Trends,causes, and risk factors of mortality among children under 5 in Ethiopia, 1990–2013: findings from the Global Burden of Disease Study 2013

Background

Ethiopia has made remarkable progress in reducing child mortality over the last two decades. However, the under-5 mortality rate in Ethiopia is still higher than the under-5 mortality rates of several low- and middle-income countries (LMIC). On the other hand, the patterns and causes of child mortality have not been well investigated in Ethiopia. The objective of this study was to investigate the mortality trend, causes of death, and risk factors among children under 5 in Ethiopia during 1990–2013.

Methods

We used Global Burden of Disease (GBD) 2013 data. Spatiotemporal Gaussian Process Regression (GPR) was applied to generate best estimates of child mortality with 95% uncertainty intervals (UI). Causes of death by age groups, sex, and year were measured using Cause of Death Ensemble modeling (CODEm). For estimation of HIV/AIDS mortality rate, the modified UNAIDS EPP-SPECTRUM suite model was used.

Results

Between 1990 and 2013 the under-5 mortality rate declined from 203.9 deaths/1000 live births to 74.4 deaths/1000 live births with an annual rate of change of 4.6%, yielding a total reduction of 64%. Similarly, child (1–4 years), post-neonatal, and neonatal mortality rates declined by 75%, 64%, and 52%, respectively, between 1990 and 2013. Lower respiratory tract infection (LRI), diarrheal diseases, and neonatal syndromes (preterm birth complications, neonatal encephalopathy, neonatal sepsis, and other neonatal disorders) accounted for 54% of the total under-5 deaths in 2013. Under-5 mortality rates due to measles, diarrhea, malaria, protein-energy malnutrition, and iron-deficiency anemia declined by more than two-thirds between 1990 and 2013. Among the causes of under-5 deaths, neonatal syndromes such as sepsis, preterm birth complications, and birth asphyxia ranked third to fifth in 2013.Of all risk-attributable deaths in 1990, 25% of the total under-5 deaths (112,288/435,962) and 48% (112,288/232,199) of the deaths due to diarrhea, LRI, and other common infections were attributable to childhood wasting. Similarly, 19% (43,759/229,333) of the total under-5 deaths and 45% (43,759/97,963) of the deaths due to diarrhea and LRI were attributable to wasting in 2013. Of the total diarrheal disease- and LRI-related deaths (n?=?97,963) in 2013, 59% (57,923/97,963) of them were attributable to unsafe water supply, unsafe sanitation, household air pollution, and no handwashing with soap.

Conclusions

LRI, diarrheal diseases, and neonatal syndromes remain the major causes of under-5 deaths in Ethiopia. These findings call for better-integrated newborn and child survival interventions focusing on the main risk factors.

     

Mortality trends among refugees in Honduras, 1984-1987

Mortality data collected from 1984 to 1987 through a routine standardized health information system in the five main refugee populations of Honduras were reviewed. The direct standardized mean annual death rate for all refugees was 5.5 per 1000 population (Honduras population as reference; Honduras mortality rate: 10.1 per 1000). Mortality decreased or remained stable among Salvadoran refugees from 1984 to 1987, but increased among Nicaraguan refugees after 1985. The highest neonatal (56.1 per 1000 livebirths), infant (126.1 per 1000 livebirths) and under-five-year-olds (35.7 per 1000 child less than five years of age) mortality rates were observed in the two Nicaraguan camps. These two camps had the highest rate of newly arriving refugees. Deaths in infants and under-five-year-olds accounted for 42 and 54.1% of all deaths respectively. Of all deaths under five years of age, respiratory infections, diarrhoeal diseases and measles accounted for 21.4%, 22.1% and 4.7%, respectively. Mortality rates, particularly among under-five-year-olds and infants increased when the rate of newly arriving refugees was higher. The importance of adapted health surveillance in refugee settlements is discussed.     

Persistent and acute diarrhoea as the leading causes of child mortality in urban Guinea Bissau.

An investigation of child mortality in a semi-urban community, Bandim II, in the capital of Guinea Bissau was carried out from April 1987 to March 1990. 153 deaths were recorded among 1426 live-born children who were followed for 2753 child-years. The under-five mortality risk was 215 per 1000 children (95% confidence interval [CI] 176-264), infant mortality 94 per 1000 (95% CI 73-115), and perinatal mortality 52 per 1000 (95% CI 41-63). By prospective registration of morbidity, post-mortem interviews, and examination of available hospital records, a presumptive cause of death was established in 86% of the deaths. Persistent and acute diarrhoea were the most frequent causes of death, accounting for 43 and 31 deaths per 1000 children, respectively. Fever deaths (possibly malaria), neonatal deaths, acute respiratory infections, and measles were other frequent causes. The access to health services was relatively easy: 75% of the children who died had attended for treatment at a hospital or a health centre. It is important to find ways of preventing and managing persistent diarrhoea, the major cause of death, and to improve the control of acute diarrhoea by a targeted approach.     

Quantifying the burden of disease associated with inadequate provision of water and sanitation in selected sub-Saharan refugee camps

A WHO methodology is used for the first time to estimate the burden of disease directly associated with incomplete water and sanitation provision in refugee camps in sub-Saharan African countries. In refugee camps of seven countries, containing just fewer than 1 million people in 2005, there were 132,000 cases of diarrhoea and over 280,000 reported cases of malaria attributable to incomplete water and sanitation provision. In the period from 2005 to 2007 1,400 deaths were estimated to be directly attributable to incomplete water and sanitation alone in refugee camps in Ethiopia, Kenya and Tanzania. A comparison with national morbidity estimates from WHO shows that although diarrhoea estimates in the camps are often higher, mortality estimates are generally much lower, which may reflect on more ready access to medical aid within refugee camps. Despite the many limitations, these estimates highlight the burden of disease connected to incomplete water and sanitation provision in refugee settings and can assist resource managers to identify camps requiring specific interventions. Additionally the results reinforce the importance of increasing dialogue between the water, sanitation and health sectors and underline the fact that efforts to reduce refugee morbidity would be greatly enhanced by strengthening water and sanitation provision.     

Vitamin/mineral supplementation and cancer, cardiovascular, and all-cause mortality in a German prospective cohort (EPIC-Heidelberg)

Purpose

To prospectively evaluate the association of vitamin/mineral supplementation with cancer, cardiovascular, and all-cause mortality.

Methods

In the Heidelberg cohort of the European Prospective Investigation into Cancer and Nutrition (EPIC-Heidelberg), which was recruited in 1994–1998, 23,943 participants without pre-existing cancer and myocardial infarction/stroke at baseline were included in the analyses. Vitamin/mineral supplementation was assessed at baseline and during follow-up. Cox regression models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs).

Results

After an average follow-up time of 11?years, 1,101 deaths were documented (cancer deaths?=?513 and cardiovascular deaths?=?264). After adjustment for potential confounders, neither any vitamin/mineral supplementation nor multivitamin supplementation at baseline was statistically significantly associated with cancer, cardiovascular, or all-cause mortality. However, baseline users of antioxidant vitamin supplements had a significantly reduced risk of cancer mortality (HR: 0.52; 95% CI: 0.28, 0.97) and all-cause mortality (HR: 0.58; 95% CI: 0.38, 0.88). In comparison with never users, baseline non-users who started taking vitamin/mineral supplements during follow-up had significantly increased risks of cancer mortality (HR: 1.74; 95% CI: 1.09, 2.77) and all-cause mortality (HR: 1.58; 95% CI: 1.17, 2.14).

Conclusions

Based on limited numbers of users and cases, this cohort study suggests that supplementation of antioxidant vitamins might possibly reduce cancer and all-cause mortality. The significantly increased risks of cancer and all-cause mortality among baseline non-users who started taking supplements during follow-up may suggest a “sick-user effect,” which researchers should be cautious of in future observational studies.     

Hospitalizations for infectious diseases in Jewish and Bedouin children in southern Israel

Two different population groups reside in the Negev region of southern Israel and have equal, and free from financial barrier, access to tertiary care at a single regional hospital. The Jewish population has a largely urban and industrialized lifestyle, while the Moslem Bedouins are in transition from their traditional nomadic life to settlement. To examine the differences in morbidity patterns reflected in hospitalizations, the computerized hospitalization records of children <15 years of age, for 1989–1991 were used (n = 15,947). Rates of hospitalizations for infectious diseases were significantly higher for Bedouins in comparison to Jews (250 and 121/10,000 child years, respectively, odds ratio (OR): 2.1, 95% confidence interval (CI): 2.0–2.2, p < 0.001). Rates of hospitalization per 10,000 child years in Bedouins and Jews for diarrhea were 114 and 32 (OR: 3.7, 95% CI: 3.3–4.0, p < 0.001), respectively, and for pneumonia 55 and 19 (OR: 2.9, 95% CI: 2.6–3.3, p < 0.001), respectively. In infants the differences were even more pronounced, especially for diarrheal diseases. In Bedouin children infectious diseases were associated with longer hospital stay, more pediatric Intensive Care hospitalizations (OR: 2.7, 95% CI: 1.7–4.5, p < 0.001), and higher in-hospital mortality (OR: 5.7, 95% CI: 2.8–12.2, p < 0.001). Thus, Bedouin children are at higher risks of hospitalizations for infectious diseases in early childhood, as compared to Jewish children. This may reflect the differences in lifestyle, environmental and social conditions of the two populations.     

Trends in socioeconomic disparities in a rapid under-five mortality transition: a longitudinal study in the United Republic of Tanzania

Objective

To explore trends in socioeconomic disparities and under-five mortality rates in rural parts of the United Republic of Tanzania between 2000 and 2011.

Methods

We used longitudinal data on births, deaths, migrations, maternal educational attainment and household characteristics from the Ifakara and Rufiji health and demographic surveillance systems. We estimated hazard ratios (HR) for associations between mortality and maternal educational attainment or relative household wealth, using Cox hazard regression models.

Findings

The under-five mortality rate declined in Ifakara from 132.7 deaths per 1000 live births (95% confidence interval, CI: 119.3–147.4) in 2000 to 66.2 (95% CI: 59.0–74.3) in 2011 and in Rufiji from 118.4 deaths per 1000 live births (95% CI: 107.1–130.7) in 2000 to 76.2 (95% CI: 66.7–86.9) in 2011. Combining both sites, in 2000–2001, the risk of dying for children of uneducated mothers was 1.44 (95% CI: 1.08–1.92) higher than for children of mothers who had received education beyond primary school and in 2010–2011, the HR was 1.18 (95% CI: 0.90–1.55). In contrast, mortality disparities between richest and poorest quintiles worsened in Rufiji, from 1.20 (95% CI: 0.99–1.47) in 2000–2001 to 1.48 (95% CI: 1.15–1.89) in 2010–2011, while in Ifakara, disparities narrowed from 1.30 (95% CI: 1.09–1.55) to 1.15 (95% CI: 0.95–1.39) in the same period.

Conclusion

While childhood survival has improved, mortality disparities still persist, suggesting a need for policies and programmes that both reduce child mortality and address socioeconomic disparities.     

Cost effectiveness of community-based therapeutic care for children with severe acute malnutrition in Zambia: decision tree model

Background

Children aged under five years with severe acute malnutrition (SAM) in Africa and Asia have high mortality rates without effective treatment. Primary care-based treatment of SAM can have good outcomes but its cost effectiveness is largely unknown.

Method

This study estimated the cost effectiveness of community-based therapeutic care (CTC) for children with severe acute malnutrition in government primary health care centres in Lusaka, Zambia, compared to no care. A decision tree model compared the costs (in year 2008 international dollars) and outcomes of CTC to a hypothetical 'do-nothing' alternative. The primary outcomes were mortality within one year, and disability adjusted life years (DALYs) after surviving one year. Outcomes and health service costs of CTC were obtained from the CTC programme, local health services and World Health Organization (WHO) estimates of unit costs. Outcomes of doing nothing were estimated from published African cohort studies. Probabilistic and deterministic sensitivity analyses were done.

Results

The mean cost of CTC per child was $203 (95% confidence interval (CI) $139–$274), of which ready to use therapeutic food (RUTF) cost 36%, health centre visits cost 13%, hospital admissions cost 17% and technical support while establishing the programme cost 34%. Expected death rates within one year of presentation were 9.2% with CTC and 20.8% with no treatment (risk difference 11.5% (95% CI 0.4–23.0%). CTC cost $1760 (95% CI $592–$10142) per life saved and $ 53 (95% CI $18–$306) per DALY gained. CTC was at least 80% likely to be cost effective if society was willing to pay at least $88 per DALY gained. Analyses were most sensitive to assumptions about mortality rates with no treatment, weeks of CTC per child and costs of purchasing RUTF.

Conclusion

CTC is relatively cost effective compared to other priority health care interventions in developing countries, for a wide range of assumptions.     

Beri-beri: the major cause of infant mortality in Karen refugees

During a prospective evaluation of malaria prophylaxis in pregnancy in a refugee population on the north-western border of Thailand from 1987 to 1990, an extremely high infant mortality rate (18%) was documented despite good access to health care. Infantile beri-beri was recognized as the main cause of death accounting for 40% of all infant mortality. Thereafter, severe vitamin B1 deficiency in infants was diagnosed and treated promptly. The impact of this was assessed prospectively from 1993 to 1996 in a second cohort study. The case fatality of infantile beri-beri fell from almost 100% to 7%. The overall infant mortality rates declined from 183 to 78 per 1000 live births. Post-neonatal deaths fell by 79% (95% CI 65-87%) while neonatal mortality remained unchanged. Mortality resulting from acute respiratory infections did not change (15 and 11 per 1000, respectively), whereas mortality attributable to beri-beri decreased from 73 to 5 per 1000 (P < 0.0001). Before its recognition approximately 7% of all infants in this population died from infantile beri-beri. This lethal but preventable syndrome may be more common than hitherto recognized, particularly in refugee populations, in this populous region.     

Potential interventions for the prevention of childhood pneumonia in developing countries: a meta-analysis of data from field trials to assess the impact of vitamin A supplementation on pneumonia morbidity and mortality. The Vitamin A and Pneumonia Working Group.

Reported are the results of a meta-analysis (12 large-scale field trials in seven countries) of the impact of vitamin A supplementation on pneumonia morbidity and mortality, undertaken as part of a wider review process of a range of possible potential interventions for the prevention of childhood pneumonia. The summary estimate of the relative risk for the impact of vitamin A supplementation on pneumonia incidence was 0.95 (95% confidence interval (CI) = 0.89, 1.01), and for pneumonia mortality, 0.98 (95% CI = 0.75, 1.28). This is in marked contrast to the substantial impact of vitamin A supplementation on all-cause mortality (combined rate ratio (RR) = 0.77, 95% CI = 0.71, 0.84), and on diarrhoea-specific and measles-specific mortality. There was no evidence for a differential impact on pneumonia mortality by age. Since the majority of pneumonia deaths occur in the first year of life, we complemented the paucity of data on pneumonia-specific mortality among this age group with a detailed examination of all-cause mortality among infants. The mortality reduction in the 6-11 month age group was consistent with that observed for older age groups (RR = 0.69; 95% CI = 0.54, 0.90), but there was no reduction for 0-5 month-olds (RR = 0.97; 95% CI = 0.73, 1.29).     

An updated historical cohort mortality study of workers exposed to asbestos in a refitting shipyard, 1947�C2007

Purpose

To evaluate the long-term health effects of occupational asbestos exposure, an updated historical cohort mortality study of workers at a refitting shipyard was undertaken.

Methods

The cohort consisted of 249 male ship repair workers (90 laggers, 159 boiler repairers). To determine relative excess mortality, standardized mortality ratios (SMRs) were calculated using mortality rates among the Japanese male population. Mortality follow-up of study subjects was performed for the period from 1947 till the end of 2007.

Results

We identified the vital status of 87 (96.7%) laggers and 150 (94.3%) boiler repairers. Of these, 63 (72.4%) and 95 (63.3%), respectively, died. Laggers, who had handled asbestos materials directly, showed a significantly elevated SMR of 2.64 (95% confidence interval [CI]: 1.06?C5.44) for lung cancer and 2.49 (95% CI: 1.36?C4.18) for nonmalignant respiratory diseases. Boiler repairers, who had many opportunities for secondary exposure to asbestos and a few for direct exposure, showed no significant elevation in SMR for lung cancer but a significantly elevated SMR of 1.78 (95% CI: 1.06?C2.81) for nonmalignant respiratory diseases. In an analysis according to duration of employment, there was a significantly elevated SMR of nonmalignant respiratory diseases in the longer working years group. Among workers from both jobs, no deaths caused by mesothelioma in addition to those in the original study were found and no subject died from larynx cancer.

Conclusion

This updated study confirmed a significant excess of asbestos-related mortality from diseases such as lung cancer and nonmalignant respiratory diseases among workers in a refitting shipyard in Japan.     

Does spending on refugees make a difference? A cross-sectional study of the association between refugee program spending and health outcomes in 70 sites in 17 countries

Background

Numerous simultaneous complex humanitarian emergencies strain the ability of local governments and the international community to respond, underscoring the importance of cost-effective use of limited resources. At the end of 2011, 42.5 million people were forcibly displaced, including 10.4 million refugees under the mandate of the United Nations High Commissioner for Refugees (UNHCR). UNHCR spent US$1.65 billion on refugee programs in 2011. We analyze the impact of aggregate-level UNHCR spending on mortality of refugee populations.

Methods

Using 2011 budget data, we calculated purchasing power parity adjusted spending, disaggregated by population planning groups (PPGs) and UNHCR Results Framework objectives. Monthly mortality reported to UNHCR’s Health Information System from 2011 to 2012 was used to calculate crude (CMR) and under-5 (U5MR) mortality rates, and expressed as ratios to country of asylum mortality. Log-linear regressions were performed to assess correlation between spending and mortality.

Results

Mortality data for 70 refugee sites representing 1.6 million refugees in 17 countries were matched to 20 PPGs. Median 2011 spending was $623.27 per person (constant 2011 US$). Median CMR was 2.4 deaths per 1,000 persons per year; median U5MR was 18.1 under-5 deaths per 1,000 live births per year. CMR was negatively correlated with total spending (p?=?0.027), and spending for fair protection processes and documentation (p?=?0.005), external relations (p?=?0.034), logistics and operations support (p?=?0.007), and for healthcare (p?=?0.046). U5MR ratio was negatively correlated with total spending (p?=?0.015), and spending for favorable protection environment (p?=?0.024), fair protection processes and documentation (p?=?0.003), basic needs and essential services (p?=?0.027), and within basic needs, for healthcare services (p?=?0.007).

Conclusion

Increased UNHCR spending on refugee populations is correlated with lower mortality, likely reflecting unique refugee vulnerabilities and dependence on aid. Future analyses using more granular data can further elucidate the health impact of humanitarian sector spending, thereby guiding policy choices.

     

Hospital-based surveillance of malaria-related paediatric morbidity and mortality in Kinshasa, Zaire

Although Plasmodium falciparum malaria is a leading cause of paediatric morbidity and mortality in Africa, few quantitative estimates are available about the impact of malaria on childhood health. To quantify the impact of the disease in an urban African setting, we reviewed the paediatric ward and mortuary records at Mama Yemo Hospital in Kinshasa, Zaire. From June 1985 to May 1986, 6208 children were admitted to the hospital, 2374 (38.2%) of whom had malaria; 500 of those with malaria died (case fatality rate, 21.1%). During this same period, there were 10,036 paediatric deaths, 1323 (13.2%) of which were attributed to malaria; 823 (62.2%) of these occurred in the emergency ward prior to hospitalization. Minimum population-based malaria mortality rates were highest for children aged less than 1 year (4.0 per 1000 per year). Over 70% of children admitted with malaria and greater than 80% of children who died from the disease were less than 5 years old. The total number of paediatric admissions and deaths remained relatively constant between 1982 and 1986; however, the proportional malaria admission rate increased from 29.5% in 1983 to 56.4% in 1986, and the proportional malaria mortality rate, from 4.8% in 1982 to 15.3% in 1986. These increases were temporally related to the emergence of chloroquine-resistant Plasmodium falciparum malaria in Kinshasa. Malaria is therefore a major cause of paediatric morbidity and mortality in the city, and this study indicates that hospital-based surveillance may be useful in monitoring disease-specific morbidity and mortality elsewhere in Africa.     

Quality-of-care audits and perinatal mortality in South Africa

Problem

Suboptimal care contributes to perinatal mortality rates. Quality-of-care audits can be used to identify and change suboptimal care, but it is not known if such audits have reduced perinatal mortality in South Africa.

Approach

We investigated perinatal mortality trends in health facilities that had completed at least five years of quality-of-care audits. In a subset of facilities that began audits from 2006, we analysed modifiable factors that may have contributed to perinatal deaths.

Local setting

Since the 1990s, the perinatal problem identification programme has performed quality-of-care audits in South Africa to record perinatal deaths, identify modifiable factors and motivate change.

Relevant changes

Five years of continuous audits were available for 163 facilities. Perinatal mortality rates decreased in 48 facilities (29%) and increased in 52 (32%). Among the subset of facilities that began audits in 2006, there was a decrease in perinatal mortality of 30% (16/54) but an increase in 35% (19/54). Facilities with increasing perinatal mortality were more likely to identify the following contributing factors: patient delay in seeking help when a baby was ill (odds ratio, OR: 4.67; 95% confidence interval, CI: 1.99–10.97); lack of use of antenatal steroids (OR: 9.57; 95% CI: 2.97–30.81); lack of nursing personnel (OR: 2.67; 95% CI: 1.34–5.33); fetal distress not detected antepartum when the fetus is monitored (OR: 2.92; 95% CI: 1.47–5.8) and poor progress in labour with incorrect interpretation of the partogram (OR: 2.77; 95% CI: 1.43–5.34).

Lessons learnt

Quality-of-care audits were not shown to improve perinatal mortality in this study.     

Burden of climate change on malaria mortality

In 2016, an estimated 445,000 deaths and 216 million cases of malaria occurred worldwide, while 70% of the deaths occurred in children under five years old. Changes in climatic exposures such as temperature and precipitation make malaria one of the most climate sensitive outcomes. Using a global malaria mortality dataset for 105 countries between 1980 and 2010, we find a non-linear relationship between temperature and malaria mortality and estimate that the global optimal temperature threshold beyond which all-age malaria mortality increases is 20.8?°C, while in the case of child mortality; a significantly lower optimum temperature of 19.3° is estimated. Our results also suggest that this optimal temperature is 28.4?°C and 26.3?°C in Africa and Asia, respectively – the continents where malaria is most prevalent. Furthermore, we estimate that child mortality (ages 0–4) is likely to increase by up to 20% in some areas due to climate change by the end of the 21st century.     

Mortality and morbidity from malaria among children in a rural area of The Gambia, West Africa

Mortality and morbidity from malaria were measured among 3000 children under the age of 7 years in a rural area of The Gambia, West Africa. Using a post-mortem questionnaire technique, malaria was identified as the probable cause of 4% of infant deaths and of 25% of deaths in children aged 1 to 4 years. The malaria mortality rate was 6.3 per 1000 per year in infants and 10.7 per 1000 per year in children aged 1 to 4 years. Morbidity surveys suggested that children under the age of 7 years experienced about one clinical episode of malaria per year. Calculation of attributable fractions showed that malaria may be responsible for about 40% of episodes of fever in children. Although the overall level of parasitaemia showed little seasonal variation, the clinical impact of malaria was highly seasonal; all malaria deaths and a high proportion of febrile episodes were recorded during a limited period at the end of the rainy season.     

Breastfeeding for reducing the risk of pneumonia morbidity and mortality in children under two: a systematic literature review and meta-analysis

Background

Suboptimal breastfeeding practices among infants and young children <24 months of age are associated with elevated risk of pneumonia morbidity and mortality. We conducted a systematic review and meta-analysis to quantify the protective effects of breastfeeding exposure against pneumonia incidence, prevalence, hospitalizations and mortality.

Methods

We conducted a systematic literature review of studies assessing the risk of selected pneumonia morbidity and mortality outcomes by varying levels of breastfeeding exposure among infants and young children <24 months of age. We used random effects meta-analyses to generate pooled effect estimates by outcome, age and exposure level.

Results

Suboptimal breastfeeding elevated the risk of pneumonia morbidity and mortality outcomes across age groups. In particular, pneumonia mortality was higher among not breastfed compared to exclusively breastfed infants 0-5 months of age (RR: 14.97; 95% CI: 0.67-332.74) and among not breastfed compared to breastfed infants and young children 6-23 months of age (RR: 1.92; 95% CI: 0.79-4.68).

Conclusions

Our results highlight the importance of breastfeeding during the first 23 months of life as a key intervention for reducing pneumonia morbidity and mortality.

     

Determinants of premature mortality in a city population: An eight-year observational study concerning subjects aged 18–64

Background

Premature deaths constitute 31.1% of all deaths in ?ód?. Analysis of the causes of premature deaths may be helpful in the evaluation of health risk factors. Moreover, findings of this study may enhance prophylactic measures.

Material and Methods

In 2001, 1857 randomly selected citizens, aged 18-64, were included in the Countrywide Integrated Noncommunicable Diseases Intervention (CINDI) Programme. In 2009, a follow-up study was conducted and information on the subjects of the study was collected concerning their health status and if they continued to live in ?ód?. The Cox proportional hazards model was used for evaluation of hazard coefficients. We adjusted our calculations for age and sex. The analysis revealed statistically significant associations between the number of premature deaths of the citizens of ?ód? and the following variables: a negative self-evaluation of health — HR = 3.096 (95% CI: 1.729–5.543), poor financial situation — HR = 2.811 (95% CI: 1.183–6.672), occurring in the year preceding the study: coronary pain — HR = 2.754 (95% CI: 1.167–6.494), depression — HR = 2.001 (95% CI: 1.222–3.277) and insomnia — HR = 1.660 (95% CI: 1.029–2.678). Our research study also found a negative influence of smoking on the health status — HR = 2.782 (95% CI: 1.581–4.891). Moreover, we conducted survival analyses according to sex and age with Kaplan-Meier curves.

Conclusions

The risk factors leading to premature deaths were found to be highly significant but possible to reduce by modifying lifestyle-related health behaviours. The confirmed determinants of premature mortality indicate a need to spread and intensify prophylactic activities in Poland, which is a post-communist country, in particular, in the field of cardiovascular diseases.     

Predicting the distribution of under-five deaths by cause in countries without adequate vital registration systems

BACKGROUND: The absence of complete vital registration and atypical nature of the locations where epidemiological studies of cause of death in children are conducted make it difficult to know the true distribution of child deaths by cause in developing countries. A credible method is needed for generating valid estimates of this distribution for countries without adequate vital registration systems. METHODS: A systematic review was undertaken of all studies published since 1980 reporting under-5 mortality by cause. Causes of death were standardized across studies, and information was collected on the characteristics of each study and its population. A meta-regression model was used to relate these characteristics to the various proportional mortality outcomes, and predict the distribution in national populations of known characteristics. In all, 46 studies met the inclusion criteria. RESULTS: Proportional mortality outcomes were significantly associated with region, mortality level, and exposure to malaria; coverage of measles vaccination, safe delivery care, and safe water; study year, age of children under surveillance, and method used to establish definitive cause of death. In sub-Saharan Africa and in South Asia, the predicted distribution of deaths by cause was: pneumonia (23% and 23%), malaria (24% and <1%), diarrhoea (22% and 23%), 'neonatal and other' (29% and 52%), measles (2% and 1%). CONCLUSIONS: For countries without adequate vital registration, it is possible to estimate the proportional distribution of child deaths by cause by exploiting systematic associations between this distribution and the characteristics of the populations in which it has been studied, controlling for design features of the studies themselves.