Validity of causes of infant death by verbal autopsy

The aim of this study was to investigate the suitability of the verbal autopsy technique in identification of cause of death during infancy. The study was carried out in 23 randomly selected clusters with 70 live births each, in districts Cuttack and Koraput of Orissa State. Each death occurrence during the reference period (1992–93) was investigated by the field investigator and cross checked by a medical professional using the same proforma. The probable cause of death in each case was analysed separately by the field investigator and then by the professionally qualified medical person. These were then compared using suitable statistical tests. A total of 179 infant deaths and 16 still births were reported by the field investigator in the area as compared to 183 deaths and 12 still births by professionally trained personnel. There was an agreement for 85.79 percent deaths and 75 percent still births. Disagreement was observed for fever, pneumonia, septicemia and meningitis as causes of deaths. It was more in rural area as compared to urban areas. The sensitivity and specificity of the tool were found to be 85.6 percent and 90.4 percent respectively. The technique is found to be cost effective, time saving and reasonably reliable. After intensive training the lay reporters can be used for recording easily recognizable signs and symptoms of infant deaths and thus help in monitoring infant mortality rate and causes of infant death in a vast country like India so as to achieve “health for all” by 2000 AD.     

Scale for identification of “at risk” families for underfive deaths

India currently has an infant mortality rate (IMR) of 73 and aims to reach 60 per 1000 live births by 2000 A.D. The “at risk” approach which has been traditionally used for Maternal and Child Health services could help to reduce costs. The main objective of the study was to identity socio-demographic “risk factors” at family level for underfive deaths and assess the validity and efficiency of a risk index scale for this purpose. A computerised database on about 71,000 individuals in 28 villages in Ballabgarh Block exists since 1987. All the underfive deaths in the study area during the period 1991–95 were compared with age and sex matched controls on socio-demographic variables. All variables which were found significant at 10% level were taken in for logistic regression. The variables found significant were used to construct a ten point scale. This scaling system was applied to all the families with an underfive child during the two year period 1996–97. Validity and efficiency of this approach was calculated. A total of 849 cases and their age and sex matched controls were studied. The variables which were significantly associated with risk of underfive deaths were: not received measles vaccine (2.19; 1.58–3.04), history of sibling death (2.03; 1.19–3.45), maternal illiteracy (1.86; 1.23–2.81), never used a contraceptive (1.59; 1.17–2.14), having more than 4 children (1.46; 1.04–2.05). About 40% of houses were labelled as high risk. The sensitivity and specificity were around 60%. The improvement in efficiency by the risk approach was 33%. Risk approach is helpful in identifying families who are at greater risk of having underfive deaths. It results in a modest increase in the efficiency of services.     

Use of verbal autopsy by health workers in under-five children

We conducted this study to ascertain whether health workers can routinely administer verbal autopsy (VA) to determine the cause of death in their area. The health workers were trained to administer verbal autopsy tool on the deaths occurring in the population under them. All the verbal autopsies of under-five deaths between January 2000 to December 2001 were reviewed by a pediatrician. There were 262 deaths of children under five years in this period, and 71% of them were infants, out of which 34% were neonatal deaths. The health workers reported PEM, fever, pneumonia, and diarrhea as the leading causes of death, based on the existing system of obtaining information provided by the family members. Verbal autopsy forms reviewed by a pediatrician also showed that apart from fever, the first three causes of death were the same i.e., PEM, diarrhea and pneumonia. This study shows that health workers can be trained to use the verbal autopsy to ascertain the cause of death.     

Causes of childhood deaths in Bangladesh: an update

Knowledge of the causes of child death is important for health-sector planning since they relate to available interventions. Little is known about causes of child death in Bangladesh from the conventional sources since there is no vital registration system and very few deaths are attended by a qualified physician. To determine the cause structure of child deaths, verbal autopsy interviews were conducted in the Bangladesh Demographic and Health Survey (BDHS) 1993/94 national sample. Verbal autopsy is a method of finding out the causes of death based on an interview with the next of kin or other caregivers. Between BDHS 1993/94 and BDHS 1996/97, 1-4-y-old child mortality in Bangladesh declined by about 27.0%. This impressive decline prompted a verbal autopsy study using the BDHS 1996/97 national sample to determine whether the cause structure had changed. The same verbal autopsy instrument and methods to collect the data and the same computer algorithm to assign causes of death were used in both surveys. Comparison of BDHS 1993/94 and 1996/97 cause-specific mortality rates revealed that deaths due to almost all causes had declined, although significantly so only for acute respiratory infections (ARI), persistent diarrhoea and drowning. Deaths due to neonatal tetanus, acute watery diarrhoea and undernutrition had not decreased at all. Conclusion: Despite an impressive decline in deaths due to ARI, this condition remains the most important known cause of death in Bangladeshi children. Neonatal tetanus and measles together account for about 10% of deaths in children under 5 y. Further improvements in child survival are possible by improving access to and quality of available child survival interventions.     

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??Abstract??Objective To analyze the evolution of disease composition and causes of death in hospitalized children in hospitals of urban Beijing. Methods Medical data of 151 336 hospitalized children in Beijing Children's Hospital and the Sino-Japanese Friendship Hospital aged 0??18 years from 2003 to 2009 were analyzed to summarize changes of disease composition and mortality of each age group and year. According to international nosology ICD-10 classification criteria?? first diagnosis of each child was classified into five catogeries?? communicable diseases?? non-communicable diseases?? perinatal diseases?? injuries and others. Results The first three diseases of hospitalized children were respiratory infection?? congenital malformation and neonatal disease?? the top five single diseases for hospitalization were pneumonia?? inguinal hernia?? cancer?? upper respiratory tract infection and allergic purpura.The top three cause-specific death of hospitalized children were congenital heart disease?? cancer and pneumonia. Congenital heart disease was the first cause of death in infants under the age of 1 year?? while cancer as the first cause of death in more than 1 year old children.The top five diseases of hospitalized children were different in each age group. Conclusion The number of congenital malformations and cancer has significantly increased in hospitalized children in the hospitals of urban Beijing?? but pneumonia still accouns for the most common disease in these children. Congenital heart disease is the first cause of death in infants?? while cancer in more than 1 year old children?? which is basically the same in developed countries.     

Nationwide study of injury‐related deaths among children aged 1–4 years in China, 2000–2008

Aims: The aims of this study are to investigate injury mortality in children aged 1–4 years, to analyse prevalent mortality rates of childhood injury and to identify the leading causes of child injury deaths in China from 2000 to 2008. Methods: The data were obtained from a nationwide mortality surveillance system for children under 5 years of age in China. The injury mortality rates of children aged 1–4 years were compared between rural and urban areas, boys and girls and among five major injury types between 2000 and 2008. Results: During the 9‐year study period, the injury mortality rates for children aged 1–4 years declined significantly by an average of 5.4% each year (P < 0.001; 95% confidence interval (CI): 3.6–7.0%) overall in China, with a decrease of 4.8% (P < 0.001; 95% CI: 2.5–7.1%) and 9.9% (P < 0.001; 95% CI: 4.9–14.7%) in rural and urban areas, respectively. The proportion of injury‐related deaths to total mortality rates dropped from 32.9% in 2000 to 18.8% in 2008 in urban areas but increased from 45.6% to 56.9% in rural areas. The injury mortality rates in both boys and girls decreased significantly by an average of 5.4% each year (P < 0.001; 95% CI: 2.6–8.0%) and 6.1% (P < 0.001; 95% CI: 2.7–9.4%), respectively. Drowning and traffic accidents were the most prevalent causes of injury‐related deaths in children aged 1–4 years. Conclusion: Childhood injury is still the leading cause of death in children aged 1–4 years in China. Drowning and traffic accidents were the most prevalent causes of childhood deaths in this study. Boys living in rural areas are at a higher risk and therefore require increased attention to help control and prevent childhood injury.     

Evaluation of mass pulse immunization with oral polio vaccine in Delhi: Is pre-registration of children necessary?

Delhi was the fourth State in India to conduct mass immunization of children (Pulse Polio Immunization) of the <3 year age group with Oral Polio Vaccine (OPV) as a strategy towards the eradication of poliomyelitis. This study attempted to evaluate the immunization coverage achieved and the channels of communication which were effective in increasing coverage in three high risk areas of Delhi during October 1994. The overall immunization coverage was 89%. Information sources like enumeration visits, posters, television, radio and schools statistically correlated with the Pulse Polio Immunization (PPI) outcome. However, the cost of enumeration was high. Other less expensive channels of communication appeared to be equally effective. Only 11% of the children surveyed were not immunized with PPI OPV. The major reasons why some children did not receive OPV was that parents were “not informed” or they were “too busy”.     

Causes of neonatal death: results from NeoKIP community-based trial in Quang Ninh province, Vietnam

Aim: To ascertain the causes of neonatal death in a province in northern Vietnam and analyse their distribution over age at death, birth weight and place of delivery. Methods: Verbal autopsy interviews using a questionnaire derived from WHO standard and adapted to Vietnamese conditions was performed on all neonatal deaths occurring in Quang Ninh province from July 2008 to June 2010. Three experienced paediatricians independently reviewed all verbal autopsy records (233) and assigned a main cause of death. In case of disagreement in the allocation of cause of death, a consensus process was initiated to decide on a final cause. Results: Neonatal mortality rate within the study area was 16/1000 (238 neonatal deaths and 14 453 live births) over the study period. Prematurity/low birth‐weight (37.8%), intrapartum‐related neonatal deaths (birth asphyxia, 33.2%), infections (13.0%) and congenital malformation (6.7%) were the four leading causes of death. Four cases of neonatal tetanus were found. Intrapartum‐related deaths dominated in the home delivery group, whereas prematurity was the most prominent cause of death at all facility levels. Most neonatal deaths occurred within the first 24 h after delivery (58.6%). Conclusion: A high proportion of deaths due to prematurity and intrapartum‐related causes, calls for improvements of delivery care and resuscitation practices at health facilities.     

Persisting malnutrition in Chandigarh: Decadal underweight trends and impact of ICDS program

Decline in malnutrition levels has been dismal since the 1990s. We ascertained decadal trend in childhood nutritional status between 1997 and 2007 in Chandigarh, India and assessed impact of Integrated Child Development Services (ICDS) on childhood undernutrition. A total of 803 under-five children, 547 children between 12–23 months age, and 218 women with an infant child were recruited for the study. Findings of present study were compared with another methodologically similar study (1997) from Chandigarh and Reproductive and Child Health Rapid Household Survey (1998) to draw decadal trends. Prevalence of underweight among under-five children remained almost stagnant in the last one decade from 51.6% (1997) to 50.4% (2007). There was insignificant difference (P=0.3) in prevalence of underweight among children registered under ICDS program (52.1%) and those not registered (48.4%) in 2007. Other health and service provision indicators had mixed results in the past decade. Health services utilization was poorest in urban slums.     

Severe outcome of children following trauma resulting from road accidents

Objective The aim of the study was to determine the risk factors of a severe outcome for children severely injured [killed or with an Injury Severity Score (ISS) ≥16] in a road accident.Materials and methods Casualties that occurred between 1996 and 2001 which involved children under 14 years of age were assessed in a population-based study based on data included in a French road trauma Registry. A severe traumatic brain injury (TBI) was defined as a head injury with an Abbreviated Injury Scale (AIS) severity score ≥3. A multivariate logistic regression was performed to quantify the risk of a “severe outcome” defined as death or an expected serious impairment 1 year later.Results The annual incidence of an ISS of 16+ was 7.7 per 100,000 children. Among the 126 severely injured children included in this study, 40 died (including 16 immediate deaths), and a severe outcome was expected for 54 of the 86 survivors. Children with an “isolated severe TBI” and those with “multiple injuries including TBI” were more likely to have a severe outcome than those who had an “isolated severe injury without TBI” (OR: 7.91; 95%CI: 1.43–43.77 and OR: 8.37; 95%CI: 1.52–46.13, respectively). Age was inversely linked to a severe outcome. The unprotected motor vehicle occupants (MVO) had an odds ratio of 7.56 (95%CI: 1.07–53.56) compared to the protected MVO. Only 30% of children who survived a severe TBI were admitted to rehabilitation.Conclusion The mechanism of the injury, an injury pattern involving the head and a young age were associated with a severe outcome following a road accident. A majority of children severely injured were not referred to inpatient rehabilitation.     

Perinatal mortality at a tertiary care hospital in punjab

The present report is a comparative analysis of perinatal mortality rate (PNMR) over two different periods of seven years each viz. 1982–1983 and 1989–1995. Data of at) the perinatal deaths in babies born at Christian Medical College and Hospital, Ludhiana from January 1989 to December 1995 was collected. The cause of death was ascertained by a detailed history, clinical examination and whenever possible, by autopsy and analysed by modified Wigglesworth’s classification. The PNMR during both the study periods was exactly the same i.e. 74/1000. There was a significant decline in the early neonatal mortality rate from 32/1000 to 25/1000. This was mainly due to improved survival of preterms as there were better life support measures available in the latter part of study period. In contrast, the still birth rate increased significantly from 42/1000 to 49/1000, thus neutralizing the fall of neonatal mortality. There was no change in the pattern of causes of death. Macerated still births occurring mainly in growth retarded babies and asphyxia remained the major causes of death. Mere provision of health services is not going to decrease PNMR. There is a need to educate ‘the ultimate’ consumers i.e. the women, for better utilization of these services. There is also an urgent need to sensitize and involve the medical practitioners imparting obstetrical services for solving these issues.     

The determinants of exclusive breast feeding in urban slums: a community based study

The actual rate of Exclusive Breast Feeding (EBF) (up to theage of 6 months) is dismally low in urban slums of India. Thereasons and determinants of this are debatable. The study wasplanned to understand the determinants of EBF in the infantsin urban slums. A community-based cross sectional study wasdone in urban slums of Gwalior, India. The data were collectedby interviewing the caregivers of 279 infants aged between 6and 11 months from November 2005 to July 2006. Only 11 (3.8%)mothers knew that EBF should be done till six months and 22(7.8%) actually practiced EBF. A total of 178 (63.8%) and 212(76.0%) newborns were given pre- and post-lacteal feeds with26.2% discarding colostrum. Only 22 (7.8%) practiced EBF. Theearly breastfeeding (BF) initiation, Ante Natal Clinic (ANC)visits, mothers’ education and immunization visits weresignificantly associated with higher probability of EBF. Therewere a number of myths and misconceptions about BF in this urbanslum population. The correct information about BF was more commonamongst the women who had frequent contacts with health facilitiesdue to any reason or during ANC or immunization visit. Similarly,it is the continuum of good health and feeding practices andthe mothers who start early BF or get their child immunizedregularly are more likely to EBF their children. Consideringthe widely prevalent myths and low rate of utilization of healthservices along with high potential benefits of EBF, every opportunityof mothers’ interaction with the health facility shouldbe utilized for promoting correct and EBF practices.     

Diagnostic criteria for Tuberculous Meningitis

Objective : Tuberculous Meningitis is associated with a high morbidity and mortality if there is a delay in diagnosis. The diagnosis is based on clinical evaluation since the bacteriological diagnosis takes time and has a low yield. This study attempts to validate these criteria in children with TBM.Methods : Forty-two children clinically suspected to have TBM were enrolled in the study. History, examination, CT scan and CSF findings were utilized to categorize patients into “definite”, “highly probable”, “probable” and “possible” TBM based on the criteria laid down by Ahuja et al. The validity of these criteria was tested against bacterial isolation and response to treatment.Results : Thirty one children, with complete data, were included for analysis. Using “improvement on therapy” as a criterion for definite TBM, we analyzed the sensitivity and specificity of the Ahuja criteria in diagnosing TBM. Using the criteria of “highly probable” TBM, the sensitivity was 65% with a specificity of 75%. When the criteria of “probable” TBM were used, the sensitivity increased to 96% while the specificity dropped to 38%. In an attempt to make these criteria more appropriate for children, we modified the criteria by including mantoux reaction, and family history of exposure in the criteria. The modified criteria gave a sensitivity of 83% and a specificity of 63%.Discussion : A sensitivity of 65% (highly probable group) implies that 35% of TBM patients will be missed, while the probable criteria gave a 63% false positive rate suggesting that the trade-off for a higher sensitivity makes the criteria very unreliable. Our modification of the criteria gave us a reasonable sensitivity of 83% with a higher specificity of 63%. The false positive rate was also reduced to 38%. Thus the modified Ahuja criteria worked better for children with TBM.Conclusion : The modified Ahuja criteria are better applicable for use in pediatric patients with TBM. Since the number of patients was small in this study, the study needs to be validated with a larger sample size     

Causes and differentials of childhood mortality in Iraq

Background  

Limited information is available in Iraq regarding the causes of under-five mortality. The vital registration system is deficient in its coverage, particularly from rural areas where access to health services is limited and most deaths occur at home, i.e. outside the health system, and hence the cause of death goes unreported. Knowledge of patterns and trends in causes of under-five mortality is essential for decision-makers in assessing programmatic needs, prioritizing interventions, and monitoring progress. The aim of this study was to identify causes of under-five children deaths using a simplified verbal autopsy questionnaire.     

Six-monthly de-worming in infants to study effects on growth

Objective: The study was conducted to assess the effectiveness of six monthly albendazole (ABZ) for improving the weight and height of preschool children when initia ted at 0.5–1 year of age in populations with a high transmission rate of intestinal roundworm,Ascaris lumbricoides. It was a cluster randomized trial in the urban slums of Lucknow, North India.Methods: Control children received 2 ml (1 ml to infants) of Vitamin A every six month whereas those in the ABZ areas received, in addition, 400 mg of ABZ suspension (Zentel, SKB) every six month. Sixty-three and sixty-one slum areas were randomized to albendazole (ABZ) or to control groups, respectively. Children aged 0.5–1 year were recruited in April 1996 and followed up for 1.5 years. Of 1022 children recruited from control and 988 from ABZ areas, the loss to follow-up at 1.5 year was 15.6% and 14.6% respectively. Mean (±SE) weight gain in Kg in control versus ABZ areas was 3.04 (0.03) versus 3.22 (0.03), (p=0.01).Results: After controlling for the presence of weight-for age z-score <-2.00 at enrollment in the ordinary least square’s regression model, the extra weight gain in 1.5 years in those who received ABZ plus vitamin A was 0.13 Kg (95% Cl:0.004 to 0.26 Kg., p value=0.043) when compared to those who received only vitamin A; underweight children at enrollment benefiting more than the normal ones.Conclusion: It was concluded that there was an improvement in weight with six monthly ABZ over 1.5 years. However, a much larger trial would be needed to determine whether there is any net effect of improvement in weight on under five mortality rate.     

Drug dosing error with drops—severe clinical course of codeine intoxication in twins

In spite of the lack of evidence for its efficacy, and of sporadic reports of severe adverse events, codeine is still widely used as an antitussive agent in children. A 3-year-old boy (twin 1) was found lying in vomit and apnoeic at night; he was resuscitated and immediately transferred to our paediatric intensive care unit (PICU). Two and a half hours later, his twin brother (twin 2) was found dead in his bed at home. Twin 1 required mechanical ventilation for 3 days, but he eventually made a full recovery; autopsy in twin 2 showed massive aspiration of gastric content. History revealed that the monozygotic twins had an upper respiratory tract infection for several days and had both been given codeine at a dose of “10 drops per day” by their mother. The blood of both twins was found to contain high levels of codeine and its metabolites. The weight of “10 drops” was determined experimentally and was found to range from 494 to 940 mg. Thus, the highest possible dose given by mother was 23.5 mg of codeine instead of the recommended 10 mg. The twins had identical CYP2D6 gene polymorphisms corresponding to the “extensive metaboliser” type. Conclusions: Because of the variability of drop size drug dosage, dosage “by drops” is unprecise and may result in accidental overdose. The combination of repeated overdosing and extensive metabolism to morphine is likely to have caused apnoea in these twins. These cases illustrate the danger of codeine as an antitussive in young children.     

Impact assessment of mass measles vaccination

Objective : The mass measles vaccination campaign was conducted in the slums of Surat City, in Gujarat State, as a part of urban measles control initiative in India. One dose each of the vaccine was administered to children in the age range of 9–59 months residing in these slums, regardless of their previous vaccination status.Methods : One year later, (October 2000), the present study was carried out in order to assess the impact of the mass vaccination campaign on the vaccination coverage and on the incidence of measles by comparing the findings with those of the baseline survey carried out in May98. This was a retrospective study with a recall period of the preceding year. 3147 children under five were studied in thirty slum clusters selected by the cluster sampling method. The parentsJcaretakers of these children were interviewed for information on any episode of fever with rash conforming to the case definition.Result : The incidence rate for measles declined from 7.7 percent reported in the baseline (May 1998) to 3.5 percent in the impact assessment study. The incidence was 8 times higher in unvaccinated children. The mean and median age at contracting the illness increased from 26 + 14.2 months and 26 months in the baseline to 30.9 ± 14.7 months and 30 months respectively in the impact assessment. The vaccination coverage had improved from 48.3 percent to 73.7 percent following the campaign.Conclusion : The compaign increased vaccination coverage decreased disease incidence and caused a shift towards higher age-groups in vaccinated children.     

Diagnosis and management of acute pharyngitis in a paediatric population: a cost–effectiveness analysis

Acute pharyngitis is one of the most frequent causes of primary care physician visits; however, there is no agreement about which is the best strategy to diagnose and manage acute pharyngitis in children. The aim of the current study was to evaluate the cost–effectiveness of the recommended strategies to diagnose and manage acute pharyngitis in a paediatric population. A decision tree analysis was performed to compare the following six strategies: “treat all”, “clinical scoring”, “rapid test”, “culture”, “rapid test + culture” and “clinical scoring + rapid test”. The cost data came from the Spanish National Health Service sources. Cost–effectiveness was calculated from the payer’s perspective. Effectiveness was measured as the proportion of patients cured without complications from the disease and did not have any reaction to penicillin therapy; a sensitivity analysis was performed. The findings revealed that the “clinical scoring + rapid test” strategy is the most cost-effective, with a cost–effectiveness ratio of 50.72 €. This strategy dominated all others except “culture”, which was the most effective but also the most costly. The sensitivity analysis showed that “rapid test” became the most cost-effective strategy when the clinical scoring sensitivity was <91% and its specificity was ≤9%. In conclusion, the use of a clinical scoring system to triage the diagnoses and performing a rapid antigen test for those with a high score is the most cost-effective strategy for the diagnosis and management of acute pharyngitis in children. When the clinical scoring system has a low diagnostic accuracy, testing all patients with rapid test becomes the most cost-effective strategy.     

Acute lower respiratory infections: a major cause of death in children in Bangladesh

The importance of acute lower respiratory infections (ALRI) as a cause of death in children was estimated using systematically collected demographic data on the population of the Teknaf area of southern Bangladesh. Of 1349 children aged 1-59 months who died between 1 January 1982 and 31 December 1985, ALRI was diagnosed by verbal autopsy in 390 (29%) and was the leading cause of death. ALRI mortality rates were highest in the youngest age groups (136/1000 for those less than or equal to 5 months) and decreased in older children (16/1000 for those 3-4 years old). Half of all fatal ALRI cases occurred in children less than 6 months old. In older children, ALRI-associated deaths tended to occur during the months October to January, while deaths in infants tended to follow the seasonal birth pattern. Significant predisposing factors for fatal ALRI were malnutrition and measles, detected, respectively, in 18% and 8% of children who died from ALRI. This study emphasizes the importance of ALRI as a major cause of death in developing countries and suggests that interventions to reduce childhood mortality are needed and should be targeted to specific age groups at risk.     

Understanding and addressing childhood immunization coverage in urban slums

The National Population Policy (2000) aims at complete protection of all children against vaccine preventable diseases by 2010. Urban poor, many residing in slums, comprise about one fourth of India's 285 million urban population. 60% of the children aged 12-23 months in urban India are fully immunized; coverage among urban poor children is a dismal 43%. The inter state variations of immunization coverage in urban areas, reveals a service coverage gap which calls for a rethink on resource allocation and strengthening processes to improve immunization coverage amongst urban poor. Debilitating environmental conditions and high population density in slums expedite disease transmission. Comparisons of urban rural disease incidence indicate a particular urban risk for vaccine preventable diseases. This paper attempts to understand the current scenario and challenges in improving immunization coverage in urban slums; immunization being one of the most successful public health interventions of the past century. It also discusses possible mechanisms for effectively reaching the often left out urban poor. Coordinated activities by the multitude of providers, accurate information based outreach, effective monitoring and community enablement to demand quality services are critical for improving utilization of immunization services by a heterogeneous urban poor population.