1. Allegheny County Child Death Review Allegheny County Health Department Office of Epidemiology and Biostatistics Presenter: Erin Austin Faculty Advisor: Sam Stebbins, MD, MPH Internship Advisor: Ron Voorhees, MD, MPH October 7, 2010

2. Background The purpose of Child Death Review is to conduct a comprehensive, multidisciplinary review of child deaths, to better understand how and why children die, and use the findings to take action that can prevent other deaths and improve the health and safety of children. Currently, all fifty states and the District of Columbia employ Child Death Review programs in some format, either at the local level, state level, or occasionally both, as is the case in Pennsylvania. Pennsylvania established the Public Health Child Death Review Act (Act 87) on October 8, 2008, which requires the deaths of children 21 years of age and younger to be reviewed on a county level. However, Allegheny County has been reviewing child deaths since 1997 with the primary goal of preventing future deaths among county residents.

3. Objectives To analyze Child Death Review data of Allegheny County in order to identify trends and risk factors related to child deaths. To identify deficiencies in the Child Death Review surveillance and reporting systems, and in the review procedures.

4. Allegheny County Child Death Review, 2005-2008 The Allegheny County Child Death Review Team (CDRT) reviewed deaths in children 19 years of age and younger for the period of 2005 to 2008, as it was prior to the passing of Act 87. Due to surveillance and review limitations not all child deaths were reviewed by the CDRT during this period. The review of child deaths in 2007 is incomplete due to a change in the child death review process. Child deaths in 2005 and 2006 were reviewed in a retrospective manner; however in 2008 the review process was converted to near real-time reviews. This change allowed for more timely recommendations and preventions to be enacted in response to deaths of children.

5. Pennsylvania State legislation requires that local Child Death Review Teams should include, but are not limited to, the following members: Director of children and youth agency District attorney Representative of local law enforcement Representative of the court of common pleas Pediatric physician Medical examiner Representative of emergency medical services Director of local public health agency In addition, Allegheny County CDRT includes members from: Mental health services Public schools Cribs for Kids SIDS of PA Healthy Start

6. Methods The reviewed deaths submitted to the National Center for Child Death Review database for Allegheny County were matched with deaths certificates gathered by the Office of Epidemiology and Biostatistics at the Allegheny County Health Department for 2005 to 2008. The deaths were matched on four identifying variables: date of birth, date of death, sex, race, and manner of death. Number counts and rates using the 2000 Allegheny County Census data were calculated for matched child deaths. Child deaths that occurred in Allegheny County but were not reviewed by the CDRT were also examined to identify any trends as to why those deaths may have been missed by surveillance.

7. Disclaimer Statistics for 2007 are incomplete, however the available data have still been incorporated into this presentation. For purposes of calculating averages the data from year 2007 have been omitted.

8. Results Figure 1: Vital Statistics vs. Child Death Review, Allegheny County, 2005-2008. A total of 710 child deaths, age birth to 19 years occurred from 2005 to 2008, of these 620 were reviewed. The overall child mortality rate of in Allegheny County decreased steadily between 2005 and 2007, from 57.5 to 53.0 deaths per 100,000 children and then jumped in 2008 to 60.7 deaths per 100,000 children.

9. Figure 2: Number of Deaths by Manner, 2005-2008. The majority of reviewed child deaths were due to natural causes, with an average of 70% (N=356) categorized as natural deaths, whereas unintentional deaths accounted for 10% (N=52), homicide 14% (N=70), suicide 3% (N=15), and undetermined 3% (N=16). In comparison, for child deaths reviewed by Pennsylvania in 2008, natural deaths accounted for 62%, unintentional deaths 17%, homicide 11%, suicide 3%, and undetermined deaths 3%. 2005, 2006, 2008

10. Figure 3: Number of Deaths by Race, 2005-2008. Whites represented on average 52% (N=263) of all child deaths in Allegheny County, while blacks represented 47% (N=239) of deaths, and Asian races (including Chinese and Indian) for 1% (N=10) of deaths. On average blacks were 4 times more likely to die between birth through 19 years of age compared to whites in Allegheny County. The death rate was 142 deaths per 100,000 children among blacks compared to 36 deaths per 100,000 among whites. 2005, 2006, 2008

11. Figure 4: Number of Deaths by Sex, 2005-2008. The distribution of reviewed child deaths by sex was very similar across years. On average males accounted for almost two-thirds (65%) of all deaths and their rate of death was 1.8 times higher compared to that of females.

12. Figure 5: Number of Deaths by Age, 2005-2008. The age distribution of child deaths in Allegheny County had a very distinct pattern for this 4 year time period. Over half of reviewed child deaths were in children under 1 year of age, followed by a by decrease in the number of deaths through age 9 until an increase, particularly between ages 15 to 19.

13. Figure 6: Number of Natural Deaths by Cause, 2005-2008. The most common cause of natural death was due to prematurity (49%) in infants. This substantial number of prematurity deaths can be attributed to fetal deaths from as young as 16 weeks gestation being considered infant deaths in Allegheny County. Congenital anomalies, cancer, and SIDS also contributed to a portion of natural deaths.

14. Figure 7: Number of Unintentional Deaths by Cause, 2005-2008. Unintentional deaths were most prevalent in white males, accounting for 53% of all unintentional deaths. Almost half (N=26, 44%) of unintentional deaths in children between 2005 and 2008 resulted from motor vehicle accidents. Accidental carbon monoxide poisoning caused two out of the three poisoning deaths in 2006, where as all poisoning deaths in 2008 were due to accidental drug overdose.

15. Figure 8: Rate of Homicides by Race, 2005-2008. A total of 77 homicides in children were observed from 2005 to 2008. The percentage of black homicide victims (87%) is disproportionate to the population distribution by race in Allegheny County, where 18% of the population under 20 years is black. On average, the rate of homicide in black males is 39 times higher compared to white males, 79 times higher than white females, and 7.5 times higher than black females.

16. Figure 9: Homicides by Location of Residence, 2005-2008. The majority of homicides occurred within the city limits of Pittsburgh, with noticeable occurrences in the surrounding communities of Wilkinsburg, West Mifflin, and McKeesport. In addition, 84% of homicides in Allegheny County were due to the use of a firearm and occurred mostly in children 15 to 19 years of age

17. Figure 10: Number of Deaths Not Reviewed by Allegheny County Child Death Review by Manner, 2005-2008. The majority of child deaths missed by Child Death Review surveillance were natural and unintentional deaths, with the exception of 2007 which also had a disproportionate number of homicides not reviewed.

18. Conclusion Black children between birth and age 19 years comprise 18% of the population in Allegheny County but accounted for 48% of all the child deaths between 2005 and 2008. A disproportionate number of black males were victim to homicide, particularly between the ages of 15 and 19. White males accounted for over half of child deaths due to unintentional injuries. Prematurity in infants resulted in a substantial number of natural deaths that may be preventable through modifiable risk factor of pregnant mothers. These findings indicate areas for intervention among children in Allegheny County.

19. Discussion Systematic collection and review of child deaths is necessary to identify significant risk factors as well as patterns in child mortality, injury, and safety. In addition, findings from the Child Death Review should be reported regularly and disseminated to relevant local and state stakeholders for appropriate implementation of prevention strategies. Presently there is no national policy requiring unified organizational and operational structure for the review and reporting of child deaths. Without standard protocols and definitions, certain Child Death Review statistics may not be comparable between states or at the national level.