Summary Background Up-to-date information on the causes of child deaths is crucial to guide global efforts to improve child survival. We report new estimates for 2008 of the major causes of death in ...children younger than 5 years. Methods We used multicause proportionate mortality models to estimate deaths in neonates aged 0–27 days and children aged 1–59 months, and selected single-cause disease models and analysis of vital registration data when available to estimate causes of child deaths. New data from China and India permitted national data to be used for these countries instead of predictions based on global statistical models, as was done previously. We estimated proportional causes of death for 193 countries, and by application of these proportions to the country-specific mortality rates in children younger than 5 years and birth rates, the numbers of deaths by cause were calculated for countries, regions, and the world. Findings Of the estimated 8·795 million deaths in children younger than 5 years worldwide in 2008, infectious diseases caused 68% (5·970 million), with the largest percentages due to pneumonia (18%, 1·575 million, uncertainty range UR 1·046 million–1·874 million), diarrhoea (15%, 1·336 million, 0·822 million–2·004 million), and malaria (8%, 0·732 million, 0·601 million–0·851 million). 41% (3·575 million) of deaths occurred in neonates, and the most important single causes were preterm birth complications (12%, 1·033 million, UR 0·717 million–1·216 million), birth asphyxia (9%, 0·814 million, 0·563 million–0·997 million), sepsis (6%, 0·521 million, 0·356 million–0·735 million), and pneumonia (4%, 0·386 million, 0·264 million–0·545 million). 49% (4·294 million) of child deaths occurred in five countries: India, Nigeria, Democratic Republic of the Congo, Pakistan, and China. Interpretation These country-specific estimates of the major causes of child deaths should help to focus national programmes and donor assistance. Achievement of Millennium Development Goal 4, to reduce child mortality by two-thirds, is only possible if the high numbers of deaths are addressed by maternal, newborn, and child health interventions. Funding WHO, UNICEF, and Bill & Melinda Gates Foundation.
Summary 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.
Summary Background Artemisinin-based combination therapies (ACTs) are the most effective treatment for uncomplicated Plasmodium falciparum malaria infection. A commonly used indicator for monitoring ...and assessing progress in coverage of malaria treatment is the proportion of children younger than 5 years with reported fever in the previous 14 days who have received an ACT. We propose an improved indicator that incorporates parasite infection status (as assessed by a rapid diagnostic test RDT), which is available in recent household surveys. In this study we estimated the annual proportion of children younger than 5 years with fever and a positive RDT in Africa who received an ACT in 2003–15. Methods Our modelling study used cross-sectional data on treatment for fever and RDT status for children younger than 5 years compiled from all nationally available representative household surveys (the Malaria Indicator Surveys, Demographic and Health Surveys, and Multiple Indicator Cluster Surveys) across sub-Saharan Africa between 2003 and 2015. Estimates for the proportion of children younger than 5 years with a fever within the previous 14 days and P falciparum infection assessed by RDT who received an ACT were incorporated in a generalised additive mixed model, including data on ACT distributions, to estimate coverage across all countries and time periods. We did random effects meta-analyses to examine individual, household, and community effects associated with ACT coverage. Findings We obtained data on 201 704 children younger than 5 years from 103 surveys (22 MIS, 61 DHS, and 20 MICS) across 33 countries. RDT results were available for 40 of these surveys including 40 261 (20%) children, and we predicted RDT status for the remaining 161 443 (80%) children. Our results showed that ACT coverage in children younger than 5 years with a fever and P falciparum infection increased across sub-Saharan Africa in 2003–15, but even in 2015, only 19·7% (95% CI 15·6–24·8) of children younger than 5 years with a fever and P falciparum infection received an ACT. In meta-analyses, children younger than 5 years were more likely to receive an ACT for fever and P falciparum infection if they lived in an urban area ( vs rural area; odds ratio OR 1·18, 95% CI 1·06–1·31), had household wealth above the national median ( vs wealth below the median; OR 1·26, 1·16–1·39), had a caregiver with any education ( vs no education; OR 1·31, 1·22–1·41), had a household insecticide-treated net (ITN; vs no ITN; OR 1·21, 1·13–1·29), were older than 2 years ( vs ≤2 years; OR 1·09, 1·01–1·17), or lived in an area with a higher mean P falciparum prevalence in children aged 2–10 years (OR 1·12, 1·02–1·23). In the subgroup of children for whom treatment was sought, those who sought treatment in the public sector were more likely to receive an ACT ( vs the private sector; OR 3·18, 2·67–3·78). Interpretation Despite progress during the 2003–15 malaria programme, ACT treatment for children with malaria remains unacceptably low. More work is needed at the country level to understand how health-care access, service delivery, and ACT supply might be improved to ensure appropriate treatment for all children with malaria. Funding US President's Malaria Initiative and Medicines for Malaria Venture.
Summary Background Rapid declines in malaria prevalence, cases, and deaths have been achieved globally during the past 15 years because of improved access to first-line treatment and vector control. ...We aimed to assess the intervention coverage needed to achieve further gains over the next 15 years. Methods We used a mathematical model of the transmission of Plasmodium falciparum malaria to explore the potential effect on case incidence and malaria mortality rates from 2015 to 2030 of five different intervention scenarios: remaining at the intervention coverage levels of 2011–13 (Sustain), for which coverage comprises vector control and access to treatment; two scenarios of increased coverage to 80% (Accelerate 1) and 90% (Accelerate 2), with a switch from quinine to injectable artesunate for management of severe disease and seasonal malaria chemoprevention where recommended for both Accelerate scenarios, and rectal artesunate for pre-referral treatment at the community level added to Accelerate 2; a near-term innovation scenario (Innovate), which included longer-lasting insecticidal nets and expansion of seasonal malaria chemoprevention; and a reduction in coverage to 2006–08 levels (Reverse). We did the model simulations at the first administrative level (ie, state or province) for the 80 countries with sustained stable malaria transmission in 2010, accounting for variations in baseline endemicity, seasonality in transmission, vector species, and existing intervention coverage. To calculate the cases and deaths averted, we compared the total number of each under the five scenarios between 2015 and 2030 with the predicted number in 2015, accounting for population growth. Findings With an increase to 80% coverage, we predicted a reduction in case incidence of 21% (95% credible intervals CrI 19–29) and a reduction in mortality rates of 40% (27–61) by 2030 compared with 2015 levels. Acceleration to 90% coverage and expansion of treatment at the community level was predicted to reduce case incidence by 59% (Crl 56–64) and mortality rates by 74% (67–82); with additional near-term innovation, incidence was predicted to decline by 74% (70–77) and mortality rates by 81% (76–87). These scenarios were predicted to lead to local elimination in 13 countries under the Accelerate 1 scenario, 20 under Accelerate 2, and 22 under Innovate by 2030, reducing the proportion of the population living in at-risk areas by 36% if elimination is defined at the first administrative unit. However, failing to maintain coverage levels of 2011–13 is predicted to raise case incidence by 76% (Crl 71–80) and mortality rates by 46% (39–51) by 2020. Interpretation Our findings show that decreases in malaria transmission and burden can be accelerated over the next 15 years if the coverage of key interventions is increased. Funding UK Medical Research Council, UK Department for International Development, the Bill & Melinda Gates Foundation, the Swiss Development Agency, and the US Agency for International Development.
India had the largest number of under-5 deaths of all countries in 2015, with substantial subnational disparities. We estimated national and subnational all-cause and cause-specific mortality among ...children younger than 5 years annually in 2000–15 in India to understand progress made and to consider implications for achieving the Sustainable Development Goal (SDG) child survival targets.
We used a multicause model to estimate cause-specific mortality proportions in neonates and children aged 1–59 months at the state level, with causes of death grouped into pneumonia, diarrhoea, meningitis, injury, measles, congenital abnormalities, preterm birth complications, intrapartum-related events, and other causes. AIDS and malaria were estimated separately. The model was based on verbal autopsy studies representing more than 100 000 neonatal deaths globally and 16 962 deaths among children aged 1–59 months at the subnational level in India. By applying these proportions to all-cause deaths by state, we estimated cause-specific numbers of deaths and mortality rates at the state, regional, and national levels.
In 2015, there were 25·121 million livebirths in India and 1·201 million under-5 deaths (under-5 mortality rate 47·81 per 1000 livebirths). 0·696 million (57·9%) of these deaths occurred in neonates. There were disparities in child mortality across states (from 9·7 deaths Goa to 73·1 deaths Assam per 1000 livebirths) and regions (from 29·7 deaths the south to 63·8 deaths the northeast per 1000 livebirths). Overall, the leading causes of under-5 deaths were preterm birth complications (0·330 million 95% uncertainty range 0·279–0·367; 27·5% of under-5 deaths), pneumonia (0·191 million 0·168–0·219; 15·9%), and intrapartum-related events (0·139 million 0·116–0·165; 11·6%), with cause-of-death distributions varying across states and regions. In states with very high under-5 mortality, infectious-disease-related causes (pneumonia and diarrhoea) were among the three leading causes, whereas the three leading causes were all non-communicable in states with very low mortality. Most states had a slower decline in neonatal mortality than in mortality among children aged 1–59 months. Ten major states must accelerate progress to achieve the SDG under-5 mortality target, while 17 are not on track to meet the neonatal mortality target.
Efforts to reduce vaccine-preventable deaths and to reduce geographical disparities should continue to maintain progress achieved in 2000–15. Enhanced policies and programmes are needed to accelerate mortality reduction in high-burden states and among neonates to achieve the SDG child survival targets in India by 2030.
Bill & Melinda Gates Foundation.
Abstract Background Although US$2·3 billion in 2011 was spent on malaria control globally, a financing gap of $2·8 billion remains. While equity in intervention coverage is the ultimate goal, with ...limited resources, it is crucial to target interventions strategically. Developments in cartographic methods for estimating Plasmodium falciparum parasite rate ( Pf PR) at low geospatial levels and availability of household surveys with global positioning system (GPS) coordinates now allow for estimation of malaria intervention coverage stratified by level of infection risk. Taking advantage of this information, we aim to identify whether malaria interventions are targeted to those populations most at risk of malaria infection. Methods Our study spanned 24 countries and used all 38 Malaria Indicator Surveys and Demographic and Health Surveys with GPS coordinates and survey questions on use of insecticide-treated mosquito nets (ITNs). For these surveys, conducted between 2003 and 2011, we obtained cluster-level Pf PR by matching coordinates of surveyed clusters to coordinates from Malaria Atlas Project Pf PR maps. For each survey, we calculated the proportion of household availability of ITNs and prevalence of indoor residual spraying (IRS) by level of malaria endemicity (low, intermediate, high). We sought to further explain variation in coverage of vector control interventions by examining Pf PR by wealth quintile and urban or rural residence. Findings Coverage of ITNs or IRS by endemicity level varies greatly by country and year. In only four (Burundi, Ethiopia, Senegal, Zimbabwe) of the 24 surveyed countries did the coverage of IRS or availability of ITNs increase monotonically with increasing endemicity level. While coverage of ITNs or IRS in Senegal in 2010 among populations at low risk was 16·4% (95% CI 13·2–19·6), coverage among those at intermediate and high risk was 31·7% (27·8–35·5) and 64·6% (30·0–99·0), respectively. By contrast, coverage in Tanzania in the same year was 73·5% (95% CI 69·3–77·6) among those at lowest risk, and 67·5% (64·4–70·7) and 53·0 (48·2–57·8) among those at medium and high risk, respectively. Nearly all surveys indicate lower coverage of vector control interventions and higher Pf PR in poorer, more rural areas. Interpretation In the countries examined in this study, coverage of vector control interventions did not necessarily increase with increasing malaria risk. If limited resources preclude protecting all persons at risk of malaria with vector control interventions, strategies for targeting interventions (such as on the basis of malaria risk) should be devised to achieve their greatest lifesaving potential. Funding None.
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