News Release

Child deaths in individual countries and regions worldwide: More than two-thirds of 8.8 million

Global children under 5 deaths caused by infectious diseases; UK has most deaths in Western Europe

Peer-Reviewed Publication

The Lancet_DELETED

More than two thirds of the estimated 8•8 million deaths in children under-5 worldwide are caused by infectious diseases such as pneumonia, diarrhoea, malaria, and sepsis. Preterm birth complications, birth asphyxia, and congenital abnormalities are also important causes of death. High-income countries make up a very small (around 1%) proportion of the total deaths, while almost half of all under-5 deaths occur in just five countries—India, Nigeria, Democratic Republic of the Congo, Pakistan, and China. The UK has more child deaths in this age group than any other country in Western Europe. This global analysis is reported in an Article published Online First and in an upcoming Lancet, written by Professor Robert E Black, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA, and colleagues on behalf of the Child Health Epidemiology Reference Group (CHERG) of the World Health Organisation and UNICEF.

The study, funded by WHO, UNICEF, and the Bill & Melinda Gates Foundation through a grant to the US Fund for UNICEF, shows that, of estimated 8•8 million deaths in children younger than 5 years worldwide in 2008, infectious diseases caused 68% (5•97 million), with the largest percentages due to pneumonia (18%, 1•58 million), diarrhoea (15%, 1•34 million), and malaria (8%, 0•73 million).

41% (3•58 million) of deaths in children under-5 occurred in neonates (aged 0-27 days), and the most important single causes were preterm birth complications (1•03 million, 12% of all under-5 deaths), birth asphyxia (0•81 million, 9% of all under-5 deaths), sepsis (0.52 million, 6% of all under-5 deaths) and pneumonia (4%, 0•39 million of all under-5 deaths, but this figure for pneumonia in neonates is included in the total figure for pneumonia in the previous paragraph).

Distribution of deaths and their causes varied widely across the WHO regions (see figures 5 and 6 of the full paper). The largest numbers of deaths were in the Africa region (4•20 million) and in the southeast Asia region (2•39 million). These two regions had differing patterns of causes of death: a lower proportion of neonatal deaths occurred in the Africa region than in the southeast Asia region (29%, 1•22 million vs 54%, 1•30 million); and a higher proportion of deaths in Africa were due to malaria (16%, 0•68 million) and AIDS (4%, 0•18 million) than in southeast Asia, in which about 1% (0•02 million) were due to these two diseases combined.

In some regions, especially those with increased income and lowered mortality, such as the Americas, Europe, and developed Asian countries, including China (western Pacific region), a high proportion of child deaths occurred during the neonatal period, ranging from 48% (0•137 million out of 0•284 million) in the Americas to 54% (1•295 million out of 2•390 million) in southeast Asia, with preterm birth complications, congenital abnormalities, and birth-related asphyxia as leading causes (figure 6, full paper). In countries with very low neonatal mortality rates, congenital causes became proportionately more important.

There were far more under-5 child deaths in the UK than any other country in Western Europe, a difference that cannot solely be accounted for by population size. The UK, with a population of around 61 million, had 4,324 deaths in children under 5 in 2008, way ahead of France (population 64 million, deaths 3,090), Germany (population 82 million, deaths 2,943), and Italy (population 60 million, deaths 2,350). And while the UK total under-5 deaths total is very small in the global context, even in this high-income setting many deaths are preventable. 55% of under-5 deaths in the UK were in neonates. 147 deaths (3%) were due to pneumonia, and 74 (2%) to meningitis. Preterm birth complications (1549 deaths/36%) congenital abnormalities (1109 deaths/26%), and birth asphyxia (306 deaths/7%), and injuries (175 deaths/4%) were the leading single causes of death in children under-5 in the UK in 2008.

Not surprisingly, this contrasts sharply with a country such as India, which with 1.8 million under-5 child deaths is the country with the highest proportion (21%) of the global total of such deaths in 2008. Pneumonia (371 605 deaths /20%), preterm birth complications (248993 deaths/14%), and diarrhoea (237482 deaths /13%) are the leading single causes of death in India.

92% (0•68 million) of deaths due to malaria, and 90% (0•18 million) of deaths due to AIDS occurred in the Africa region. The authors note that successful vaccination programmes have reduced the worldwide total for deaths caused by measles and neonatal tetanus, but each of these diseases was still responsible for about 1% of deaths worldwide. Injuries were shown to be important preventable causes of death in nearly all countries, with 32% (0•09 million) of all such deaths in India and China. In high-income countries, injuries caused a higher proportional burden: eg, in the USA, 11% (4013) of 35238 total deaths in children under-5 were caused by injuries (although the USA's child injury deaths appear proportionally higher than most other high-income countries).

Despite a continuing increase in the population of children younger than 5 years, the mortality rate is declining: 8•8 million deaths occurred in 2008 versus 10•6 million per year during 2000󈝯. With greater declines in mortality in children aged 1󈞧 months than in neonates, the proportion of deaths in neonates has increased from 37% in 2000󈝯 to 41% (3•58 million) of 8•8 million deaths in children younger than 5 years in 2008. Thus, the main causes of death in the neonatal period—preterm birth complications, birth asphyxia, and neonatal sepsis and pneumonia—have become even more important.

The authors say that undernutrition, including stunting, severe wasting, deficiencies of vitamin A and zinc, and suboptimum breastfeeding, is not presented as a direct cause of death in these statistics, but has been found to be an underlying cause in a third of deaths in children younger than 5 years. They say: "In countries with adequate vital registration data, malnutrition was rarely listed as a cause of death, and verbal autopsy classification systems greatly underestimate the role of these nutritional deficiencies. Thus, we chose to allocate the few deaths reported to be caused by malnutrition to major infectious diseases that often precipitate severe wasting. Successful implementation of interventions to prevent the development of undernutrition and micronutrient deficiencies and to treat severe acute malnutrition would substantially reduce child mortality and improve the health and development of surviving children."

They add: "The concentration of all-cause child deaths and deaths due to some specific causes, such as diarrhoea, pneumonia, malaria, and AIDS, in a small set of countries is striking. This result is partly related to the large populations of children younger than 5 years in these countries, but also some diseases are concentrated because of epidemiological and social conditions. Success in disease control efforts in these countries is essential if Millennium Development Goal 4 targets are to be achieved. However, nearly all countries still face the challenge to reduce child deaths from preventable conditions, irrespective of their number or cause. These national estimates of the causes of child death in 2008 should help to identify priority interventions for child survival, and how to allocate national and international resources."

They conclude: "CHERG will continue to work with WHO and UNICEF to identify data, improve estimation methods, and encourage use of resulting cause-specific child mortality numbers and rates in national and global health planning and priority setting. We anticipate updating these estimates every year to complement yearly updates in total deaths in children younger than 5 years. We challenge countries and programmes to advance the quality and consistency of data on causes of death, and, most importantly to use such data in the design of programmes to achieve maximum progress in the crucial few years before [The Millennium Development Goal target of] 2015."

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Professor Robert E Black, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA T) +1 410 955 3934 E) rblack@jhsph.edu

For full Article, see: http://press.thelancet.com/childmort.pdf

*Note to editors: An accompanying Comment is not available at this time but will be available when the Article appears in an upcoming issue of The Lancet, date to be confirmed


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