Trends in socioeconomic inequalities in cause-specific premature mortality in Belgium, 1998-2019.

BACKGROUND: Higher levels of socioeconomic deprivation have been consistently associated with increased risk of premature mortality, but a detailed analysis by causes of death is lacking in Belgium. We aim to investigate the association between area deprivation and all-cause and cause-specific premature mortality in Belgium over the period 1998-2019. METHODS: We used the 2001 and 2011 Belgian Indices of Multiple Deprivation to assign statistical sectors, the smallest geographical units in the country, into deprivation deciles. All-cause and cause-specific premature mortality rates, population attributable fraction, and potential years of life lost due to inequality were estimated by period, sex, and deprivation deciles. RESULTS: Men and women living in the most deprived areas were 1.96 and 1.78 times more likely to die prematurely compared to those living in the least deprived areas over the period under study (1998-2019). About 28% of all premature deaths could be attributed to socioeconomic inequality and about 30% of potential years of life lost would be averted if the whole population of Belgium faced the premature mortality rates of the least deprived areas. CONCLUSION: Premature mortality rates have declined over time, but inequality has increased due to a faster pace of decrease in the least deprived areas compared to the most deprived areas. As the causes of death related to poor lifestyle choices contribute the most to the inequality gap, more effective, country-level interventions should be put in place to target segments of the population living in the most deprived areas as they are facing disproportionately high risks of dying.

Health and development from preconception to 20 years of age and human capital.

Optimal health and development from preconception to adulthood are crucial for human flourishing and the formation of human capital. The Nurturing Care Framework, as adapted to age 20 years, conceptualises the major influences during periods of development from preconception, through pregnancy, childhood, and adolescence that affect human capital. In addition to mortality in children younger than 5 years, stillbirths and deaths in 5-19-year-olds are important to consider. The global rate of mortality in individuals younger than 20 years has declined substantially since 2000, yet in 2019 an estimated 8·6 million deaths occurred between 28 weeks of gestation and 20 years of age, with more than half of deaths, including stillbirths, occurring before 28 days of age. The 1000 days from conception to 2 years of age are especially influential for human capital. The prevalence of low birthweight is high in sub-Saharan Africa and even higher in south Asia. Growth faltering, especially from birth to 2 years, occurs in most world regions, whereas overweight increases in many regions from the preprimary school period through adolescence. Analyses of cohort data show that growth trajectories in early years of life are strong determinants of nutritional outcomes in adulthood. The accrual of knowledge and skills is affected by health, nutrition, and home resources in early childhood and by educational opportunities in older children and adolescents. Linear growth in the first 2 years of life better predicts intelligence quotients in adults than increases in height in older children and adolescents. Learning-adjusted years of schooling range from about 4 years in sub-Saharan Africa to about 11 years in high-income countries. Human capital depends on children and adolescents surviving, thriving, and learning until adulthood.

An evaluation of truncated birth histories for the rapid measurement of fertility and child survival.

BACKGROUND: Full birth histories (FBHs) are a key tool for estimating fertility and child mortality in low- and middle-income countries, but they are lengthy to collect. This is not desirable, especially for rapid turnaround surveys that ought to be short (e.g., mobile phone surveys). To reduce the length of the interview, some surveys resort to truncated birth histories (TBHs), where questions are asked only on recent births. METHODS: We used 32 Malaria Indicator Surveys that included TBHs from 18 countries in sub-Saharan Africa. Each set of TBHs was paired and compared to an overlapping set of FBHs (typically from a standard Demographic and Health Survey). We conducted a variety of data checks, including a comparison of the proportion of children reported in the reference period and a comparison of the fertility and mortality estimates. RESULTS: Fertility and mortality estimates from TBHs are lower than those based on FBHs. These differences are driven by the omission of events and the displacement of births backward and out of the reference period. CONCLUSIONS: TBHs are prone to misreporting errors that will bias both fertility and mortality estimates. While we find a few significant associations between outcomes measured and interviewer's characteristics, data quality markers correlate more consistently with respondent attributes, suggesting that truncation creates confusion among mothers being interviewed. Rigorous data quality checks should be put in place when collecting data through this instrument in future surveys.

Inequalities in mortality associated with housing conditions in Belgium between 1991 and 2020.

BACKGROUND: Poor housing conditions have been associated with increased mortality. Our objective is to investigate the association between housing inequality and increased mortality in Belgium and to estimate the number of deaths that could be prevented if the population of the whole country faced the mortality rates experienced in areas that are least deprived in terms of housing. METHODS: We used individual-level mortality data extracted from the National Register in Belgium and relative to deaths that occurred between Jan. 1, 1991, and Dec. 31, 2020. Spatial and time-specific housing deprivation indices (1991, 2001, and 2011) were created at the level of the smallest geographical unit in Belgium, with these units assigned into deciles from the most to the least deprived. We calculated mortality associated with housing inequality as the difference between observed and expected deaths by applying mortality rates of the least deprived decile to other deciles. We also used standard life table calculations to estimate the potential years of life lost due housing inequality. RESULTS: Up to 18.5% (95% CI 17.7-19.3) of all deaths between 1991 and 2020 may be associated with housing inequality, corresponding to 584,875 deaths. Over time, life expectancy at birth increased for the most and least deprived deciles by about 3.5 years. The gap in life expectancy between the two deciles remained high, on average 4.6 years. Life expectancy in Belgium would increase by approximately 3 years if all deciles had the mortality rates of the least deprived decile. CONCLUSIONS: Thousands of deaths in Belgium could be avoided if all Belgian neighborhoods had the mortality rates of the least deprived areas in terms of housing. Hotspots of housing inequalities need to be located and targeted with tailored public actions.

The shifting rural-urban gap in mortality over the life course in low- and middle-income countries.

Studies have shown that children in rural areas face excess risks of dying, but the little research on spatial inequalities in adult mortality has reached mixed conclusions. We examine rural-urban differences in mortality in 53 low- and middle-income countries. We consider how the rural-urban mortality gap evolves from birth to age 60 by estimating mortality based on birth and sibling histories from 138 Demographic and Health Surveys run between 1992 and 2018. We observe excess rural mortality until age 15, finding the largest differences between urban and rural sectors among 1-59-month-olds. While we cannot claim higher mortality among urban adults than those in rural areas, we find a reduced gap between the sectors over the life course and a diminishing urban advantage in adult mortality with age. This shift over the life course reflects a divergence in the epidemiologic transition between the rural and urban sectors.

Errors in reported ages and dates in surveys of adult mortality: A record linkage study in Niakhar (Senegal).

Sibling survival histories are a major source of adult mortality estimates in countries with incomplete death registration. We evaluate age and date reporting errors in sibling histories collected during a validation study in the Niakhar Health and Demographic Surveillance System (Senegal). Participants were randomly assigned to either the Demographic and Health Survey questionnaire or a questionnaire incorporating an event history calendar, recall cues, and increased probing strategies. We linked 60-62 per cent of survey reports of siblings to the reference database using manual and probabilistic approaches. Both questionnaires showed high sensitivity (>96 per cent) and specificity (>97 per cent) in recording siblings' vital status. Respondents underestimated the age of living siblings, and age at and time since death of deceased siblings. These reporting errors introduced downward biases in mortality estimates. The revised questionnaire improved reporting of age of living siblings but not of age at or timing of deaths.

Estimating cause-specific mortality in Madagascar: an evaluation of death notification data from the capital city.

BACKGROUND: Trends in cause-specific mortality in most African countries are currently estimated from epidemiological models because the coverage of the civil registration system is low and national statistics on causes of death are unreliable at the national level. We aim to evaluate the performance of the death notification system in Antananarivo, the capital city of Madagascar, to inform cause-of-death statistics. METHODS: Information on the sex of the deceased, dates of birth and death, and underlying cause of death were transcribed from death registers maintained in Antananarivo. Causes of death were coded in ICD-9 and mapped to cause categories from the Global Burden of Disease 2016 Study (GBD). The performance of the notification system was assessed based on the Vital Statistics Performance Index, including six dimensions: completeness of death registration, quality of cause of death reporting, quality of age and sex reporting, internal consistency, level of cause-specific detail, and data availability and timeliness. We redistributed garbage codes and compared cause-specific mortality fractions in death records and estimates from the GBD with concordance correlation coefficients. RESULTS: The death notification system in Antananarivo performed well on most dimensions, although 31% of all deaths registered over the period 1976-2015 were assigned to ICD codes considered as "major garbage codes" in the GBD 2016. The completeness of death notification, estimated with indirect demographic techniques, was higher than 90% in the period 1975-1993, and recent under-five mortality rates were consistent with estimates from Demographic and Health Surveys referring to the capital city. After redistributing garbage codes, cause-specific mortality fractions derived from death notification data were consistent with GBD 2016 for the whole country in the 1990s, with concordance correlation coefficients higher than 90%. There were larger deviations in recent years, with concordance correlation coefficients in 2015 at 0.74 (95% CI 0.66-0.81) for men and 0.81 (95% CI 0.74-0.86) for women. CONCLUSIONS: Death notification in Antananarivo is a low-cost data source allowing real-time mortality monitoring, with a potential to improve disease burden estimates. Further efforts should be directed towards evaluating data quality in urban centers in Madagascar and other African countries to fill important data gaps on causes of death.

Socioeconomic factors contributing to under-five mortality in sub-Saharan Africa: a decomposition analysis.

BACKGROUND: In sub-Saharan Africa, socioeconomic factors such as place of residence, mother's educational level, or household wealth, are strongly associated with risk factors of under-five mortality (U5M) such as health behavior or exposure to diseases and injuries. The aim of the study was to assess the relative contribution of four known socioeconomic factors to the variability in U5M in sub-Saharan countries. METHODS: The study was based on birth histories from the Demographic and Health Surveys conducted in 32 sub-Saharan countries in 2010-2016. The relative contribution of sex of the child, place of residence, mother's educational level, and household wealth to the variability in U5M was assessed using a regression-based decomposition of a Gini-type index. RESULTS: The Gini index - measuring the variability in U5M related to the four socioeconomic factors - varied from 0.006 (95%CI: 0.001-0.010) in Liberia 2013 to 0.034 (95%CI: 0.029-0.039) in Côte d'Ivoire 2011/12. The main contributors to the Gini index (with a relative contribution higher than 25%) were different across countries: mother's educational level in 13 countries, sex of the child in 12 countries, household wealth in 11 countries, and place of residence in 8 countries (in some countries, more than one main contributor was identified). CONCLUSIONS: Factors related to socioeconomic status exert varied effects on the variability in U5M in sub-Saharan African countries. The findings provide evidence in support of prioritizing intersectoral interventions aiming at improving child survival in all subgroups of a population.

Continuities and changes in spatial patterns of under-five mortality at the district level in India (1991-2011).

BACKGROUND: India has the largest number of under-five deaths globally, and large variations in under-five mortality persist between states and districts. Relationships between under-five mortality and numerous socioeconomic, development and environmental health factors have been explored at the national and state levels, but the possible spatial heterogeneity in these relationships has seldom been investigated at the district level. This study seeks to unravel local variation in key determinants of under-five mortality based on the 1991 and 2011 censuses. METHODS: Using geocoded district-level data from the last two census rounds (1991 and 2011) and ordinary least squares and geographically weighted regressions, we identify district-specific relationships between under-five mortality rate and a series of determinants for two periods separated by 20 years (1986-1987 and 2006-2007). To identify spatial groupings of coefficients, we perform a cluster analysis based on t-values of the geographically weighted regression. RESULTS: The geographically weighted regression analysis shows that relationships between the under-five mortality rate and factors for socioeconomic, development, and environmental health factors vary spatially in terms of direction, strength, and extent when considering: female literacy and labor force participation; share of scheduled castes and scheduled tribes; access to electricity; safe water and sanitation; road infrastructure; and medical facilities. This spatial heterogeneity is accompanied by significant changes over time in the roles that these factors play in under-five mortality. Important local determinants of under-five mortality in 2011 were female literacy, female labor force participation, access to sanitation facilities and electricity; while the key local determinants in 1991 were road infrastructure, safe water, and medical facilities. We identify six different clusters based on geographically weighted regression coefficients that broadly encompass the same districts in both periods; but these clusters do not follow the regional boundaries suggested by the previous studies. In particular, the high mortality states of India that are often typically classified as high focus states were classified into three different clusters based on the relationship of the factors associated with under-five mortality. CONCLUSION: This study demonstrates the utility of combining geographically weighted regression and cluster analyses as a methodological approach to study local-level variation in public health indicators, and it could be applied in any country using aggregate-level information from census or survey data. Identifying local predictors of under-five mortality is important for designing interventions in specific districts. Additional reduction in under-five mortality will only be possible with intervention programs designed at the local level, which take into consideration local level determinants of under-five mortality.

Improving survey data on pregnancy-related deaths in low-and middle-income countries: a validation study in Senegal.

OBJECTIVE: In low- and middle-income countries (LMICs), siblings' survival histories (SSH) are often used to estimate maternal mortality, but SSH data on causes of death at reproductive ages have seldom been validated. We compared the accuracy of two SSH instruments: the standard questionnaire used during the demographic and health surveys (DHS) and the siblings' survival calendar (SSC), a new questionnaire designed to improve survey reports of deaths among women of reproductive ages. METHODS: We recruited 1189 respondents in a SSH survey in Niakhar, Senegal. Mortality records from a health and demographic surveillance system (HDSS) constituted the reference data set. Respondents were randomly assigned to an interview with the DHS or SSC questionnaires. A total of 164 respondents had a sister who died at reproductive ages over the past 15 years before the survey according to the HDSS. RESULTS: The DHS questionnaire led to selective omissions of deaths: DHS respondents were significantly more likely to report their sister's death if she had died of pregnancy-related causes than if she had died of other causes (96.4% vs. 70.9%, P < 0.007). Among reported deaths, both questionnaires had high sensitivity (>90%) in recording pregnancy-related deaths. But the DHS questionnaire had significantly lower specificity than the SSC (79.5% vs. 95.0%, P = 0.015). The DHS questionnaire overestimated the proportion of deaths due to pregnancy-related causes, whereas the SSC yielded unbiased estimates of this parameter. CONCLUSION: Statistical models informed by SSH data collected using the DHS questionnaire might exaggerate maternal mortality in Senegal and similar settings. A new questionnaire, the SSC, could permit better tracking progress towards the reduction in maternal mortality.

Improving the quality of adult mortality data collected in demographic surveys: validation study of a new siblings' survival questionnaire in Niakhar, Senegal.

BACKGROUND: In countries with limited vital registration, adult mortality is frequently estimated using siblings' survival histories (SSHs) collected during Demographic and Health Surveys (DHS). These data are affected by reporting errors. We developed a new SSH questionnaire, the siblings' survival calendar (SSC). It incorporates supplementary interviewing techniques to limit omissions of siblings and uses an event history calendar to improve reports of dates and ages. We hypothesized that the SSC would improve the quality of adult mortality data. METHODS AND FINDINGS: We conducted a retrospective validation study among the population of the Niakhar Health and Demographic Surveillance System in Senegal. We randomly assigned men and women aged 15-59 y to an interview with either the DHS questionnaire or the SSC. We compared SSHs collected in each group to prospective data on adult mortality collected in Niakhar. The SSC reduced respondents' tendency to round reports of dates and ages to the nearest multiple of five or ten ("heaping"). The SSC also had higher sensitivity in recording adult female deaths: among respondents whose sister(s) had died at an adult age in the past 15 y, 89.6% reported an adult female death during SSC interviews versus 75.6% in DHS interviews (p = 0.027). The specificity of the SSC was similar to that of the DHS questionnaire, i.e., it did not increase the number of false reports of deaths. However, the SSC did not improve the reporting of adult deaths among the brothers of respondents. Study limitations include sample selectivity, limited external validity, and multiple testing. CONCLUSIONS: The SSC has the potential to collect more accurate SSHs than the questionnaire used in DHS. Further research is needed to assess the effects of the SSC on estimates of adult mortality rates. Additional validation studies should be conducted in different social and epidemiological settings. TRIAL REGISTRATION: Controlled-Trials.com ISRCTN06849961

Divergences in trends in child and adult mortality in sub-Saharan Africa: survey evidence on the survival of children and siblings.

This paper provides an overview of trends in mortality in children aged under 5 and adults between the ages of 15 and 60 in sub-Saharan Africa, using data on the survival of the children and siblings collected in Demographic and Health Surveys. If conspicuous stalls in the 1990s are disregarded, child mortality levels have generally declined and converged over the last 30-40 years. In contrast, adult mortality in many East and Southern African countries has increased markedly, echoing earlier increases in the incidence of HIV. In recent years, adult mortality levels have begun to decline once again in East Africa, in some instances before the large-scale expansion of antiretroviral therapy programmes. More surprising is the lack of sustained improvements in adult survival in some countries that have not experienced severe HIV epidemics. Because trends in child and adult mortality do not always evolve in tandem, we argue that model-based estimates, inferred by matching indices of child survival onto standard mortality schedules, can be very misleading.

Enhancing the value of death registration with verbal autopsy data: a pilot study in the Senegalese urban population in 2019.

BACKGROUND: There is no source of data on causes of death in Senegal that covers both community and hospital deaths. Yet the death registration system in the Dakar region is relatively complete (>80%) and could be expanded to provide information on the diseases and injuries that led to death. METHODS: In this pilot study, we recorded all deaths that occurred over 2 months and were reported in the 72 civil registration offices in the Dakar region. We selected the deaths of residents of the region and administered a verbal autopsy to a relative of the deceased to identify the underlying causes of death. Causes of death were assigned using the InterVA5 model. RESULTS: The age structure of deaths registered at the civil registry differed from that of the census, with a proportion of infant deaths about twice as high as in the census. The main causes of death were prematurity and obstetric asphyxia in newborns. Meningitis and encephalitis, severe malnutrition, and acute respiratory infections were the leading causes from 1 month to 15 years of age. Cardiovascular diseases accounted for 27% of deaths in adults aged 15-64 and 45% of deaths among adults above age 65, while neoplasms accounted for 20% and 12% of deaths in these two age groups, respectively. CONCLUSIONS: This study demonstrates that the epidemiological transition is at an advanced stage in urban areas of Dakar, and underlines the importance of conducting regular studies based on verbal autopsies of deaths reported in civil registration offices.

Measuring under-5 mortality and fertility through mobile phone surveys: an assessment of selection bias in 34 low-income and middle-income countries.

OBJECTIVES: This study aims to assess sample selection bias in mobile phone survey estimates of fertility and under-5 mortality. DESIGN: With data from the Demographic and Health Surveys, we use logistic regressions to identify sociodemographic correlates of mobile phone ownership and access, and Poisson regressions to estimate the association between mobile phone ownership (or access) and fertility and under-5 mortality estimates. We evaluate the potential reasons why estimates by mobile phone ownership differ using a set of behavioural characteristics. SETTING: 34 low-income and middle-income countries, mostly in sub-Saharan Africa. PARTICIPANTS: 534 536 women between the ages of 15 and 49. OUTCOME MEASURES: Under-5 mortality rate (U5MR) and total fertility rate (TFR). RESULTS: Mobile phone ownership ranges from 23.6% in Burundi to 96.7% in Armenia. The median TFR ratio and U5MR ratio between the non-owners and the owners of a mobile phone are 1.48 and 1.29, respectively. Fertility and mortality rates would be biased downwards if estimates are only based on women who own or have access to mobile phones. Estimates of U5MR can be adjusted through poststratification using age, educational level, area of residence, wealth and marital status as weights. However, estimates of TFR remain biased even after adjusting for these covariates. This difference is associated with behavioural factors (eg, contraceptive use) that are not captured by the poststratification variables, but for which there are also differences between mobile phone owners and non-owners. CONCLUSIONS: Mobile phone surveys need to collect data on sociodemographic background characteristics to be able to weight and adjust mortality estimates ex post facto. Fertility estimates from mobile phone surveys will be biased unless further research uncovers the mechanisms driving the bias.

Measuring small-area level deprivation in Belgium: The Belgian Index of Multiple Deprivation.

BACKGROUND: In the past, deprivation has been mostly captured through simple and univariate measures such as low income or poor educational attainment in research on health and social inequalities in Belgium. This paper presents a shift towards a more complex, multidimensional measure of deprivation at the aggregate level and describes the development of the first Belgian Indices of Multiple Deprivation (BIMDs) for the years 2001 and 2011. METHODS: The BIMDs are constructed at the level of the smallest administrative unit in Belgium, the statistical sector. They are a combination of six domains of deprivation: income, employment, education, housing, crime and health. Each domain is built on a suite of relevant indicators representing individuals that suffer from a certain deprivation in an area. The indicators are combined to create the domain deprivation scores, and these scores are then weighted to create the overall BIMDs scores. The domain and BIMDs scores can be ranked and assigned to deciles from 1 (the most deprived) to 10 (the least deprived). RESULTS: We show geographical variations in the distribution of the most and least deprived statistical sectors in terms of individual domains and overall BIMDs, and we identify hotspots of deprivation. The majority of the most deprived statistical sectors are located in Wallonia, whereas most of the least deprived statistical sectors are in Flanders. CONCLUSION: The BIMDs offer a new tool for researches and policy makers for analyzing patterns of deprivation and identifying areas that would benefit from special initiatives and programs.

Sex differences in mortality among children, adolescents, and young people aged 0-24 years: a systematic assessment of national, regional, and global trends from 1990 to 2021.

BACKGROUND: Differences in mortality exist between sexes because of biological, genetic, and social factors. Sex differentials are well documented in children younger than 5 years but have not been systematically examined for ages 5-24 years. We aimed to estimate the sex ratio of mortality from birth to age 24 years and reconstruct trends in sex-specific mortality between 1990 and 2021 for 200 countries, major regions, and the world. METHODS: We compiled comprehensive databases on the mortality sex ratio (ratio of male to female mortality rates) for individuals aged 0-4 years, 5-14 years, and 15-24 years. The databases contain mortality rates from death registration systems, full birth and sibling histories from surveys, and reports on household deaths in censuses. We modelled the sex ratio of age-specific mortality as a function of the mortality in both sexes using Bayesian hierarchical time-series models. We report the levels and trends of sex ratios and estimate the expected female mortality and excess female mortality rates (the difference between the estimated female mortality and the expected female mortality) to identify countries with outlying sex ratios. FINDINGS: Globally, the mortality sex ratio was 1·13 (ie, boys were more likely to die than girls of the same age) for ages 0-4 years (90% uncertainty interval 1·11 to 1·15) in 2021. This ratio increased with age to 1·16 (1·12 to 1·20) for 5-14 years, reaching 1·65 for 15-24 years (1·52 to 1·75). In all age groups, the global sex ratio of mortality increased between 1990 and 2021, driven by faster declines in female mortality. In 2021, the probability of a newborn male reaching age 25 years was 94·1% (93·7 to 94·4), compared with 95·1% for a newborn female (94·7 to 95·3). We found a disadvantage of females versus males (compared with countries with similar total mortality) in 2021 in five countries for ages 0-4 years (Algeria, Bangladesh, Egypt, India, and Iran), one country (Suriname) for ages 5-14 years, and 13 countries for ages 15-24 years (including Bangladesh and India). We found the reverse pattern (disadvantage of males vs females compared with countries of similar total mortality) in one country in ages 0-4 years (Vietnam) and eight countries in ages 15-24 years (including Brazil and Mexico). Globally, the number of excess female deaths from birth to age 24 years was 86 563 (-6059 to 164 000) in 2021, down from 544 636 (453 982 to 633 265) in 1990. INTERPRETATION: The global sex ratio of mortality for all age groups in the first 25 years of life increased between 1990 and 2021. Targeted interventions should focus on countries with outlying sex ratios of mortality to reduce disparities due to discrimination in health care, nutrition, and violence. FUNDING: The Bill & Melinda Gates Foundation, US Agency for International Development, and King Abdullah University of Science and Technology.

Excess mortality associated with the COVID-19 pandemic during the 2020 and 2021 waves in Antananarivo, Madagascar.

INTRODUCTION: COVID-19-associated mortality remains difficult to estimate in sub-Saharan Africa because of the lack of comprehensive systems of death registration. Based on death registers referring to the capital city of Madagascar, we sought to estimate the excess mortality during the COVID-19 pandemic and calculate the loss of life expectancy. METHODS: Death records between 2016 and 2021 were used to estimate weekly excess mortality during the pandemic period. To infer its synchrony with circulation of SARS-CoV-2, a cross-wavelet analysis was performed. Life expectancy loss due to the COVID-19 pandemic was calculated by projecting mortality rates using the Lee and Carter model and extrapolating the prepandemic trends (1990-2019). Differences in life expectancy at birth were disaggregated by cause of death. RESULTS: Peaks of excess mortality in 2020-21 were associated with waves of COVID-19. Estimates of all-cause excess mortality were 38.5 and 64.9 per 100 000 inhabitants in 2020 and 2021, respectively, with excess mortality reaching ≥50% over 6 weeks. In 2021, we quantified a drop of 0.8 and 1.0 years in the life expectancy for men and women, respectively attributable to increased risks of death beyond the age of 60 years. CONCLUSION: We observed high excess mortality during the pandemic period, in particular around the peaks of SARS-CoV-2 circulation in Antananarivo. Our study highlights the need to implement death registration systems in low-income countries to document true toll of a pandemic.

Heterogeneity in subnational mortality in the context of the COVID-19 pandemic: the case of Belgian districts in 2020.

BACKGROUND: The COVID-19 pandemic has led to major shocks in mortality trends in many countries. Yet few studies have evaluated the heterogeneity of the mortality shocks at the sub-national level, rigorously accounting for the different sources of uncertainty. METHODS: Using death registration data from Belgium, we first assess change in the heterogeneity of districts' standardized mortality ratios in 2020, when compared to previous years. We then measure the shock effect of the pandemic using district-level values of life expectancy, comparing districts' observed and projected life expectancy, accounting for all sources of uncertainty (stemming from life-table construction at district level and from projection methods at country and district levels). Bayesian modelling makes it easy to combine the different sources of uncertainty in the assessment of the shock. This is of particular interest at a finer geographical scale characterized by high stochastic variation in annual death counts. RESULTS: The heterogeneity in the impact of the pandemic on all-cause mortality across districts is substantial: while some districts barely show any impact, the Bruxelles-Capitale and Mons districts experienced a decrease in life expectancy at birth of 2.24 (95% CI:1.33-3.05) and 2.10 (95% CI:0.86-3.30) years, respectively. The year 2020 was associated with an increase in the heterogeneity of mortality levels at a subnational scale in comparison to past years, measured in terms of both standardized mortality ratios and life expectancies at birth. Decisions on uncertainty thresholds have a large bearing on the interpretation of the results. CONCLUSION: Developing sub-national mortality estimates taking careful account of uncertainty is key to identifying which areas have been disproportionately affected.

Global, regional, and national trends in under-5 mortality between 1990 and 2019 with scenario-based projections until 2030: a systematic analysis by the UN Inter-agency Group for Child Mortality Estimation.

BACKGROUND: The Sustainable Development Goals (SDGs), set in 2015 by the UN General Assembly, call for all countries to reach an under-5 mortality rate (U5MR) of at least as low as 25 deaths per 1000 livebirths and a neonatal mortality rate (NMR) of at least as low as 12 deaths per 1000 livebirths by 2030. We estimated levels and trends in under-5 mortality for 195 countries from 1990 to 2019, and conducted scenario-based projections of the U5MR and NMR from 2020 to 2030 to assess country progress in, and potential for, reaching SDG targets on child survival and the potential under-5 and neonatal deaths over the next decade. METHODS: Levels and trends in under-5 mortality are based on the UN Inter-agency Group for Child Mortality Estimation (UN IGME) database on under-5 mortality, which contains around 18 000 country-year datapoints for 195 countries-nearly 10 000 of those datapoints since 1990. The database includes nationally representative mortality data from vital registration systems, sample registration systems, population censuses, and household surveys. As with previous sets of national UN IGME estimates, a Bayesian B-spline bias-reduction model (B3) that considers the systematic biases associated with the different data source types was fitted to these data to generate estimates of under-5 (age 0-4 years) mortality with uncertainty intervals for 1990-2019 for all countries. Levels and trends in the neonatal mortality rate (0-27 days) are modelled separately as the log ratio of the neonatal mortality rate to the under-5 mortality rate using a Bayesian model. Estimated mortality rates are combined with livebirths data to calculate the number of under-5 and neonatal deaths. To assess the regional and global burden of under-5 deaths in the present decade and progress towards SDG targets, we constructed several scenario-based projections of under-5 mortality from 2020 to 2030 and estimated national, regional, and global under-5 mortality trends up to 2030 for each scenario. FINDINGS: The global U5MR decreased by 59% (90% uncertainty interval [UI] 56-61) from 93·0 (91·7-94·5) deaths per 1000 livebirths in 1990 to 37·7 (36·1-40·8) in 2019, while the annual number of global under-5 deaths declined from 12·5 (12·3-12·7) million in 1990 to 5·2 (5·0-5·6) million in 2019-a 58% (55-60) reduction. The global NMR decreased by 52% (90% UI 48-55) from 36·6 (35·6-37·8) deaths per 1000 livebirths in 1990, to 17·5 (16·6-19·0) in 2019, and the annual number of global neonatal deaths declined from 5·0 (4·9-5·2) million in 1990, to 2·4 (2·3-2·7) million in 2019, a 51% (47-54) reduction. As of 2019, 122 of 195 countries have achieved the SDG U5MR target, and 20 countries are on track to achieve the target by 2030, while 53 will need to accelerate progress to meet the target by 2030. 116 countries have reached the SDG NMR target with 16 on track, leaving 63 at risk of missing the target. If current trends continue, 48·1 million under-5 deaths are projected to occur between 2020 and 2030, almost half of them projected to occur during the neonatal period. If all countries met the SDG target on under-5 mortality, 11 million under-5 deaths could be averted between 2020 and 2030. INTERPRETATION: As a result of effective global health initiatives, millions of child deaths have been prevented since 1990. However, the task of ending all preventable child deaths is not done and millions more deaths could be averted by meeting international targets. Geographical and economic variation demonstrate the possibility of even lower mortality rates for children under age 5 years and point to the regions and countries with highest mortality rates and in greatest need of resources and action. FUNDING: Bill & Melinda Gates Foundation, US Agency for International Development.

Space-time smoothing of mortality estimates in children aged 5-14 in Sub-Saharan Africa.

To meet the SDG requirement of spatial disaggregation of indicators, several methods have been developed to generate estimates of under-five mortality at the sub-national level. The reliability of sub-national mortality estimates in children aged 5-14 with the available survey data has not been evaluated so far. We generate Admin-1 sub-national estimates of the risk of dying in children aged less than five (5q0) and those aged 5 to 14 years old (10q5). We use 96 Demographic and Health Surveys (DHS) in 20 Sub-Saharan countries having at least 3 surveys designed to be representative at a sub-national level. The estimates account for the complex sample design of DHS and HIV-related biases in young children. A Bayesian space-time model previously developed for under-five mortality is used to smooth estimates across space and time in both age groups to reduce problems associated with data sparsity. The posterior distributions of the probability 10q5 are used to compute coefficients of variation and assess precision. Sufficiently precise estimates are retained to study the sub-national relationship between age-specific mortality rates (5q0 and 10q5), accounting for uncertainty in sub-national levels. Out of 1,132 space-time estimates, 62.3% are considered sufficiently precise with high heterogeneity across countries. Across all periods, sub-national estimates of mortality in children aged 0-4 are highly correlated with those in older children and young adolescents but this correlation is largely driven by the mortality decline. Within specific periods of time, it is often impossible to assess the relationship between mortality rates in the two age groups at the sub-national level, except in Nigeria, Ethiopia, Cameroon, Senegal and Zambia. As increased attention is devoted to survival after age 5, more research is needed to ensure that sub-national areas with specific interventions required for older children can be correctly identified.