Estimated impact of the 2020 economic downturn on under-5 mortality for 129 countries.

In low- and middle-income countries (LMICs), economic downturns can lead to increased child mortality by affecting dietary, environmental, and care-seeking factors. This study estimates the potential loss of life in children under five years old attributable to economic downturns in 2020. We used a multi-level, mixed effects model to estimate the relationship between gross domestic product (GDP) per capita and under-5 mortality rates (U5MRs) specific to each of 129 LMICs. Public data were retrieved from the World Bank World Development Indicators database and the United Nations World Populations Prospects estimates for the years 1990-2020. Country-specific regression coefficients on the relationship between child mortality and GDP were used to estimate the impact on U5MR of reductions in GDP per capita of 5%, 10%, and 15%. A 5% reduction in GDP per capita in 2020 was estimated to cause an additional 282,996 deaths in children under 5 in 2020. At 10% and 15%, recessions led to higher losses of under-5 lives, increasing to 585,802 and 911,026 additional deaths, respectively. Nearly half of all the potential under-5 lives lost in LMICs were estimated to occur in Sub-Saharan Africa. Because most of these deaths will likely be due to nutrition and environmental factors amenable to intervention, countries should ensure continued investments in food supplementation, growth monitoring, and comprehensive primary health care to mitigate potential burdens.

Factors associated with the decline in under-five diarrhea mortality in India: a LiST analysis.

BACKGROUND: India has achieved 86% reduction in the number of under-five diarrheal deaths from 1980 to 2015. Nonetheless diarrhea is still among the leading causes of under-five deaths. The aim of this analysis was to study the contribution of factors that led to decline in diarrheal deaths in the country and the effect of scaling up of intervention packages to address the remaining diarrheal deaths. METHODS: We assessed the attribution of different factors and intervention packages such as direct diarrhea case management interventions, nutritional factors and WASH interventions which contributed to diarrhea specific under-five mortality reduction (DSMR) during 1980 to 2015 using the Lives Saved Tool (LiST). The potential impact of scaling up different packages of interventions to achieve universal coverage levels by year 2030 on reducing the number of remaining diarrheal deaths were estimated. RESULTS: The major factors associated with DSMR reduction in under-fives during 1980 to 2015, were increase in ORS use, reduction in stunting prevalence, improved sanitation, changes in age appropriate breastfeeding practices, increase in the vitamin-A supplementation and persistent diarrhea treatment. ORS use and reduction in stunting were the two key interventions, each accounting for around 32% of the lives saved during this period. Scaling up the direct diarrhea case management interventions from the current coverage levels in 2015 to achieve universal coverage levels by 2030 can save around 82 000 additional lives. If the universal targets for nutritional factors and WASH interventions can be achieved, an additional 23 675 lives can potentially be saved. CONCLUSIONS: While it is crucial to improve the coverage and equity in ORS use, an integrated approach to promote nutrition, WASH and direct diarrhea interventions is likely to yield the highest impact on reducing the remaining diarrheal deaths in under-five children.

Factors associated with the decline in under five diarrhea mortality in Tanzania from 1980-2015.

BACKGROUND: Tanzania has made great progress in reducing diarrhea mortality in under- five children. We examined factors associated with the decline and projected the impact of scaling up interventions or reducing risk factors on diarrhea deaths. METHODS: We reviewed economic, health, and diarrhea-related policies, reports and programs implemented during 1980 to 2015. We used the Lives Saved Tool to determine the percentage reduction in diarrhea-specific mortality attributable to changes in coverage of the interventions and risk factors, including direct diarrhea-related interventions, nutrition, and water, sanitation and hygiene (WASH). We projected the number of diarrhea deaths that could be prevented in 2030, assuming near universal coverage of different intervention packages. RESULTS: Diarrhea-specific mortality among under-five children in Tanzania declined by 89% from 35.3 deaths per 1000 live births in 1980 to 3.9 deaths per 1000 live births in 2015. Factors associated with diarrhea-specific under-five mortality reduction included oral rehydration solution (ORS) use, changes in stunting prevalence, vitamin A supplementation, rotavirus vaccine, change in wasting prevalence and change in age-appropriate breastfeeding practices. Universal coverage of direct diarrhea, nutrition and WASH interventions has the potential reduce the diarrhea-specific mortality rate by 90%. CONCLUSIONS: Scaling up of a few key childhood interventions such as ORS and nutrition, and reducing the prevalence of stunting would address the remaining diarrhea-specific under-five mortality by 2030.

Evidence of Impact: iCCM as a strategy to save lives of children under five.

BACKGROUND: In 2013, the World Health Organization (WHO) launched the Rapid Access Expansion (RAcE) programme in the Democratic Republic of Congo, Malawi, Mozambique, Niger, and Nigeria to increase coverage of diagnostic, treatment, and referral services for malaria, pneumonia, and diarrhea among children ages 2-59 months. In 2017, a final evaluation of the six RAcE sites was conducted to determine whether the programme goal was reached. A key evaluation objective was to estimate the reduction in childhood mortality and the number of under-five lives saved over the project period in the RAcE project areas. METHODS: The Lives Saved Tool (LiST) was used to estimate reductions in all-cause child mortality due to changes in coverage of treatment for the integrated community case management (iCCM) illnesses - malaria, pneumonia, and diarrhea - while accounting for other changes in maternal and child health interventions in each RAcE project area. Data from RAcE baseline and endline household surveys, Demographic and Health Surveys, and routine health service data were used in each LiST model. The models yielded estimated change in under-five mortality rates, and estimated number of lives saved per year by malaria, pneumonia and diarrhea treatment. We adjusted the results to estimate the number of lives saved by community health worker (CHW)-provided treatment. RESULTS: The LiST model accounts for coverage changes in iCCM intervention coverage and other health trends in each project area to estimate mortality reduction and child lives saved. Under five mortality declined in all six RAcE sites, with an average decline of 10 percent. An estimated 6200 under-five lives were saved by malaria, pneumonia, and diarrhea treatment in the DRC, Malawi, Niger, and Nigeria, of which approximately 4940 (75 percent) were saved by treatment provided by CHWs. This total excludes Mozambique, where there were no estimated under-five lives saved likely due to widespread stockouts of key medications. In all other project areas, lives saved by CHW-provided treatment contributed substantially to the estimated decline in under-five mortality. CONCLUSIONS: Our results suggest that iCCM is a strategy that can save lives and measurably decrease child mortality in settings where access to health facility services is low and adequate resources for iCCM implementation are provided for CHW services.

Geographical variation in the association of child, maternal and household health interventions with under-five mortality in Burkina Faso.

BACKGROUND: Over the past 15 years, scaling up of cost effective interventions resulted in a remarkable decline of under-five mortality rates (U5MR) in sub-Saharan Africa. However, the reduction shows considerable heterogeneity. We estimated the association of child, maternal, and household interventions with U5MR in Burkina Faso at national and subnational levels and identified the regions with least effective interventions. METHODS: Data on health-related interventions and U5MR were extracted from the Burkina Faso Demographic and Health Survey (DHS) 2010. Bayesian geostatistical proportional hazards models with a Weibull baseline hazard were fitted on the mortality outcome. Spatially varying coefficients were considered to assess the geographical variation in the association of the health interventions with U5MR. The analyses were adjusted for child, maternal, and household characteristics, as well as climatic and environmental factors. FINDINGS: The average U5MR was as high as 128 per 1000 ranging from 81 (region of Centre-Est) to 223 (region of Sahel). At national level, DPT3 immunization and baby post-natal check within 24 hours after birth had the most important association with U5MR (hazard rates ratio (HRR) = 0.89, 95% Bayesian credible interval (BCI): 0.86-0.98 and HRR = 0.89, 95% BCI: 0.86-0.92, respectively). At sub-national level, the most effective interventions are the skilled birth attendance, and improved drinking water, followed by baby post-natal check within 24 hours after birth, vitamin A supplementation, antenatal care visit and all-antigens immunization (including BCG, Polio3, DPT3, and measles immunization). Centre-Est, Sahel, and Sud-Ouest were the regions with the highest number of effective interventions. There was no intervention that had a statistically important association with child survival in the region of Hauts Bassins. INTERPRETATION: The geographical variation in the magnitude and statistical importance of the association between health interventions and U5MR raises the need to deliver and reinforce health interventions at a more granular level. Priority interventions are DPT3 immunization, skilled birth attendance, baby post-natal visits in the regions of Sud-Ouest, Sahel, and Hauts Bassins, respectively. Our methodology could be applied to other national surveys, as it allows an incisive, data-driven and specific decision-making approach to optimize the allocation of health interventions at subnational level.

Lessons from the integrated community case management (iCCM) Rapid Access Expansion Program.

In 2012, the Government of Canada awarded a grant to the World Health Organization's Global Malaria Programme (GMP) to support the scale-up of integrated community case management (iCCM) of pneumonia, diarrhoea and malaria among children under 5 in sub-Saharan Africa under the Rapid Access Expansion Programme (RAcE). The two main objectives of the programme were to: (1) Contribute to the reduction of child mortality due to malaria, pneumonia and diarrhoea by increasing access to diagnostics, treatment and referral services, and (1) Stimulate policy updates in participating countries and catalyze scale-up of integrated community case management (iCCM) through documentation and dissemination of best practices. Based on the results of the implementation research and programmatic lessons, this collection provides evidence on impact and improving coverage of iCCM in routine health systems, and opportunities and challenges of implementing and sustaining delivery of iCCM at scale.

Newborn screening for sickle cell disease: an innovative pilot program to improve child survival in Dar es Salaam, Tanzania.

BACKGROUND: Sickle cell disease (SCD) is a recognized cause of childhood mortality. Tanzania has the fifth highest incidence of SCD (with an estimated 11 000 SCD annual births) worldwide. Although newborn screening (NBS) for SCD and comprehensive healthcare have been shown to reduce under-5 mortality by up to 94% in high-income countries such as the USA, no country in Africa has maintained NBS for SCD as a national health program. The aims of this program were to establish and evaluate NBS-SCD as a health intervention in Tanzania and to determine the birth prevalence of SCD. METHODS: Muhimbili University of Health and Allied Sciences conducted NBS for SCD from January 2015 to November 2016. Dried blood spot samples were collected and tested for SCD using isoelectric focusing. RESULTS: Screening was conducted on 3981 newborns. Thirty-one (0.8%) babies had SCD, 505 (12.6%) had sickle cell trait and 26 (0.7%) had other hemoglobinopathies. Twenty-eight (90.3%) of the 31 newborns with SCD were enrolled for comprehensive healthcare. CONCLUSIONS: This is the first report on NBS as a health program for SCD in Tanzania. The SCD birth prevalence of 8 per 1000 births is of public health significance. It is therefore important to conduct NBS for SCD with enrollment into a comprehensive care program.

Preventable deaths in childhood, according to actions of the Unified Health System, Brazil. / Mortes evitáveis na infância, segundo ações do Sistema Único de Saúde, Brasil.

OBJECTIVE: To analyze the mortality trend of children under five years of age living in Brazil and regions, using the "Brazilian List of Preventable Causes of Death." METHOD: Ecological time-series study of mortality rate due to preventable and non-preventable causes, with corrections for ill-defined causes and underreporting of deaths from 2000 to 2013. RESULTS: In Brazil, preventable death rates (5.1% per year) had a higher decrease compared with non-preventable ones (2.5% per year). Preventable causes associated with proper care during pregnancy had the highest concentration of deaths in 2013 (12,267) and the second lowest average percentage reduction in the year (2.1%) and for the period (24.4%). The South and Southeast regions had the lowest mortality rates in childhood. However, the Northeast region had the highest decrease in reducible child mortality (6.1% per year) and the Midwest, the lowest (3.5% per year). CONCLUSION: The decrease in childhood mortality rates was expected in the last decade, suggesting the progress in the response of health systems, in addition to improvements in health conditions and social determinants. Special attention should be given to pregnancy-related causes, i.e., expand the quality of prenatal care, in particular, due to fetal and newborn deaths resulted from maternal conditions, which increased significantly in the period (8,3% per year).

OBJETIVO: Analisar a tendência da mortalidade de crianças menores de cinco anos, residentes no Brasil e regiões, utilizando a "Lista Brasileira de Causas de Mortes Evitáveis". MÉTODO: Estudo ecológico de séries temporais da taxa de mortalidade por causas evitáveis e não evitáveis, com correções para as causas mal definidas e para o sub-registro de óbitos informados, no período de 2000 a 2013. RESULTADOS: No Brasil, houve maior declínio da taxa de mortalidade por causas evitáveis (5,1% ao ano), comparadas com as causas não evitáveis (2,5% ao ano). As causas evitáveis por adequada atenção à gestação constituíram a maior concentração de óbitos em 2013 (12.267) e tiveram a segunda menor redução percentual média anual (2,1%) e do período (24,4%). As menores taxas de mortalidade na infância foram evidenciadas nas regiões Sul e Sudeste. Observa-se, no entanto, que a Região Nordeste apresentou o maior declínio da mortalidade infantil reduzível (6,1% ao ano) e o Centro-Oeste, o menor (3,5% ao ano). CONCLUSÃO: O declínio da taxa de mortalidade na infância já era esperado nessa última década, levando a acreditar na evolução da resposta dos sistemas de saúde, além de nas melhorias nas condições de saúde e determinantes sociais. Atenção especial deve ser oferecida às causas relacionadas à gestação, ou seja, avançar na qualidade do pré-natal, em particular, em razão da ocorrência de mortes no feto e no recém-nascido oriundas de afecções maternas que apresentaram importante acréscimo no período (8,3% ao ano).

Estimating child mortality associated with maternal mortality from breast and cervical cancer.

BACKGROUND: Large-scale population studies demonstrate an association between mothers' deaths and child mortality in both lower and higher income countries. The authors estimated children's deaths in association with mothers' deaths from breast or cervical cancer, 2 common cancers in low-income and middle-income countries affecting women of reproductive age, to develop a comprehensive assessment of the death burden of these cancers. METHODS: A Monte Carlo simulation model was devised whereby women were at risk of dying from breast cancer, cervical cancer, or another cause. Compared with children who have living mothers, children of women who die before they reached age 10 years have an elevated risk of death from all causes. Therefore, simulations were conducted, and the impact of mothers' deaths from cervical and breast cancer on associated child mortality was quantified for Bangladesh, Burkina Faso, and Denmark (benchmark analysis), then the analyses were extended to all African countries. RESULTS: Benchmark estimates of child deaths associated with mothers' deaths from breast and cervical cancer resulted in an increment in cancer-related mortality of approximately 2% in Bangladesh, 14% in Burkina Faso, and less than 1% in Denmark. The model predicted an increment in comprehensive cancer deaths when including child death estimates by as high as 30% in certain African countries. CONCLUSIONS: To the authors' knowledge, this is the first study to estimate the impact of a mother's death from cancer on child mortality. The model's estimates call for further investigation into this correlation and underscore the relevance of adequate access to prevention and treatment among women of childbearing age.

Mortes evitáveis na infância, segundo ações do Sistema Único de Saúde, Brasil / Preventable deaths in childhood, according to actions of the Unified Health System, Brazil

RESUMO: Objetivo: Analisar a tendência da mortalidade de crianças menores de cinco anos, residentes no Brasil e regiões, utilizando a "Lista Brasileira de Causas de Mortes Evitáveis". Método: Estudo ecológico de séries temporais da taxa de mortalidade por causas evitáveis e não evitáveis, com correções para as causas mal definidas e para o sub-registro de óbitos informados, no período de 2000 a 2013. Resultados: No Brasil, houve maior declínio da taxa de mortalidade por causas evitáveis (5,1% ao ano), comparadas com as causas não evitáveis (2,5% ao ano). As causas evitáveis por adequada atenção à gestação constituíram a maior concentração de óbitos em 2013 (12.267) e tiveram a segunda menor redução percentual média anual (2,1%) e do período (24,4%). As menores taxas de mortalidade na infância foram evidenciadas nas regiões Sul e Sudeste. Observa-se, no entanto, que a Região Nordeste apresentou o maior declínio da mortalidade infantil reduzível (6,1% ao ano) e o Centro-Oeste, o menor (3,5% ao ano). Conclusão: O declínio da taxa de mortalidade na infância já era esperado nessa última década, levando a acreditar na evolução da resposta dos sistemas de saúde, além de nas melhorias nas condições de saúde e determinantes sociais. Atenção especial deve ser oferecida às causas relacionadas à gestação, ou seja, avançar na qualidade do pré-natal, em particular, em razão da ocorrência de mortes no feto e no recém-nascido oriundas de afecções maternas que apresentaram importante acréscimo no período (8,3% ao ano).

ABSTRACT: Objective: To analyze the mortality trend of children under five years of age living in Brazil and regions, using the "Brazilian List of Preventable Causes of Death." Method: Ecological time-series study of mortality rate due to preventable and non-preventable causes, with corrections for ill-defined causes and underreporting of deaths from 2000 to 2013. Results: In Brazil, preventable death rates (5.1% per year) had a higher decrease compared with non-preventable ones (2.5% per year). Preventable causes associated with proper care during pregnancy had the highest concentration of deaths in 2013 (12,267) and the second lowest average percentage reduction in the year (2.1%) and for the period (24.4%). The South and Southeast regions had the lowest mortality rates in childhood. However, the Northeast region had the highest decrease in reducible child mortality (6.1% per year) and the Midwest, the lowest (3.5% per year). Conclusion: The decrease in childhood mortality rates was expected in the last decade, suggesting the progress in the response of health systems, in addition to improvements in health conditions and social determinants. Special attention should be given to pregnancy-related causes, i.e., expand the quality of prenatal care, in particular, due to fetal and newborn deaths resulted from maternal conditions, which increased significantly in the period (8,3% per year).

Assessing levels and trends of child health inequality in 88 developing countries: from 2000 to 2014.

BACKGROUND: Reducing child mortality was one of the Millennium Development Goals. In the current Sustainable Development Goals era, achieving equity is prioritized as a major aim. OBJECTIVE: This study aims to provide a comprehensive and updated picture of inequalities in child health intervention coverage and child health outcomes by wealth status, as well as their trends between 2000 and 2014. METHODS: Using data from Demographic Health Surveys and Multiple Indicator Cluster Surveys, we adopted three measures of inequality, including one absolute inequality indicator and two relative inequality indicators, to estimate the level and trends of inequalities in three child health outcome variables and 17 intervention coverages in 88 developing countries. RESULTS: While improvements in child health outcomes and coverage of interventions have been observed between 2000 and 2014, large inequalities remain. There was a high level of variation between countries' progress toward reducing child health inequalities, with some countries significantly improving, some deteriorating, and some remaining statistically unchanged. Among child health interventions, the least equitable one was access to improved sanitation (The absolute difference in coverages between the richest quintile and the poorest quintile reached 49.5% [42.7, 56.2]), followed by access to improved water (34.1% [29.5, 38.6]), and skilled birth attendant (SBA) (34.1% [28.8, 39.4]). The most equitable intervention coverage was insecticide-treated bed net for children (1.0% [-3.9, 5.9]), followed by oral rehydration therapy for diarrhea ((8.0% [5.2, 10.8]), and vitamin A supplement (8.4% [5.1, 11.7]). These findings were robust to various inequality measurements. CONCLUSIONS: Although child health outcomes and coverage of interventions have improved largely over the study period for almost all wealth quintiles, insufficient progress was made in reducing child health inequalities between the poorest and richest wealth quintiles. Future efforts should focus on reaching the poorest children by increasing investments toward expanding the coverage of interventions in resource-limited settings.

The Role of Public Health Nutrition in Achieving the Sustainable Development Goals in the Asia Pacific Region.

The Sustainable Development Goals (SDGs) replaced the Millennium Development Goals (MDCs) in 2015, which included several goals and targets primarily related to nutrition: to eradicate extreme poverty and hunger and to reduce child mortality and improve maternal health. In the Asia-Pacific Academic Consortium for Public Health (APACPH) member countries as a group, infant and child mortality were reduced by more than 65% between 1990 and 2015, achieving the MDG target of two-thirds reduction, although these goals were not achieved by several smaller countries. The SDGs are broader in focus than the MDGs, but include several goals that relate directly to nutrition: 2 (zero hunger-food), 3 (good health and well-being-healthy life), and 12 (responsible consumption and production-sustainability). Other SDGs that are closely related to nutrition are 4 and 5 (quality education and equality in gender-education and health for girls and mothers, which is very important for infant health) and 13 (climate action). Goal 3 is "good health and well-being," which includes targets for child mortality, maternal mortality, and reducing chronic disease. The Global Burden of Disease Project has confirmed that the majority of risk for these targets can be attributed to nutrition-related targets. Dietary Guidelines were developed to address public health nutrition risk in the Asia Pacific region at the 48th APACPH 2016 conference and they are relevant to the achievement of the SDGs. Iron deficiency increases the risk of maternal death from haemorrhage, a cause of 300000 deaths world-wide each year. Improving diets and iron supplementation are important public health interventions in the APACPH region. Chronic disease and obesity rates in the APACPH region are now a major challenge and healthy life course nutrition is a major public health priority in answering this challenge. This article discusses the role of public health nutrition in achieving the SDGs. It also examines the role of APACPH in education and advocacy and in fulfilling the educational needs of public health students in public health nutrition.

The impact of eliminating within-country inequality in health coverage on maternal and child mortality: a Lives Saved Tool analysis.

BACKGROUND: Inequality in healthcare across population groups in low-income countries is a growing topic of interest in global health. The Lives Saved Tool (LiST), which uses health intervention coverage to model maternal, neonatal, and child health outcomes such as mortality rates, can be used to analyze the impact of within-country inequality. METHODS: Data from nationally representative household surveys (98 surveys conducted between 1998 and 2014), disaggregated by wealth quintile, were used to create a LiST analysis that models the impact of scaling up health intervention coverage for the entire country from the national average to the rate of the top wealth quintile (richest 20% of the population). Interventions for which household survey data are available were used as proxies for other interventions that are not measured in surveys, based on co-delivery of intervention packages. RESULTS: For the 98 countries included in the analysis, 24-32% of child deaths (including 34-47% of neonatal deaths and 16-19% of post-neonatal deaths) could be prevented by scaling up national coverage of key health interventions to the level of the top wealth quintile. On average, the interventions with most unequal coverage rates across wealth quintiles were those related to childbirth in health facilities and to water and sanitation infrastructure; the most equally distributed were those delivered through community-based mass campaigns, such as vaccines, vitamin A supplementation, and bednet distribution. CONCLUSIONS: LiST is a powerful tool for exploring the policy and programmatic implications of within-country inequality in low-income, high-mortality-burden countries. An "Equity Tool" app has been developed within the software to make this type of analysis easily accessible to users.

Declines in Malaria Burden and All-Cause Child Mortality following Increases in Control Interventions in Senegal, 2005-2010.

Malaria is endemic in Senegal. The national malaria control strategy focuses on achieving universal coverage for major interventions, with a goal of reaching preelimination status by 2018. Senegal began distribution of insecticide-treated nets (ITNs) and introduced artemisinin-based combination therapy in 2006, then introduced rapid diagnostic tests in 2007. We evaluated the impact of these efforts using a plausibility design based on malaria's contribution to all-cause under-five mortality (ACCM) and considering other contextual factors which may influence ACCM. Between 2005 and 2010, household ownership of ITNs increased from 20% to 63%, and the proportion of people sleeping under an ITN the night prior to the survey increased from 6% to 29%. Malaria parasite prevalence declined from 6% to 3% from 2008 to 2010 among children under five. Some nonmalaria indicators of child health improved, for example, increase of complete vaccination coverage from 58% to 64%; however, nutritional indicators deteriorated, with an increase in stunting from 16% to 26%. Although economic indicators improved, environmental conditions favored an increase in malaria transmission. ACCM decreased 40% between 2005 and 2010, from 121 (95% confidence interval [CI] 113-129) to 72 (95% CI 66-77) per 1,000, and declines were greater among age groups, epidemiologic zones, and wealth quintiles most at risk for malaria. After considering coverage of malaria interventions, trends in malaria morbidity, effects of contextual factors, and trends in ACCM, it is plausible that malaria control interventions contributed to a reduction in malaria mortality and to the impressive gains in child survival in Senegal.

Malaria Control Interventions Contributed to Declines in Malaria Parasitemia, Severe Anemia, and All-Cause Mortality in Children Less Than 5 Years of Age in Malawi, 2000-2010.

Malaria control intervention coverage increased nationwide in Malawi during 2000-2010. Trends in intervention coverage were assessed against trends in malaria parasite prevalence, severe anemia (hemoglobin < 8 g/dL), and all-cause mortality in children under 5 years of age (ACCM) using nationally representative household surveys. Associations between insecticide-treated net (ITN) ownership, malaria morbidity, and ACCM were also assessed. Household ITN ownership increased from 27.4% (95% confidence interval [CI] = 25.9-29.0) in 2004 to 56.8% (95% CI = 55.6-58.1) in 2010. Similarly intermittent preventive treatment during pregnancy coverage increased from 28.2% (95% CI = 26.7-29.8) in 2000 to 55.0% (95% CI = 53.4-56.6) in 2010. Malaria parasite prevalence decreased significantly from 60.5% (95% CI = 53.0-68.0) in 2001 to 20.4% (95% CI = 15.7-25.1) in 2009 in children aged 6-35 months. Severe anemia prevalence decreased from 20.4% (95% CI: 17.3-24.0) in 2004 to 13.1% (95% CI = 11.0-15.4) in 2010 in children aged 6-23 months. ACCM decreased 41%, from 188.6 deaths per 1,000 live births (95% CI = 179.1-198.0) during 1996-2000, to 112.1 deaths per 1,000 live births (95% CI = 105.8-118.5) during 2006-2010. When controlling for other covariates in random effects logistic regression models, household ITN ownership was protective against malaria parasitemia in children (odds ratio [OR] = 0.81, 95% CI = 0.72-0.92) and severe anemia (OR = 0.82, 95% CI = 0.72-0.94). After considering the magnitude of changes in malaria intervention coverage and nonmalaria factors, and given the contribution of malaria to all-cause mortality in malaria-endemic countries, the substantial increase in malaria control interventions likely improved child survival in Malawi during 2000-2010.

Impact of Insecticide-Treated Net Ownership on All-Cause Child Mortality in Malawi, 2006-2010.

Insecticide-treated nets (ITNs) have been shown to be highly effective at reducing malaria morbidity and mortality in children. However, there are limited studies that assess the association between increasing ITN coverage and child mortality over time, at the national level, and under programmatic conditions. Two analytic approaches were used to examine this association: a retrospective cohort analysis of individual children and a district-level ecologic analysis. To evaluate the association between household ITN ownership and all-cause child mortality (ACCM) at the individual level, data from the 2010 Demographic and Health Survey (DHS) were modeled in a Cox proportional hazards framework while controlling for numerous environmental, household, and individual confounders through the use of exact matching. To evaluate population-level association between ITN ownership and ACCM between 2006 and 2010, program ITN distribution data and mortality data from the 2006 Multiple Indicator Cluster Survey and the 2010 DHS were aggregated at the district level and modeled using negative binomial regression. In the Cox model controlling for household, child and maternal health factors, children between 1 and 59 months in households owning an ITN had significantly lower mortality compared with those without an ITN (hazard ratio = 0.75, 95% confidence interval [CI] = 0.62-90). In the district-level model, higher ITN ownership was significantly associated with lower ACCM (incidence rate ratio = 0.77; 95% CI = 0.60-0.98). These findings suggest that increasing ITN ownership may have contributed to the decline in ACCM during 2006-2010 in Malawi and represent a novel use of district-level data from nationally representative surveys.

Cooking fuel and risk of under-five mortality in 23 Sub-Saharan African countries: a population-based study.

Relationship between cooking fuel and under-five mortality has not been adequately established in Sub-Saharan Africa (SSA). We therefore investigated the association between cooking fuel and risk of under-five mortality in SSA, and further investigated its interaction with smoking. Using the most recent Demographic Health Survey data of 23 SSA countries (n = 783,691), Cox proportional hazard was employed to determine the association between cooking fuel and risk of under-five deaths. The adjusted hazard ratios were 1.21 (95 % CI, 1.10-1.34) and 1.20 (95 % CI, 1.08-1.32) for charcoal and biomass cooking fuel, respectively, compared to clean fuels. There was no positive interaction between biomass cooking fuel and smoking. Use of charcoal and biomass were associated with the risk of under-five mortality in SSA. Disseminating public health information on health risks of cooking fuel and development of relevant public health policies are likely to have a positive impact on a child's survival.

The resource curse and child mortality, 1961-2011.

There is now an extensive literature on the adverse effect of petroleum wealth on the political, economic and social well-being of a country. In this study we examine whether the so-called resource curse extends to the health of children, as measured by under-five mortality. We argue that the type of revenue available to governments in petroleum-rich countries reduces their incentive to improve child health. Whereas the type of revenue available to governments in petroleum-poor countries encourages policies designed to improve child health. In order to test that line of argument we employ a panel of 167 countries (all countries with populations above 250,000) for the years 1961-2011. We find robust evidence that petroleum-poor countries outperform petroleum-rich countries when it comes to reducing under-five mortality. This suggests that governments in oil abundant countries often fail to effectively use the resource windfall at their disposal to improve child health.

Time to revisit the strategy of massive vitamin A prophylaxis dose administration to the under five children in India - An analysis of available evidence.

Childhood blindness due to corneal ulceration has historically been prevalent among poor Indian children. To tackle this situation the National Institute of Nutrition (NIN), Hyderabad, India, launched (after field-testing) massive dose based national vitamin A (Vit-A) prophylaxis program. Over a period of time reduction in childhood mortality was also hailed as a beneficial effect of the program. Data from the Indian Council for Medical Research (ICMR) indicate that in most Indian states there has been a gradual reduction in the prevalence of Bitot's spots. However, it was not attributed to the prophylaxis program because of its low and patchy coverage. It was, rather, attributed to the control of malnutrition, along with measles vaccination and improvement in healthcare access. Various studies have concluded that massive dose vitamin A prophylaxis does not reduce childhood mortality; this may have been due to the Hawthorne effect; whereby beneficial effects arose from frequent contact of health workers with community members. Paradoxically, harmful effects of massive doses of Vit-A are documented, e.g. acute toxicity in certain groups of children, ranging from increased intracranial pressure, mental retardation (postnatal period), and even death. Vit-A also intensifies bone demineralization, and increased levels can lead to calcium deficiency and, hence, growth retardation in vulnerable children. According to the present authors, for children who have Bitot's spots or who have just recovered from an attack of measles, the best approach is to give Vit-A in therapeutic doses along with adequate daily intake of vegetables and fruits. Public-spirited citizens, along with the scientific community, must ensure the scrapping of the universal massive dose Vit-A prophylaxis approach, to avoid Vit-A toxicity and reduce economic burden to the health system.

Effects of the integrated Community Case Management of Childhood Illness Strategy on Child Mortality in Ethiopia: A Cluster Randomized Trial.

We conducted a cluster randomized trial of the effects of the integrated community case management of childhood illness (iCCM) strategy on careseeking for and coverage of correct treatment of suspected pneumonia, diarrhea, and malaria, and mortality among children aged 2-59 months in 31 districts of the Oromia region of Ethiopia. We conducted baseline and endline coverage and mortality surveys approximately 2 years apart, and assessed program strength after about 1 year of implementation. Results showed strong iCCM implementation, with iCCM-trained workers providing generally good quality of care. However, few sick children were taken to iCCM providers (average 16 per month). Difference in differences analyses revealed that careseeking for childhood illness was low and similar in both study arms at baseline and endline, and increased only marginally in intervention (22.9-25.7%) and comparison (23.3-29.3%) areas over the study period (P = 0.77). Mortality declined at similar rates in both study arms. Ethiopia's iCCM program did not generate levels of demand and utilization sufficient to achieve significant increases in intervention coverage and a resulting acceleration in reductions in child mortality. This evaluation has allowed Ethiopia to strengthen its strategic approaches to increasing population demand and use of iCCM services.