographs representing three categories of behavioral antecedents were taken: activities of daily living, visual or tactile sensations, and handwashing-related hardware and activities. Finally, the research team conducted ranking exercises with a new set of participants, from the same area, to assess the perceived importance of each antecedent illustrated by the photographs. The research team probed about perceptions regarding how and why that particular antecedent, represented by the photograph, influences handwashing behavior.

RESULTS

After coming out of the bathroom and dirt (moyla) on hands were the two antecedents that ranked highest. In all the categories, intervention-related antecedents (three key times for handwashing which included handwashing after coming out of the bathroom, after cleaning a child's anus and before food preparation; intervention provided items that included handwashing station, soapy water bottle, handwashing reminders from posters and community health provider visits) that were being promoted actively in this community were perceived favorably in the qualitative responses, but did not consistently rank higher than non-intervention items. However, many other antecedents were reported to influence when and where people wash their hands: cutting greasy fish, starting a meal, contact with oil and fat stuck to dishes, oil and lice from hair, sweat, unwashed vegetables, reminders from son and daughter or observing others wash hands, and observing the sunset.

CONCLUSIONS

Beyond well-recognized antecedents related to fecal contact and dirt on hands, we identified a broader set of antecedents not reported in the literature. Adopting a handwashing promotional strategy to highlight existing antecedents that people themselves have identified as important can help inform the content of an intervention that is more relatable and effective in increasing handwashing practices.

Evaluation of the Measles Surveillance System in Kaduna State, Nigeria (2010-2012)

Objective

To evaluate the case-based measles surveillance system in Kaduna State of Nigeria and identify gaps in its operation.

Introduction

In Africa, approximately 13 million cases, 650,000 deaths due to measles occur annually, with sub-Saharan Africa having the highest morbidity and mortality. Measles infection is endemic in Nigeria and has been documented to occur all year round, despite high measles routine and supplemental immunization coverage. The frequent outbreaks of measles in Kaduna State prompted the need for the evaluation of the measles case-based surveillance system.

Methods

We interviewed stakeholders and conducted a retrospective record review of the measles case-based surveillance data from 2010 – 2012 and adapted the 2001 CDC guidelines on surveillance evaluation and the Framework for Evaluating Public Health Surveillance Systems for Early Detection of Outbreaks, to assess the systems usefulness, representativeness, timeliness, stability, acceptability and data quality. We calculated the annualized detection rate of measles and non-measles febrile rash, proportion of available results, proportion of LGAs (Districts) that investigated at least one case with blood, proportion of cases that were IgM positive and the incidence of measles. We compared the results with WHO(2004) recommended performance indicators to determine the quality and effectiveness of measles surveillance system.

Results

According to the Stakeholders, the case-based surveillance system was useful and acceptable. Median interval between specimen collection and release of result was 7days (1 – 25 days) in 2010, 38 days (Range: 16 – 109 days) in 2011 and 11 days (Range: 1 – 105 days) in 2012. The annualized detection rate of measles rash in 2010 was 2.1 (target: ³2), 1.0 (target: ³2) in 2011 and 1.4 (target: ³2) in 2012. The annualized detection rate of non-measles febrile rash in 2010 was 2.1 (target: ³2), 0.6 (target: ³2) in 2011 and 0.8 (target: ³2) in 2012. Case definitions are simple and understood by all the operators.

Conclusion

This evaluation showed that the surveillance system was still useful. Also, the efficiency and effectiveness of the laboratory component as captured by the “median interval between specimen collection and the release of results improved in 2010 and 2012 compared to 2011. However, there was a progressive decline in the timeliness and completeness of weekly reports in the years under review.

When, Where, and Why Are Babies Dying? Neonatal Death Surveillance and Review in Bangladesh

BACKGROUND

Better data on cause of, and factors contributing to, neonatal deaths are needed to improve interventions aimed at reducing neonatal mortality in low- and middle-income countries.

METHODS

Community surveillance to identify all neonatal deaths across four districts in Bangladesh. Verbal autopsy for every fifth case and InterVA-4 used to assign likely cause of death.

FINDINGS

6748 neonatal deaths identified, giving a neonatal mortality rate of 24.4 per 1000 live births. Of these, 51.3% occurred in the community and 48.7% at or on the way to a health facility. Almost half (46.1%) occurred within 24 hours of birth with 83.6% of all deaths occurring in the first seven days of life. Birth asphyxia was the leading cause of death (43%), followed by infections (29.3%), and prematurity (22.2%). In 68.3% of cases, care had been provided at a health facility before death occurred. Care-seeking was significantly higher among mothers who were educated (RR 1.18, 95% CI: 1.04-1.35) or who delivered at a health facility (RR 1.48, 95% CI 1.37-1.60) and lower among mothers who had 2-4 previous births (RR 0.89, 95% CI 0.82-0.96), for baby girls (RR 0.87, 95% CI 0.80-0.93), and for low birth weight babies (RR 0.89, 95% CI 0.82-0.96).

INTERPRETATION

Most parents of neonates who died had accessed and received care from a qualified healthcare provider. To further reduce neonatal mortality, it is important that the quality of care provided, particularly skilled birth attendance, emergency obstetric care, and neonatal care during the first month of life is improved, such that it is timely, safe, and effective.

Hygiene Practices During Food Preparation in Rural Bangladesh: Opportunities to Improve the Impact of Handwashing Interventions

This study explored the steps of food preparation, related handwashing opportunities, current practices, and community perceptions regarding foods at high-risk of contamination such as mashed foods and salads. In three rural Bangladeshi villages, we collected qualitative and observational data. Food preparation was a complex and multistep process. Food preparation was interrupted by tasks that could contaminate the preparers' hands, after which they continued food preparation without washing hands. Community members typically ate hand-mixed, uncooked mashed food and salad as accompaniments to curry and rice at meals. Hand-mixed dried foods were mostly consumed as a snack. Observers recorded handwashing during preparation of these foods. Among 24 observed caregivers, of 85 opportunities to wash hands with soap during food preparation, washing hands with soap occurred twice, both times after cutting fish, whereas washing hands with water alone was common. A simple and feasible approach is promotion of handwashing with soap upon entering and re-entering the food preparation area, and ensuring that everything needed for handwashing should be within easy reach.

Current Progress in Developing Subunit Vaccines against Enterotoxigenic Escherichia coli-Associated Diarrhea

Diarrhea continues to be a leading cause of death in children <5 years of age, and enterotoxigenic Escherichia coli (ETEC) is the most common bacterial cause of children's diarrhea. Currently, there are no available vaccines against ETEC-associated diarrhea. Whole-cell vaccine candidates have been under development but require further improvements because they provide inadequate protection and produce unwanted adverse effects. Meanwhile, a newer approach using polypeptide or subunit vaccine candidates focusing on ETEC colonization factor antigens (CFAs) and enterotoxins, the major virulence determinants of ETEC diarrhea, shows substantial promise. A conservative CFA/I adhesin tip antigen and a CFA MEFA (multiepitope fusion antigen) were shown to induce cross-reactive antiadhesin antibodies that protected against adherence by multiple important CFAs. Genetic fusion of toxoids derived from ETEC heat-labile toxin (LT) and heat-stable toxin (STa) induced antibodies neutralizing both enterotoxins. Moreover, CFA-toxoid MEFA polypeptides, generated by fusing CFA MEFA to an STa-LT toxoid fusion, induced antiadhesin antibodies that broadly inhibited adherence of the seven most important ETEC CFAs associated with about 80% of the diarrhea cases caused by ETEC strains with known CFAs. This same antigen preparation also induced antitoxin antibodies that neutralized both toxins that are associated with all cases of ETEC diarrhea. Results from these studies suggest that polypeptide or subunit vaccines have the potential to effectively protect against ETEC diarrhea. In addition, novel adhesins and mucin proteases have been investigated as potential alternatives or, more likely, additional antigens for ETEC subunit vaccine development.

Deriving causes of child mortality by re-analyzing national verbal autopsy data applying a standardized computer algorithm in Uganda, Rwanda and Ghana

Background

To accelerate progress toward the Millennium Development Goal 4, reliable information on causes of child mortality is critical. With more national verbal autopsy (VA) studies becoming available, how to improve consistency of national VA derived child causes of death should be considered for the purpose of global comparison. We aimed to adapt a standardized computer algorithm to re–analyze national child VA studies conducted in Uganda, Rwanda and Ghana recently, and compare our results with those derived from physician review to explore issues surrounding the application of the standardized algorithm in place of physician review.

Methods and Findings

We adapted the standardized computer algorithm considering the disease profile in Uganda, Rwanda and Ghana. We then derived cause–specific mortality fractions applying the adapted algorithm and compared the results with those ascertained by physician review by examining the individual– and population–level agreement. Our results showed that the leading causes of child mortality in Uganda, Rwanda and Ghana were pneumonia (16.5–21.1%) and malaria (16.8–25.6%) among children below five years and intrapartum–related complications (6.4–10.7%) and preterm birth complications (4.5–6.3%) among neonates. The individual level agreement was poor to substantial across causes (kappa statistics: –0.03 to 0.83), with moderate to substantial agreement observed for injury, congenital malformation, preterm birth complications, malaria and measles. At the population level, despite fairly different cause–specific mortality fractions, the ranking of the leading causes was largely similar.

Conclusions

The standardized computer algorithm produced internally consistent distribution of causes of child mortality. The results were also qualitatively comparable to those based on physician review from the perspective of public health policy. The standardized computer algorithm has the advantage of requiring minimal resources from the health care system and represents a promising way to re–analyze national or sub-national VA studies in place of physician review for the purpose of global comparison.

Direct estimates of national neonatal and child cause-specific mortality proportions in Niger by expert algorithm and physician-coded analysis of verbal autopsy interviews

BACKGROUND

This study was one of a set of verbal autopsy investigations undertaken by the WHO/UNCEF-supported Child Health Epidemiology Reference Group (CHERG) to derive direct estimates of the causes of neonatal and child deaths in high priority countries of sub-Saharan Africa. The objective of the study was to determine the cause distributions of neonatal (0-27 days) and child (1-59 months) mortality in Niger.

METHODS

Verbal autopsy interviews were conducted of random samples of 453 neonatal deaths and 620 child deaths from 2007 to 2010 identified by the 2011 Niger National Mortality Survey. The cause of each death was assigned using two methods: computerized expert algorithms arranged in a hierarchy and physician completion of a death certificate for each child. The findings of the two methods were compared to each other, and plausibility checks were conducted to assess which is the preferred method. Comparison of some direct measures from this study with CHERG modeled cause of death estimates are discussed.

FINDINGS

The cause distributions of neonatal deaths as determined by expert algorithms and the physician were similar, with the same top three causes by both methods and all but two other causes within one rank of each other. Although child causes of death differed more, the reasons often could be discerned by analyzing algorithmic criteria alongside the physician's application of required minimal diagnostic criteria. Including all algorithmic (primary and co-morbid) and physician (direct, underlying and contributing) diagnoses in the comparison minimized the differences, with kappa coefficients greater than 0.40 for five of 11 neonatal diagnoses and nine of 13 child diagnoses. By algorithmic diagnosis, early onset neonatal infection was significantly associated (χ(2) = 13.2, P < 0.001) with maternal infection, and the geographic distribution of child meningitis deaths closely corresponded with that for meningitis surveillance cases and deaths.

CONCLUSIONS

Verbal autopsy conducted in the context of a national mortality survey can provide useful estimates of the cause distributions of neonatal and child deaths. While the current study found reasonable agreement between the expert algorithm and physician analyses, it also demonstrated greater plausibility for two algorithmic diagnoses and validation work is needed to ascertain the findings. Direct, large-scale measurement of causes of death complement, can strengthen, and in some settings may be preferred over modeled estimates.

Observed practices and perceived advantages of different hand cleansing agents in rural Bangladesh: ash, soil, and soap

Bangladeshi communities have historically used ash and soil as handwashing agents. A structured observation study and qualitative interviews on the use of ash/soil and soap as handwashing agents were conducted in rural Bangladesh to help develop a handwashing promotion intervention. The observations were conducted among 1,000 randomly selected households from 36 districts. Fieldworkers observed people using ash/soil to wash their hand(s) on 13% of occasions after defecation and on 10% after cleaning a child's anus. This compares with 19% of people who used soap after defecation and 27% after cleaning a child who defecated. Using ash/soil or soap was rarely (< 1%) observed at other times recommended for handwashing. The qualitative study enrolled 24 households from three observation villages, where high usage of ash/soil for handwashing was detected. Most informants reported that ash/soil was used only for handwashing after fecal contact, and that ash/soil could clean hands as effectively as soap.

Country level economic disparities in child injury mortality

BACKGROUND

Injuries are a neglected cause of child mortality globally and the burden is unequally distributed in resource poor settings. The aim of this study is to explore the share and distribution of child injury mortality across country economic levels and the correlation between country economic level and injuries.

METHODS

All-cause and injury mortality rates per 100,000 were extracted for 187 countries for the 1-4 age group and under 5s from the Global Burden of Disease Study 2010. Countries were grouped into four economic levels. Gross domestic product (GDP) per capita was used to determine correlation with injury mortality.

RESULTS

For all regions and country economic levels, the share of injuries in all-cause mortality was greater when considering the 1-4 age group than under 5s, ranging from 36.6% in Organization for Economic Cooperation and Development countries to 10.6% in Sub-Saharan Africa. Except for Sub-Saharan Africa, there is a graded association between country economic level and 1-4 injury mortality across regions, with all low-income countries having the highest rates. Except for the two regions with the highest overall injury mortality rates, there is a significant negative correlation between GDP and injury mortality in Latin America and the Caribbean, Eastern Europe/Central Asia, Asia East/South-East and Pacific and North Africa/ Middle East.

CONCLUSIONS

Child injury mortality is unevenly distributed across regions and country economic level to the detriment of poorer countries. A significant negative correlation exists between GDP and injury in all regions, exception for the most resource poor where the burden of injuries is highest.

Trends in non-communicable disease mortality among adult residents in Nairobi's slums, 2003-2011: applying InterVA-4 to verbal autopsy data

BACKGROUND

About 80% of deaths from non-communicable diseases (NCDs) occur in developing countries such as Kenya. However, not much is known about the burden of NCDs in slums, which account for about 60% of the residences of the urban population in Kenya. This study examines trends in NCD mortality from two slum settings in Nairobi.

DESIGN

We use verbal autopsy data on 1954 deaths among adults aged 35 years and older who were registered in the Nairobi Urban Health and Demographic Surveillance System between 2003 and 2011. InterVA-4, a computer-based program, was used to assign causes of death for each case. RESULTS are presented as annualized cause-specific mortality rates (CSMRs) and cause-specific mortality fractions (CSMFs) by sex.

RESULTS

The CSMRs for NCDs did not appear to change significantly over time for both males and females. Among males, cardiovascular diseases (CVDs) and neoplasms were the leading NCDs--contributing CSMFs of 8 and 5%, respectively, on average over time. Among females, CVDs contributed a CSMF of 14% on average over time, while neoplasms contributed 8%. Communicable diseases and related conditions remained the leading causes of death, contributing a CSMF of over 50% on average in males and females over time.

CONCLUSIONS

Our findings are consistent with the Global Burden of Disease 2010 study which shows that communicable diseases remain the dominant cause of death in Africa, although NCDs were still significant contributors to mortality. We recommend an integrated approach towards disease prevention that focuses on health systems strengthening in resource-limited settings such as slums.

Cause-specific neonatal deaths in rural Bangladesh, 1987-2005: levels, trends, and determinants

This paper reports on an analysis of neonatal mortality from communicable and non-communicable diseases in Bangladesh. The competing-risks model employed incorporated both observed and unobserved heterogeneity and allowed the two heterogeneity terms to be correlated. The data used came from the Health and Demographic Surveillance System, Matlab. The results confirm the conclusions of previous studies about the levels, trends, and causes of neonatal death in the Matlab area: the education of the mother helps protect her children from death from both communicable and non-communicable diseases; the children of a father in a low-status occupation are particularly vulnerable to death from communicable diseases; and children born to mothers aged less than 20 face a particularly high risk of dying from a non-communicable disease. The risks of dying from a communicable disease and from a non-communicable disease were both found to fall significantly as the distance to the nearest health centre decreased.

The contribution of reduction in malaria as a cause of rapid decline of under-five mortality: evidence from the Rufiji Health and Demographic Surveillance System (HDSS) in rural Tanzania

Background

Under-five mortality has been declining rapidly in a number of sub-Saharan African settings. Malaria-related mortality is known to be a major component of childhood causes of death and malaria remains a major focus of health interventions. The paper explored the contribution of malaria relative to other specific causes of under-five deaths to these trends.

Methods

This paper uses longitudinal demographic surveillance data to examine trends and causes of death of under-five mortality in Rufiji, whose population has been followed for over nine years (1999–2007). Causes of death, determined by the verbal autopsy technique, are analysed with Arriaga’s decomposition method to assess the contribution of declining malaria-related mortality relative to other causes of death as explaining a rapid decline in overall childhood mortality.

Results

Over the 1999–2007 period, under-five mortality rate in Rufiji declined by 54.3%, from 33.3 to 15.2 per 1,000 person-years. If this trend is sustained, Rufiji will be a locality that achieves MDG4 target. Although hypotrophy at birth remained the leading cause of death for neonates, malaria remains as the leading cause of death for post-neonates followed by pneumonia. However, declines in malaria death rates accounted for 49.9% of the observed under-five mortality decline while all perinatal causes accounted for only 19.9%.

Conclusion

To achieve MDG 4 in malaria endemic settings, health programmes should continue efforts to reduce malaria mortality and more efforts are also needed to improve newborn survival.

InterVA versus Spectrum: how comparable are they in estimating AIDS mortality patterns in Nairobi's informal settlements?

Background

The Spectrum computer package is used to generate national AIDS mortality estimates in settings where vital registration systems are lacking. Similarly, InterVA-4 (the latest version of the InterVA programme) is used to estimate cause-of-mortality data in countries where cause-specific mortality data are not available.

Objective

This study aims to compare trends in adult AIDS-related mortality estimated by Spectrum with trends from the InterVA-4 programme applied to data from a Health and Demographic Surveillance System (HDSS) in Nairobi, Kenya.

Design

A Spectrum model was generated for the city of Nairobi based on HIV prevalence data for Nairobi and national antiretroviral therapy coverage, underlying mortality, and migration assumptions. We then used data, generated through verbal autopsies, on 1,799 deaths that occurred in the HDSS area from 2003 to 2010 among adults aged 15–59. These data were then entered into InterVA-4 to estimate causes of death using probabilistic modelling. Estimates of AIDS-related mortality rates and all-cause mortality rates from Spectrum and InterVA-4 were compared and presented as annualised trends.

Results

Spectrum estimated that HIV prevalence in Nairobi was 7%, while the HDSS site measured 12% in 2010. Despite this difference, Spectrum estimated higher levels of AIDS-related mortality. Between 2003 and 2010, the proportion of AIDS-related mortality in Nairobi decreased from 63 to 40% according to Spectrum and from 25 to 16% according to InterVA. The net AIDS-related mortality in Spectrum was closer to the combined mortality rates when AIDS and tuberculosis (TB) deaths were included for InterVA-4.

Conclusion

Overall trends in AIDS-related deaths from both methods were similar, although the values were closer when TB deaths were included in InterVA. InterVA-4 might not accurately differentiate between TB and AIDS deaths.

Health care-seeking behavior for childhood diarrhea in Mirzapur, rural Bangladesh

We evaluated patterns of health care use for diarrhea among children 0–59 months of age residing in Mirzapur, Bangladesh, using a baseline survey conducted during May–June 2007 to inform the design of a planned diarrheal etiology case/control study. Caretakers of 7.4% of 1,128 children reported a diarrheal illness in the preceding 14 days; among 95 children with diarrhea, 24.2% had blood in the stool, 12.2% received oral rehydration solution, 27.6% received homemade fluids, and none received zinc at home. Caretakers of 87.9% sought care outside the home; 49.9% from a pharmacy, and 22.1% from a hospital or health center. The primary reasons for not seeking care were maternal perception that the illness was not serious enough (74.0%) and the high cost of treatment (21.9%). To improve management of childhood diarrhea in Mirzapur, Bangladesh, it will be important to address knowledge gaps in caretakers' assessment of illness severity, appropriate home management, and when to seek care in the formal sector. In addition, consideration should be given to inclusion of the diverse care-giving settings in clinical training activities for diarrheal disease management.

Causes of deaths in children under-five years old at a tertiary hospital in Limpopo province of South Africa

Objective:

Accurate and timely information on the causes of child deaths is essential in guiding efforts to improve child survival, by providing data from which health profiles can be constructed and relevant health policies formulated. The purpose of this study was to identify causes of death in children younger than 5 years-old in a tertiary hospital in South Africa.

Methods:

Death certificates from the Pietersburg/Mankweng hospital complex, for the period of January 1, 2008 through December 31, 2010, were obtained for all patients younger than 5 years and were retrospectively reviewed. Data were collected using a data collection form designed for the study. Information abstracted included: date of death, age, sex, and cause of death.

Results:

A total of 1266 deaths were recorded, the sex ratio was 1.26 boys per girl. About 611 (48%) of deaths were listed as neonatal deaths (0-28 days), 387 (31%) were listed as infant deaths (29 days-11 months), and 268 (21%) as children’s death (1-4 years). For neonates the leading causes of death were: prematurity/low birth weight, birth asphyxia and pneumonia. For the infant death group, the leading causes of death were pneumonia, diarrhea, and HIV/AIDS; and in the children’s group, the leading causes were injuries, diarrhea and pneumonia. There was no statistical significant difference in the proportions of causes of death based on the sex of children.

Conclusion:

The top 10 leading causes of death in children under-5 years old treated at Pietersburg/Mankweng Hospital Complex were in descending order: prematurity/low birth weight, pneumonia, diarrheal diseases, birth asphyxia, and severe malnutrition, HIV/AIDS, hydrocephalus, unintentional injuries, meningitis and other infections. These ten conditions represent 73.9% of causes of death at this facility. A mix of multi-faceted interventions is needed to address these causes of death in children.

Mortality causes in children 1-59 months in iran

BACKGROUND

Mortality rate indicator for children under 5 years old is one of the important indicators in countries' development. Identifying the most common causes of mortality is one of the most important attempts to reduce mortality in children less than 5 years. The purpose of this study was to identify distribution of the mortality causes in Iranian children less than 5 years.

METHODS

This cross-sectional study has been carried out based on the results of data from the Child Mortality Surveillance System since 2007 to 2008. To determine the causes of death questionnaires have been designed which include personal data of the deceased child, medical history, and information on procedures at the time of hospitalization or death.

RESULTS

Of 5926 deaths on children under 5 years which the questionnaires were filled out, 63.2% were postneonatal deaths (1-11 month). Totally 60% of mortalities occurred in the rural areas and 52% of them had been among boys. The most common causes of mortality were the congenital and chromosomal abnormalities with 23.4%. The most incidences among diseases were respiratory system diseases.

CONCLUSIONS

Carrying out more epidemiologic studies, providing health programs to control and prevent diseases with high incidences and delivering more specialized health facilities and services could be the proper strategies to reduce under 5 mortality rates in Iran.

Temporal trends and gender differentials in causes of childhood deaths at Ballabgarh, India - need for revisiting child survival strategies

BACKGROUND

Relating Information on causes of deaths to implementation of health interventions provides vital information for program planning and evaluation. This paper from Ballabgarh Health and Demographic Surveillance System (HDSS) site in north India looks at temporal trends and gender differentials in the causes of death among under-five children.

METHODS

Data on causes of death for 1972-74, 1982-84, 1992-94, 2002-04 were taken from existing HDSS publications and database. Physicians' assigned causes of death were based on narratives by lay health worker till 1994 and later by verbal autopsy. Cause Specific Mortality Fractions (CSMF) and Cause Specific Mortality Rates (CSMR) per 1000 live births were calculated for neonatal (<1 month) and childhood (1-59 months) period. Gender difference was estimated by calculating ratio of CSMR between girls and boys. Available information on coverage of childhood interventions in the HDSS was retrieved and compiled.

RESULTS

The CSMF of prematurity and sepsis was 32% and 17.6% during neonatal period in 2002-04. The share of infections in all childhood deaths decreased from 55.2% in 1972-74 to 43.6% in 2002-04. All major causes of mortality (malnutrition, diarrhea and acute lower respiratory infection) except injuries showed a steep decline among children and seem to have plateued in last decade. Most of disease specific public health interventions were launched in mid eighties. . Girls reported significantly higher mortality rates for prematurity (RR 1.52; 95% CI 1.01-2.29); diarrhea (2.29; 1.59 - 3.29), and malnutrition (3.37; 2.05 - 5.53).

CONCLUSIONS

The findings of the study point out to the need to move away from disease-specific to a comprehensive approach and to address gender inequity in child survival through socio-behavioural approaches.

Global, regional, and national causes of child mortality: an updated systematic analysis for 2010 with time trends since 2000

BACKGROUND

Information about the distribution of causes of and time trends for child mortality should be periodically updated. We report the latest estimates of causes of child mortality in 2010 with time trends since 2000.

METHODS

Updated total numbers of deaths in children aged 0-27 days and 1-59 months were applied to the corresponding country-specific distribution of deaths by cause. We did the following to derive the number of deaths in children aged 1-59 months: we used vital registration data for countries with an adequate vital registration system; we applied a multinomial logistic regression model to vital registration data for low-mortality countries without adequate vital registration; we used a similar multinomial logistic regression with verbal autopsy data for high-mortality countries; for India and China, we developed national models. We aggregated country results to generate regional and global estimates.

FINDINGS

Of 7·6 million deaths in children younger than 5 years in 2010, 64·0% (4·879 million) were attributable to infectious causes and 40·3% (3·072 million) occurred in neonates. Preterm birth complications (14·1%; 1·078 million, uncertainty range [UR] 0·916-1·325), intrapartum-related complications (9·4%; 0·717 million, 0·610-0·876), and sepsis or meningitis (5·2%; 0·393 million, 0·252-0·552) were the leading causes of neonatal death. In older children, pneumonia (14·1%; 1·071 million, 0·977-1·176), diarrhoea (9·9%; 0·751 million, 0·538-1·031), and malaria (7·4%; 0·564 million, 0·432-0·709) claimed the most lives. Despite tremendous efforts to identify relevant data, the causes of only 2·7% (0·205 million) of deaths in children younger than 5 years were medically certified in 2010. Between 2000 and 2010, the global burden of deaths in children younger than 5 years decreased by 2 million, of which pneumonia, measles, and diarrhoea contributed the most to the overall reduction (0·451 million [0·339-0·547], 0·363 million [0·283-0·419], and 0·359 million [0·215-0·476], respectively). However, only tetanus, measles, AIDS, and malaria (in Africa) decreased at an annual rate sufficient to attain the Millennium Development Goal 4.

INTERPRETATION

Child survival strategies should direct resources toward the leading causes of child mortality, with attention focusing on infectious and neonatal causes. More rapid decreases from 2010-15 will need accelerated reduction for the most common causes of death, notably pneumonia and preterm birth complications. Continued efforts to gather high-quality data and enhance estimation methods are essential for the improvement of future estimates.

FUNDING

The Bill & Melinda Gates Foundation.