The Spectrum projection package: improvements in estimating incidence by age and sex, mother-to-child transmission, HIV progression in children and double orphans.

BACKGROUND: The Spectrum program is used to estimate key HIV indicators from the trends in incidence and prevalence estimated by the Estimation and Projection Package or the Workbook. These indicators include the number of people living with HIV, new infections, AIDS deaths, AIDS orphans, the number of adults and children needing treatment, the need for prevention of mother-to-child transmission and the impact of antiretroviral treatment on survival. The UNAIDS Reference Group on Estimates, Models and Projections regularly reviews new data and information needs, and recommends updates to the methodology and assumptions used in Spectrum. METHODS: The latest update to Spectrum was used in the 2009 round of global estimates. This update contains new procedures for estimating: the age and sex distribution of adult incidence, new child infections occurring around delivery or through breastfeeding, the survival of children by timing of infection and the number of double orphans.

Gambian cultural beliefs, attitudes and discourse on reproductive health and mortality: Implications for data collection in surveys from the interviewer's perspective.

BACKGROUND: A community's cultural beliefs, attitudes and discourse can affect their responses in surveys. Knowledge of these cultural factors and how to comply with them or adjust for them during data collection can improve data quality. OBJECTIVE: This study describes implications of features of Gambian culture related to women's reproductive health, and mortality, when collecting data in surveys. METHODS: 13 in-depth interviews of female interviewers and a focus group discussion among male interviewers were conducted in two rural health and demographic surveillance systems as well as three key informant interviews in three regions in The Gambia. RESULTS: From the fieldworker's viewpoint, questions relating to reproduction were best asked by women as culturally pregnancies should be concealed, and menstruation is considered a sensitive topic. Gambians were reluctant to speak about decedents and the Fula did not like to be counted, potentially affecting estimation of mortality. Asking about siblings proved problematic among the Fula and Serahule communities. Proposals made to overcome these challenges were that culturally-appropriate metaphors and symbols should be used to discuss sensitive matters and to enumerating births/deaths singly instead of collecting summary totals, which had threatening connotations. This was as opposed to training interviewers to ask standardised and precise verbatim questions. CONTRIBUTION: This paper presents indigenous Gambian solutions by fieldworkers to culturally sensitive topics when collecting pregnancy outcomes and mortality data in demographic and health surveys. For researchers collecting maternal mortality data, it highlights the potential shortcomings of the sibling history methodology.

Impact of the HIV epidemic on mortality in sub-Saharan Africa: evidence from national surveys and censuses.

OBJECTIVE: To measure recent trends in all-cause child and adult mortality in national populations in sub-Saharan Africa. DESIGN: Secondary analysis of data collected in national household surveys and censuses. METHODS: The index of infant and child mortality is the probability of dying before age 5 years (under-five mortality). For adult mortality, it is the probability of dying between ages 15 and 60 years. Mortality trends are assessed in three ways: (i) by comparison of data collected in the 1990s with those from the 1980s; (ii) using the retrospective reports of the survival of women's children and siblings collected by Demographic and Health Survey inquiries; and (iii) by comparing the latter estimates with estimates from data on orphanhood. RESULTS: Under-five mortality is stagnant or rising in several African countries. In some countries, however, adverse trends developed too early in the 1980s to be attributable to HIV. In most countries, the three approaches to monitoring adult mortality yield consistent results. Adult death rates doubled or tripled between the 1980s and mid-1990s in Uganda, Zambia, and Zimbabwe. Mortality also rose substantially elsewhere in East and Central Africa but not in West Africa. Increases in mortality are concentrated among young adults. In general, men are worst affected, but in Uganda the rise in women's mortality is greater. CONCLUSIONS: Data can be collected in national household surveys and censuses to monitor the mortality impact of HIV in Africa. Such data have begun to document the differential impact of the epidemic. In those countries with data in which HIV became prevalent by the late 1980s, massive rises in adult mortality occurred by the mid-1990s.

PIP: Measures of mortality during the 1990s are presented for the African countries which have collected census and survey data on mortality in their national populations. Mortality trends are assessed in the following manners: by comparing data collected during the 1990s with those from the 1980s, using the retrospective reports of the survival of women's children and siblings collected in Demographic and Health Surveys (DHS), and by comparing the DHS estimates with estimates made from data on orphanhood. Under-five mortality is either stagnant or rising in several African countries. However, in some countries, such adverse trends developed too early in the 1980s to be attributable to HIV. The three described approaches to monitoring adult mortality have yielded consistent results in most countries. Adult death rates doubled or tripled between the 1980s and mid-1990s in Uganda, Zambia, and Zimbabwe, while levels of mortality also rose considerably elsewhere in East and Central Africa, but not in West Africa. Increases in mortality are concentrated among young adults, with men being the worst affected overall, although in Uganda the increase in women's mortality is greater.

The impact of HIV-1 infection on mortality in children under 5 years of age in sub-Saharan Africa: a demographic and epidemiologic analysis.

OBJECTIVE: To estimate the effects of the HIV-1 epidemic on mortality in children under 5 years of age in urban and rural populations in eastern and central, and southern Africa. METHODS: A lifetable method that allows for the effects of competing causes (i.e., mortality due to HIV and other causes) was used to estimate mortality. Our calculations used published and unpublished data on HIV-1 infection in African adults and children (incidence and prevalence, vertical transmissions, transmission by blood transfusion and natural history), and typical baseline fertility and child mortality data. The results were applied to model rural and urban populations to explore the effects of parameters such as mortality in HIV-1-infected children, fertility in infected mothers and overall population growth. RESULTS: We estimate that child mortality will rise substantially because of the prevalence of HIV-1 in urban areas. There will be little difference in the absolute levels of increase in mortality between areas in eastern and central, and southern Africa with similar levels of HIV infection; however, in relative terms the effect will be more noticeable in southern Africa because of the lower baseline mortality. Towns with severe epidemics (30% adult seroprevalence) might experience a rise in child mortality of one-third in eastern and central Africa and three-quarters in southern Africa. This will cancel or reverse existing advantages in urban over rural levels of child mortality and this effect will be more pronounced in southern Africa. The exact impact of HIV-1 will vary according to mortality among HIV-1-infected children and to fertility among infected women. However, changes in age structure and population growth have relatively little impact on mortality. CONCLUSIONS: There are likely to be substantial increases in child mortality in sub-Saharan Africa as a result of HIV-1 infection. The main determinant of childhood infection is the scale of the epidemic among adults. Increases in mortality will depend on local adult seroprevalence but are hard to predict precisely because of possible variation in death rates among HIV-1-infected children. In rural areas with low seroprevalence other diseases will remain the main cause of mortality. However, in urban areas families and health services will have to face considerably increased demands from ill and dying children.

PIP: The objective was to estimate the effects of the HIV-1 epidemic on mortality in children under 5 years of age in urban and rural populations in eastern, central, and southern Africa. Epidemiologic parameters were applied to three populations with different characteristics: a rural population with an HIV-1 prevalence of 3%, an urban population (Town A) with 10% seroprevalence, and a second urban population (Town B) with 30% seroprevalence among women of childbearing age, respectively. The output measures were the absolute increases in and the level of the under-5-years' mortality rate, which represents the probability of a child dying before his or her fifth birthday per 1000 births. It was estimated that child mortality will rise substantially because of the prevalence of HIV-1 in urban areas. There will be little difference in the absolute levels of increase in mortality between areas in eastern, central, and southern Africa with similar levels of HIV infection; however, in relative terms the effect will be more noticeable in southern Africa because of the lower baseline mortality. Towns with severe epidemics (30% adult seroprevalence) might experience a rise in child mortality of 1/3 in eastern and central Africa and 3/4 in southern Africa. This will cancel or reverse existing advantages in urban over rural levels of child mortality with more pronounced effect in southern Africa. The exact impact of HIV-1 will vary according to mortality among HIV-1-infected children and according to fertility among infected women. The main determinant of childhood infection is the scale of the epidemic among adults. The educated urban elite can be expected to suffer from more young adult AIDS-related mortality. In rural areas with low seroprevalence, other diseases will remain the main cause of mortality. In urban areas, health services will have to face considerably increased demands from ill and dying children.

Health surveys in developing countries: the objectives and design of an international programme.

There have been calls recently for a major international effort to collect epidemiological information in developing countries. One approach to a World Health Survey is considered, namely single-round retrospective interview surveys. Surveys can contribute to the improvement of national health information systems by providing person-based, rather than episode-based, measures related to health that apply to the entire population. A programme of health interview surveys could be used to ascertain patterns of morbidity and mortality, to measure access to and use of health services and to develop and disseminate methodologies for collecting and analysing health related data. Single-round surveys could not be used to evaluate the impact of investments on health and would be of limited use for improving our understanding of the determinants of ill health. Attention is drawn to a number of conceptual, technical and logistic issues to be considered in the design of a World Health Survey.

Estimation of adult mortality from paternal orphanhood: a reassessment and a new approach.

"This article proposes a new procedure for estimating men's mortality from paternal orphanhood which generally yields more accurate results than the existing approach. A procedure for estimating mortality from maternal orphanhood data based on consistent assumptions is also presented. The theory underlying these methods is outlined.... The article also points out an error made in the tabulation of the weighting factors used until now to estimate mortality from paternal orphanhood. Investigations using simulated data are presented which support the theoretical arguments that suggest that the paternal orphanhood method is more robust than has often been assumed and which confirm that the new approach usually produces more accurate estimates than the weighting factors."

Measurement of adult mortality in less developed countries: a comparative review.

"This paper compares the direct and indirect methods used to measure adult mortality in the developing world. No other approach can substitute fully for accurate and complete vital registration, but in many countries it is unrealistic to expect the registration system to cover the majority of the population in the foreseeable future.... The difficulties involved in measuring adult mortality using surveys and other ad hoc inquiries are discussed.... While the choice of methods must depend on each country's situation, direct questions require very large samples and are unreliable in single-round inquiries. On the other hand, although indirect methods provide less detailed and up-to-date information than is ideal, they are adequate for many practical purposes. In particular, the experience of the 1980s suggests that questions about orphanhood perform better than earlier assessments indicated, and recent methodological developments have circumvented some of the limitations of the indirect approach."

Estimation of mortality from orphanhood in adulthood.

This paper extends earlier research into methods for estimating adult mortality from information on the recent incidence of orphanhood. It presents a series of regression coefficients for estimating female and male mortality from synthetic cohort data on the subsequent orphanhood of those who had a living mother or father at exact age 20. Such information can be obtained either where questions about parental survival have been asked in two inquiries or by asking retrospectively about dates of orphanhood in a single survey. Although the method is somewhat sensitive to errors in the reporting of ages and dates, it is a promising source of up-to-date estimates of adult mortality that are free from bias due to the underreporting of the orphanhood of young children ("the adoption effect").

Has a fertility transition begun in West Africa?

PIP: Data from 4 World Fertility Surveys (WFS) and Demographic and Health Surveys (DHS) in Senegal and Ghana are used to examine whether fertility decline has occurred and whether a decline is consistent with changes in proximate determinants of fertility. The 1980s were a period marked by initiation of fertility decline throughout southern Africa and in most of eastern Africa where war or civil strife were absent. In Senegal evidence suggests a slight decline in fertility by age 40 years from 6.5 to 5.7 children during 1975-77 and 1986. In Ghana separate analysis of each survey suggests a slight decline in fertility, however, between survey periods there appears to be a slight increase in fertility. Senegal experienced a period of stability in fertility rates in the 15 years prior to 1978 and a change in rates in only the 5 years prior to 1986. Fertility decline was apparent among older age groups. In Ghana the reported cohort-period fertility rates were fairly constant in the 5-30 years prior to 1979-80 and showed a slight decline in the 5 years just before the survey in 1979-80, particularly among older women. Prior to 1988 rates declined steadily over time, except for rates among women around 30 years old. Findings support a decline in Senegal appearing around 1980 and an earlier decline in Ghana that suggests a fertility rate of about 6.4 by the mid-1980s. Parity progression ratios suggest limitation of births among women in their 30s with 6 children. Gaps between urban and rural fertility are apparent. Declines occurred among urban women and better educated women. Mean age at marriage increased, particularly among middle school educated women. Educated Ghanian women married earlier than Senegalese educated women. Contraceptive use was low in both countries, and use of traditional methods was high. Proximate determinants predicted a decline of 1 child in Senegal and confirmed the importance of secondary education and the rise in marriage age, and predicted a decline of 0.44 child in Ghana. Sustained fertility decline was not supported, and evidence was equivocal about the impact of economic conditions on fertility decline.^ieng

Mortality transition in the Ovamboland region of Namibia, 1930-1990.

Few long-term statistical series exist that can document the mortality transition in Africa. This paper uses data from the parish registers of the Evangelical Lutheran Church in Namibia to study morality in Ovamboland between 1930 and 1990. The paper identifies significant discontinuities and reversals in the trend in mortality. Much of the mortality transition occurred in a rapid breakthrough concentrated between the early 1950s and early 1960s. Adult mortality fell more than existing model life tables would predict and the pattern of relatively high early-age mortality typical of modern Africa emerged only at this time. While a range of developments in Ovamboland contributed to the overall decline in mortality, the most important factor was the establishment, by the Finnish Mission, of a Western system of health care. In Ovamboland, the drive to 'good health at low cost' was articulated not through political institutions but through the church.

The impact of HIV-1 infection on child health in sub-Saharan Africa: the burden on the health services.

HIV-1 infection in sub-Saharan Africa is resulting in substantial child mortality and an increase in the number of sick children presenting to health services. Many of the sick children come to health centres and hospitals, inflating numbers on paediatric wards. The presentations of childhood HIV-1 infection are many and varied so that HIV-1 infection is the new "great imitator' of other conditions. Some other infections are more severe in HIV-1 infected children (specifically bacterial infections and measles). However, there is no clear evidence of consequent rises in the incidence of other childhood infections, though this is likely to be the case of tuberculosis. HIV-1 infected children with other infections often respond to locally available anti-microbials, but may require longer courses. Treatment is problematic because of the impossibility of distinguishing infected from uninfected children and because of shortages of medicines, which are being intensified further by the child and adult HIV-1 epidemics. Severe HIV disease in adult family members is adding to child morbidity and creating substantial orphanhood. Staff fear nosocomial infection, while simultaneously experiencing falling personal incomes and lacking resources to care for their patients. Substantial numbers of trained staff are being lost because of HIV-1 caused disease and death. The reality of HIV-1 infection through breast-feeding is not yet appreciated. When this becomes generally apparent, there is a risk that a lethal increase in bottle feeding could occur in some areas. Reduction in the number of new paediatric HIV-1 infections in sub-Saharan Africa can be achieved only by ameliorating the adult HIV-1 epidemic, reducing unnecessary blood transfusions and ensuring a safe blood supply.

Identifying health problems and health research priorities in developing countries.

When we were invited to prepare this background paper on the health problems of the developing countries for the Commission on Health Research for Development, our first thought was to compile and organize available data on the causes of morbidity and mortality affecting different age groups in various populations. It soon became clear that this would not be especially useful. There are major gaps in the available data, particularly from the poorer countries and for people above 5 years of age. The data that are available are often of poor or uncertain quality, collected from unrepresentative or undefined subpopulations, and not strictly comparable due to different definitions and data-collection methods. Additionally, in the absence of agreed definitions and analytical frameworks, it is not clear what could or should be done with the data on health problems so amassed. More fundamentally, we have come to doubt whether the current array of epidemiological concepts and tools is sufficient for the task. We therefore decided that, while giving an overview of current knowledge on levels and trends of morbidity and mortality, the emphasis of this paper should be more towards concepts, methods, and data deficiencies. In Section 1, we set out definitions and frameworks for considering health problems and health research; we review recent conceptual models for the analysis of the determinants of child survival; and we outline a framework, focusing on modifiable determinants of health and life-cycle health effects, which is used in subsequent sections. In Section 2, relationships between national and societal level determinants and health are reviewed and then set aside. In Section 3, we review available data on world patterns and trends of morbidity and mortality, highlighting the data deficiencies and lacunae. In Section 4, we follow the life of a woman in a developing country and examine the health problems, and their determinants, which she and her children face. In Section 5, we draw these strands together and, having reviewed current approaches to prioritizing health problems and suggested some ways in which they could be improved, in Section 6 identify several research priorities, emphasizing the need for methodological research. This paper was commissioned in March 1987; prepared in draft and presented to a meeting at Chateau de Bossey, Geneva, Switzerland during 15-17 July; and revised and completed in September 1987. It is in no sense definitive or final.(ABSTRACT TRUNCATED AT 400 WORDS)

PIP: The fact that economic progress has a bearing on health can be seen in most developing countries where widespread poverty causes poor health and high mortality. Childhood mortality is highest in Africa and in Southern Asia. The rate of decline in mortality has decreased in these areas since the 1950s. In Sri Lanka, approximately 5% of the children 5 years old die, yet yearly 1/3 of the children 5 Afghanistan and a few West African countries die. In less developed countries, adult mortality is high: in places where the life expectancy of a 15-year-old is under 50 years, 30-40% will die before age 60. 80-90% of the deaths from water and food borne diseases are accounted for by diarrhea and dysentery, and 60-70% of the deaths from airborne diseases by pneumonia and bronchitis. Present estimates from 4 localities indicate that measles, malaria, tetanus, and acute respiratory infection account for more than 90% of all child mortality. Various estimates suggest that there are 100-300 million cases of malaria and 1-2 million malaria-related deaths annually. Estimates indicate a ratio of abortions varying between 9/1000 live births in East Africa to 325/1000 live births in Latin America. 1986 WHO data indicate that induced abortion is responsible for 7-50% of all maternal deaths in developing countries. More than 90 countries now that operational diarrheal disease control programs, 47 countries are producing oral rehydration solutions, 8450 health personnel have been trained in diarrhea program supervisory skills, and oral rehydration use rates are slowly rising.