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 Age-specific mortality rates Under-5 and adult mortality rates Complete vital registration Sample registration system DHS, MICS and other surveys Life tables Country-level all-cause mortality envelope by age and sex Incomplete vital registration Censuses UN estimates UN population estimates

Child mortality trends in Egypt Source: UNICEF

Trends in child mortality relative to MDG-4 Sub-Saharan Africa South Asia Latin America East Asia Under- Five Mortality Rate MDG-4 Goals Source: The State of the World’s Children, 2006

Average annual rate of reduction UNICEF Region % Current % Needed to Achieve MDG % L. America/ Caribbean E. Asia Mid-East/ N. Africa S. Asia Sub Saharan Africa Current and needed annual rate of reduction in child mortality to achieve MDG-4 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

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 Country-level all-cause mortality envelope by age and sex Cause-specific mortality patterns Independent studies/reports/models, e.g.,CHERG WHO program estimates UNAIDS estimates Global and regional level age, sex and cause specific mortality estimates Country level age-, sex- and cause- specific mortality 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 under- five deaths. Role of undernutrition must also be considered.

Relative Risk (RR) of death by cause due to underweight, estimated from random effects models RR Source: Caulfield L, et al., Am J Clin Nutr, 2004

Prevalence of underweight in children years old, by WHO region Source: de Onis and Blossner, Int J Epi, Prevalence (%)

Major causes of death in neonates and children aged 28 days to 5 years (yearly average for ) Deaths among children aged 28 days to five years (  6.6 million/year) Neonatal deaths (  4 million/year) The % of deaths due to maternal and neonatal undernutrition is under study 52% 61% 57% Under Study Under Study 45% The % of deaths from this infection that are due to the presence of undernutrition

Global distribution of disease burden attributable to 20 selected risk factors 0.0%1.0%2.0%3.0%4.0%5.0%6.0%7.0%8.0%9.0%10.0% 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 Illicit drugs Unsafe health care injections Lack of contraception Childhood sexual abuse Attributable DALY (% of global DALY - Total 1.46 billion) High-mortality developing Lower-mortality developing Developed Source: Ezzati M et al., Lancet 2002

Implications for child survival 1. 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

2. 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. 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. Implications for child survival

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.