Transcript Document

Child deaths:
Causes and epidemiological dimensions
Robert E. Black, M.D., M.P.H.
Johns Hopkins Bloomberg School
of Public Health
10.5 milllion annual child deaths
 Where are they?
 How much progress is there?
 What are the causes?
UNICEF/WHO methods for
estimating the child mortality envelope
Complete vital registration
Age-specific
mortality rates
Sample registration system
Censuses
DHS, MICS and
other surveys
UN estimates
Incomplete vital registration
Under-5 and adult
mortality rates
Life tables
UN population
estimates
Country-level all-cause
mortality envelope
by age and sex
Child mortality trends in Egypt
Source: UNICEF
Trends in child mortality
relative to MDG-4
Sub-Saharan Africa
South Asia
244
Latin America
206
East Asia
188
UnderFive
Mortality
Rate
171
123
129
122
92
58
36
54
31
1970
1990
2004
Source: The State of the World’s Children, 2006
62
42.6
19.1
17.8
2015
MDG-4
Goals
Current and needed
annual rate of reduction in child mortality
to achieve MDG-4
Average annual rate of reduction
1970-1990
%
Current
1990-2004
%
Needed to Achieve MDG4
2005-2015
%
L. America/
Caribbean
4.1
4.0
1.2
E. Asia
3.7
3.4
1.5
Mid-East/
N. Africa
4.4
2.6
2.7
S. Asia
2.3
2.4
4.5
Sub Saharan
Africa
1.3
0.7
9.9
UNICEF
Region
Source: The State of the World’s Children, 2006
Where do we need to focus
to achieve MDG-4?
Achievement of MDG-4
will depend on accelerating
interventions in South Asia and
sub-Saharan Africa.
Trends in childhood mortality in Bangladesh
140
Under-5 mortality
Neonatal mortality
120
100
80
60
40
20
0
1989-93
1992-6
1995-9
2000-4
Relation between U5MR and
percentage of deaths in neonates
Source: Black et al., Lancet 2003
Age group focus
 Currently nearly 4 million
neonatal deaths
 Achievement of MDG-4 will
depend on success with neonatal
interventions
WHO methods for
estimating cause-specific child mortality
Independent
studies/reports/models,
e.g.,CHERG
WHO program
estimates
Cause-specific
mortality patterns
Country-level all-cause
mortality envelope
by age and sex
Country level
age-, sex- and causespecific mortality estimates
Global and regional level age,
sex and cause specific
mortality estimates
UNAIDS
estimates
Causes of under-five child mortality
Source: Bryce J. et al., Lancet, 2005
Causes of Under 5 Mortality
by WHO Region
Source: Bryce J. et al., Lancet, 2005
New evidence on causes of death
Advances in building the evidence base on
causes of child deaths must be incorporated
into policies and programs:
•
Five causes (pneumonia/sepsis,
diarrhea, malaria, preterm birth, and birth
asphyxia) account for 73% of all underfive deaths.
•
Role of undernutrition must also be
considered.
Relative Risk (RR) of death by cause
due to underweight, estimated from
random effects models
14
Diarrhea
12
Pneumonia
10
RR
Malaria
Measles
8
Overall
6
4
2
0
-3.5
-2.5
Average weight-for-age z-score
Source: Caulfield L, et al., Am J Clin Nutr, 2004
-1.5
Prevalence of underweight in children
0 - 4 years old, by WHO region
Prevalence (%)
2 - 11
11 - 20
20 - 28
28 - 37
37 - 46
Source: de Onis and Blossner, Int J Epi, 2001
Major causes of death in neonates and
children aged 28 days to 5 years
(yearly average for 2000-03)
Deaths among children
aged 28 days to five years
( 6.6 million/year)
Neonatal deaths
( 4 million/year)
Pneumonia
Pneumonia/
sepsis
Other infectious
52%
Diarrhoea
Under
Study
Injuries
Other noncommunicable
Malaria
Tetanus
Asphyxia
Other
57%
Under
Study
HIV/AIDS
45%
Congenital
Measles
Preterm
61%
Diarrhoea
The % of deaths from this infection that are due to the
presence of undernutrition
The % of deaths due to maternal and
neonatal undernutrition is under study
Global distribution of disease burden
attributable to 20 selected risk factors
Underweight
Unsafe sex
High blood pressure
Tobacco
Alcohol
Unsafe water, sanitation & hygiene
High cholesterol
Indoor smoke from solid fuels
Iron deficiency
High BMI
Zinc deficiency
Low fruit and vegetable intake
Vitamin A deficiency
Physical inactivity
Occupational injury
Lead exposure
High-mortality developing
Lower-mortality developing
Illicit drugs
Unsafe health care injections
Lack of contraception
Childhood sexual abuse
0.0%
Developed
1.0%
2.0%
3.0%
4.0%
5.0%
6.0%
7.0%
8.0%
9.0%
Attributable DALY (% of global DALY - Total 1.46 billion)
Source: Ezzati M et al., Lancet 2002
10.0%
Implications for child survival
1. Focused acceleration of child survival
interventions is critical now to achieve
MDG-4
• South Asia and sub-Saharan Africa
• Neonatal deaths, nearly 40% and
more important as child mortality
declines
Implications for child survival
2. Evidence on causes of child deaths
must be incorporated into policies and
programs:

Five causes in particular must be addressed
-
Pneumonia/sepsis, including in neonates
Diarrhea
Malaria
Preterm birth
Birth asphyxia
Implications for child survival
3. Undernutrition is an underlying cause in
half of deaths from diarrhea,
pneumonia, malaria and measles.

Interventions to improve nutrition can have a large
effect because of reduced fatality from several
major infectious causes.

The role of undernutrition in cause-specific deaths
in the neonatal period needs further study.
Conclusion
Knowledge of the causes of child
deaths, especially at the country
level, can lead to rational choices
of interventions and delivery
strategies to have the greatest
impact on child mortality.