Geospatial correlations and variations in child mortality and stunting in South Africa: Evaluating distal vs structural determinants.

South Africa has one of the highest child mortality and stunting rates in the world. Flexible geoadditive models were used to investigate the geospatial variations in child mortality and stunting in South Africa. We used consecutive rounds of national surveys (2008-2017). The child mortality declined from 31 % to 24 % over time. Lack of medical insurance, black ethnicity, low-socioeconomic conditions, and poor housing conditions were identified as the most significant correlates of child mortality. The model predicted degrees of freedom which was estimated as 19.55 (p < 0.001), provided compelling evidence for sub-geographical level variations in child mortality which ranged from 6 % to 35 % across the country. Population level impact of the distal characteristics on child mortality and stunting exceeded that of other risk factors. Geospatial analysis can help in monitoring trends in child mortality over time and in evaluating the impact of health interventions.

An explanation of the stagnant under-5 mortality rate in Bangladesh using multilevel, multivariable analysis of three Demographic and Health Surveys.

Despite remarkable success in the Millennium Development Goal era, Bangladesh experienced a sluggish reduction in the under-5 mortality rate (U5MR) between 2014 and 2017-18. Our study aimed to explain this stagnancy by examining the variation in the key predictor-specific mortality risks over time, using the Bangladesh Demographic and Health Survey 2011, 2014 and 2017-18 data. We applied multilevel mixed effects logistic regression to examine the extent to which the under-5 mortality (U5M) risks were associated with the key sociodemographic and health service-specific predictors. We found that the rise in mortality risks attributable to maternal age 18 years or below, low maternal education, mother's overweight or obesity and the absence of a handwashing station within the household were the key contributors to the stagnant U5MR between 2014 and 2017-18. Poverty and low education aggravated the mortality risks. Besides, antenatal care (ANC) and postnatal care (PNC) did not impact U5M risks as significantly as expected. Compulsory use of ANC and PNC cards and strict monitoring of their use may improve the quality of these health services. Leveraging committees like the Upazila Hospital Management Committee can bring harmony to implementing policies and programmes in the sectors related to U5M.

Exploring the determinants of under-five mortality and morbidity from infectious diseases in Cambodia-a traditional and machine learning approach.

Cambodia has made progress in reducing the under-five mortality rate and burden of infectious diseases among children over the last decades. However the determinants of child mortality and morbidity in Cambodia is not well understood, and no recent analysis has been conducted to investigate possible determinants. We applied a multivariable logistical regression model and a conditional random forest to explore possible determinants of under-five mortality and under-five child morbidity from infectious diseases using the most recent Demographic Health Survey in 2021-2022. Our findings show that the majority (58%) of under-five deaths occurred during the neonatal period. Contraceptive use of the mother led to lower odds of under-five mortality (0.51 [95% CI 0.32-0.80], p-value 0.003), while being born fourth or later was associated with increased odds (3.25 [95% CI 1.09-9.66], p-value 0.034). Improved household water source and higher household wealth quintile was associated with lower odds of infectious disease while living in the Great Lake or Coastal region led to increased odds respectively. The odds ratios were consistent with the results from the conditional random forest. The study showcases how closely related child mortality and morbidity due to infectious disease are to broader social development in Cambodia and the importance of accelerating progress in many sectors to end preventable child mortality and morbidity.

Measuring spatial inequalities in maternal and child mortalities in Pakistan: evidence from geographically weighted regression.

BACKGROUND: In developing countries, the death probability of a child and mother is more significant than in developed countries; these inequalities in health outcomes are unfair. The present study encompasses a spatial analysis of maternal and child mortalities in Pakistan. The study aims to estimate the District Mortality Index (DMI), measure the inequality ratio and slope, and ascertain the spatial impact of numerous factors on DMI scores across Pakistani districts. METHOD: This study used micro-level household datasets from multiple indicator cluster surveys (MICS) to estimate the DMI. To find out how different the DMI scores were, the inequality ratio and slope were used. This study further utilized spatial autocorrelation tests to determine the magnitude and location of the spatial dependence of the clusters with high and low mortality rates. The Geographically Weighted Regression (GWR) model was also applied to examine the spatial impact of socioeconomic, environmental, health, and housing attributes on DMI. RESULTS: The inequality ratio for DMI showed that the upper decile districts are 16 times more prone to mortalities than districts in the lower decile, and the districts of Baluchistan depicted extreme spatial heterogeneity in terms of DMI. The findings of the Local Indicator of Spatial Association (LISA) and Moran's test confirmed spatial homogeneity in all mortalities among the districts in Pakistan. The H-H clusters of maternal mortality and DMI were in Baluchistan, and the H-H clusters of child mortality were seen in Punjab. The results of GWR showed that the wealth index quintile has a significant spatial impact on DMI; however, improved sanitation, handwashing practices, and antenatal care adversely influenced DMI scores. CONCLUSION: The findings reveal a significant disparity in DMI and spatial relationships among all mortalities in Pakistan's districts. Additionally, socioeconomic, environmental, health, and housing variables have an impact on DMI. Notably, spatial proximity among individuals who are at risk of death occurs in areas with elevated mortality rates. Policymakers may mitigate these mortalities by focusing on vulnerable zones and implementing measures such as raising public awareness, enhancing healthcare services, and improving access to clean drinking water and sanitation facilities.

Azithromycin to Reduce Mortality - An Adaptive Cluster-Randomized Trial.

BACKGROUND: Twice-yearly mass distribution of azithromycin to children is a promising intervention to reduce childhood mortality in sub-Saharan Africa. The World Health Organization recommended restricting distribution to infants 1 to 11 months of age to mitigate antimicrobial resistance, although this more limited treatment had not yet been tested. METHODS: We randomly assigned rural communities in Niger to four twice-yearly distributions of azithromycin for children 1 to 59 months of age (child azithromycin group), four twice-yearly distributions of azithromycin for infants 1 to 11 months of age and placebo for children 12 to 59 months of age (infant azithromycin group), or placebo for children 1 to 59 months of age. Census workers who were not aware of the group assignments monitored mortality twice yearly over the course of 2 years. We assessed three primary community-level mortality outcomes (deaths per 1000 person-years), each examining a different age group and pairwise group comparison. RESULTS: A total of 1273 communities were randomly assigned to the child azithromycin group (1229 were included in the analysis), 773 to the infant azithromycin group (751 included in the analysis), and 954 to the placebo group (929 included in the analysis). Among 382,586 children, 419,440 person-years and 5503 deaths were recorded. Lower mortality among children 1 to 59 months of age was observed in the child azithromycin group (11.9 deaths per 1000 person-years; 95% confidence interval [CI], 11.3 to 12.6) than in the placebo group (13.9 deaths per 1000 person-years; 95% CI, 13.0 to 14.8) (representing 14% lower mortality with azithromycin; 95% CI, 7 to 22; P<0.001). Mortality among infants 1 to 11 months of age was not significantly lower in the infant azithromycin group (22.3 deaths per 1000 person-years; 95% CI, 20.0 to 24.7) than in the placebo group (23.9 deaths per 1000 person-years; 95% CI, 21.6 to 26.2) (representing 6% lower mortality with azithromycin; 95% CI, -8 to 19). Five serious adverse events were reported: three in the placebo group, one in the infant azithromycin group, and one in the child azithromycin group. CONCLUSIONS: Azithromycin distributions to children 1 to 59 months of age significantly reduced mortality and was more effective than treatment of infants 1 to 11 months of age. Antimicrobial resistance must be monitored. (Funded by the Bill and Melinda Gates Foundation; AVENIR ClinicalTrials.gov number, NCT04224987.).

Birth outcomes and survival by sex among newborns and children under 2 in the Birhan Cohort: a prospective cohort study in the Amhara Region of Ethiopia.

INTRODUCTION: Despite the progress in reducing child mortality, the rate remains high, particularly in sub-Saharan African countries. Limited data exist on child survival and other birth outcomes by sex. This study compared survival rates and birth outcomes by sex among neonates and children under 2 in Ethiopia. METHODS: Women who gave birth after 28 weeks of gestation and their newborns were included in the analysis. Survival probabilities were estimated for males and females in the neonatal period as well as the 2-year period following birth using Kaplan-Meier curves. HRs and 95% CIs were compared between males and females under 2. Descriptive statistics and χ2 tests were used to determine the sex-disaggregated variation in the birth outcomes of preterm birth, low birth weight (LBW), stillbirth, small for gestational age (SGA) and large for gestational age (LGA). RESULTS: The study included a total of 3904 women and child pairs. The neonatal mortality rate for males (3.4%, 95% CI 2.6% to 4.2%) was higher compared with females (1.7%, 95% CI 1.1% to 2.3%). The hazard of death during the first 28 days of life was approximately two times higher for males compared with females (HR 1.99, 95% CI 1.30 to 3.06) but was not significantly different after this period. While there was a non-significant difference between males and females in the proportion of preterm, LBW and LGA births, we found a significantly higher proportion of stillbirth (2.7% vs 1.3%, p=0.003) and SGA (20.5% vs 15.6%, p<0.001) for males compared with females. CONCLUSIONS: This study identified a significant sex difference in mortality and birth outcomes. We recommend focusing future research on the mechanisms of these sex differences in order to better design intervention programmes to reduce disparities and improve outcomes for neonates.

Multilevel analysis of healthcare utilization for childhood diarrhea in high under five mortality countries.

Globally, 4.9 million under-five deaths occurred before celebrating their fifth birthday. Four in five under-five deaths were recorded in sub-Saharan Africa and Southern Asia. Childhood diarrhea is one of the leading causes of death and is accountable for killing around 443,832 children every year. Despite healthcare utilization for childhood diarrhea has a significant effect on the reduction of childhood mortality and morbidity, most children die due to delays in seeking healthcare. Therefore, this study aimed to assess healthcare utilization for childhood diarrhea in the top high under-five mortality countries. This study used secondary data from 2013/14 to 2019 demographic and health surveys of 4 top high under-five mortality countries. A total weighted sample of 7254 mothers of under-five children was included. A multilevel binary logistic regression was employed to identify the associated factors of healthcare utilization for childhood diarrhea. The statistical significance was declared at a p-value less than 0.05 with a 95% confidence interval. The overall magnitude of healthcare utilization for childhood diarrhea in the top high under-five mortality countries was 58.40% (95% CI 57.26%, 59.53%). Partner/husband educational status, household wealth index, media exposure, information about oral rehydration, and place of delivery were the positive while the number of living children were the negative predictors of healthcare utilization for childhood diarrhea in top high under-five mortality countries. Besides, living in different countries compared to Guinea was also an associated factor for healthcare utilization for childhood diarrhea. More than four in ten children didn't receive health care for childhood diarrhea in top high under-five mortality countries. Thus, to increase healthcare utilization for childhood diarrhea, health managers and policymakers should develop strategies to improve the household wealth status for those with poor household wealth index. The decision-makers and program planners should also work on media exposure and increase access to education. Further research including the perceived severity of illness and ORS knowledge-related factors of healthcare utilization for childhood diarrhea should also be considered by other researchers.

Evidence of health system resilience in primary health care for preventing under-five mortality in Rwanda and Bangladesh: Lessons from an implementation study during the Millennium Development Goal period and the early period of COVID-19.

Background: The coronavirus disease 2019 (COVID-19) pandemic led to disruptions of health service delivery in many countries; some were more resilient in either limiting or rapidly responding to the disruption than others. We used mixed methods implementation research to understand factors and strategies associated with resiliency in Rwanda and Bangladesh, focussing on how evidence-based interventions targeting amenable under-five mortality that had been used during the Millennium Development Goal (MDG) period (2000-15) were maintained during the early period of COVID-19. Methods: We triangulated data from three sources - a desk review of available documents, existing quantitative data on evidence-based intervention coverage, and key informant interviews - to perform a comparative analysis using multiple case studies methodology, comparing contextual factors (barriers or facilitators), implementation strategies (existing from 2000-15, new, or adapted), and implementation outcomes across the two countries. We also analysed which health system resiliency capabilities were present in the two countries. Results: Both countries experienced many of the same facilitators for resiliency of evidence-based interventions for children under five, as well as new, pandemic-specific barriers during the early COVID-19 period (March to December 2020) that required targeted implementation strategies in response. Common facilitators included leadership and governance and a culture of accountability, while common barriers included movement restrictions, workload, and staff shortages. We saw a continuity of implementation strategies that had been associated with success in care delivery during the MDG period, including data use for monitoring and decision-making, as well as building on community health worker programmes for community-based health care delivery. New or adapted strategies used in responding to new barriers included the expanded use of digital platforms. We found implementation outcomes and strong resilience capabilities, including awareness and adaptiveness, which were related to pre-existing facilitators and implementation strategies (continued and new). Conclusions: The strategies and contextual factors Rwanda and Bangladesh leveraged to build 'everyday resilience' before COVID-19, i.e. during the MDG period, likely supported the maintained delivery of the evidence-based interventions targeting under-five mortality during the early stages of the pandemic. Expanding our understanding of pre-existing factors and strategies that contributed to resilience before and during the pandemic is important to support other countries' efforts to incorporate 'everyday resilience' into their health systems.

Differentiating mortality risk of individual infants and children to improve survival: opportunity for impact.

Children are not born equal in their likelihood of survival. The risk of mortality is highest during and shortly after birth. In the immediate postnatal period and beyond, perinatal events, nutrition, infections, family and environmental exposures, and health services largely determine the risk of death. We argue that current public health programmes do not fully acknowledge this spectrum of risk or respond accordingly. As a result, opportunities to improve the care, survival, and development of children in resource-poor settings are overlooked. Children at high risk of mortality are underidentified and commonly treated using guidelines that do not differentiate care according to the magnitude or drivers of those risks. Children at low risk of mortality are often provided with more intensive care than needed, disproportionately using limited health-care resources with minimal or no benefits. Declines in newborn, infant, and child mortality rates globally are slowing, and further reductions are likely to be incrementally more difficult to achieve once simple, high impact interventions have been universally implemented. Currently, 63 countries have rates of neonatal mortality that are off track to meet the Sustainable Development Goal 2030 target of 12 deaths per 1000 livebirths or less, and 54 countries have rates of mortality in children younger than 5 years that are off track to meet the target of 25 deaths per 1000 livebirths or less. If these targets are to be met, a change of approach is needed to address infant and child mortality and for health-care systems to more efficiently address residual mortality.

Maternal preconceptional and prenatal exposure to El Niño Southern Oscillation levels and child mortality: a multi-country study.

El Niño Southern Oscillation (ENSO) has been shown to relate to the epidemiology of childhood infectious diseases, but evidence for whether they increase child deaths is limited. Here, we investigate the impact of mothers' ENSO exposure during and prior to delivery on child mortality by constructing a retrospective cohort study in 38 low- and middle-income countries. We find that high levels of ENSO indices cumulated over 0-12 lagged months before delivery are associated with significant increases in risks of under-five mortality; with the hazard ratio ranging from 1.33 (95% confidence interval [CI], 1.26, 1.40) to 1.89 (95% CI, 1.78, 2.00). Child mortality risks are particularly related to maternal exposure to El Niño-like conditions in the 0th-1st and 6th-12th lagged months. The El Niño effects are larger in rural populations and those with unsafe sources of drinking water and less education. Thus, preventive interventions are particularly warranted for the socio-economically disadvantaged.

Predictors of time to death among under-five children in pastoral regions of Ethiopia: A retrospective follow-up study.

BACKGROUND: In Ethiopia, the mortality rate for children under five is a public health concern. Regretfully, the problem is notably underestimated and underreported, making it impossible to fully recognize how serious the situation is in the nation's developing regions. Unfortunately, no single study has been conducted to reveal the rates and predictor factors of under-five child death in Ethiopia's pastoral regions. Therefore, the purpose of this study was to determine the critical variables that led to a shorter survival time to death for children in Ethiopia's pastoral regions under the age of five. METHODS: Between January 18 and June 27, 2016, a retrospective follow-up study was done among under-five children in pastoral areas of Ethiopia. The statistically significant difference between categorical predictors was shown using the log-rank test, and the Kaplan-Meier survival curve was used to determine the survival time. In order to identify the time-to-death predictor factors in children under five, Cox proportional hazards (PH) model analyses of bivariable and multivariable variables were fitted. RESULTS: A total 7,677 children were included in the study. The overall incidence rate of under-five mortality was 8.4% (95% CI 7.77%, 9.0%). In the multivariable Cox PH model analysis, children vaccinated (AHR: 0.72, 95% CI: 0.59, 0.88), mothers aged 35-40 (AHR: 1.27; 95% CI: 1.06, 1.52), and above 41 (AHR: 2.18, 95% CI: 1.59, 2.98), not initiating exclusively breastfeeding (AHR: 1.26, 95% CI: 1.02, 1.55), the agriculture sector of the mother's occupation (AHR: 2.57, 95% CI: 1.74, 3.31), the male sex of the household head (AHR: 0.67, 95% CI: 0.56, 0.81), non-anemic child (AHR: 0.67, 95% CI: 0.55, 0.83), and rural residence (AHR: 3.27, 95% CI: 1.45, 7.38) were identified as main predictors of time to death among under-five children. CONCLUSIONS: In this study, the authors found a higher rate of under-five deaths than the national figure. A child vaccinated, exclusively breastfeeding, mother's occupation, sex of household head, anemic child, mother's age, and residence were found to be the most influential predictors for time-to-death. Therefore, to lower the high incidence of under-five mortality, the government should focus on the pastoral regional states of Ethiopia.

Utilization of integrated community-based case management of childhood illness and associated factors in Ethiopia: a systematic review and meta-analysis.

BACKGROUND: Despite significant progress being made in reducing under-five mortality, three-fourths of under-five deaths are still caused by preventable conditions such as pneumonia, diarrhea, malaria, and newborn issues. Integrated community case management of childhood illnesses (ICCM) could serve as a means to reduce preventable child mortality in Low- and Middle-Income countries. Our aim was to assess the overall level of ICCM utilization and its associated factors in Ethiopia. METHODS: Candidate studies for inclusion in this review were identified through searches across various databases, including PubMed, EMBASE, Google Scholar, and university repositories online databases, spanning from February 1, 2024, to March 18, 2024. The quality assessment of the studies included in this systematic review and meta-analysis was conducted using the Newcastle-Ottawa Quality Assessment Scale (NOS). Data extraction and analysis were carried out using Microsoft Excel and Stata 17 software, respectively. Heterogeneity among the studies was assessed using Cochran's Q test and I2 statistics, while the presence of publication bias was evaluated through funnel plots and Egger's regression asymmetry test. Subgroup analysis was performed based on sample size and study site. RESULTS: In this study, the pooled level of ICCM utilization was found to be 42.73 (95%, CI 27.65%, 57.80%) based on the evidence obtained from ten primary studies. In this review, parents' awareness about illness (OR = 2.77, 95%, CI 2.06, 3.74), awareness about ICCM service (OR = 3.64, 95%, CI 2.16, 6.14), perceived severity of the disease (OR = 3.14, 95%, CI 2.33, 4.23), secondary/above level of education (OR = 2.57, 95%, CI 1.39, 4.77), and live within 30 min distance to the health post (OR = 3.93, 95%, CI 2.30, 6.74) were variables significantly associated with utilization of ICCM in Ethiopia. CONCLUSION: The utilization of ICCM was found to be low in Ethiopia. Factors such as parents' awareness about the illness, knowledge of ICCM services, perceived severity of the disease, attending a secondary or more level of education, and living within 30 min distance to the health post were significantly associated with the utilization of ICCM. Therefore, it is crucial to focus on creating awareness and improving access to high-quality ICCM services to reduce child morbidity and mortality from preventable causes.

The influence of parental occupational status on under-five mortality in Ethiopia.

Few studies have examined the mediators of the association between parental occupational status and under-five mortality risk in Ethiopia. We examine the association between parental occupational status and under-five mortality risk in Ethiopia and the role of two mediating variables, antenatal care visits and delivery by a health professional, in this relationship. Using birth data from the nationally representative 2016 Ethiopia Demographic and Health Survey, the study finds that parental occupation, antenatal care visits, and delivery by a health professional are associated with under-five mortality risk. The study also finds that after controlling for mediating variables, parents engaged in professional, agricultural, and manual labor still have lower odds of under-five mortality risk than children of non-working parents. Future research should focus on the pathway from parental employment to child mortality risk, not through access to antenatal care and delivery by health professionals.

Intergenerational Clustering of Under-Five Mortality: A Cohort Perspective in Low- and Middle-Income Countries.

A burgeoning demographic literature documents the exceedingly high rates at which contemporary cohorts of women across the Global South experience the death of their children-even amid historic declines in child mortality. Yet, the patterning of maternal bereavement remains underinvestigated, as does the extent to which it replicates across generations of the same family. To that end, we ask: Are the surviving daughters of bereaved mothers more likely to eventually experience maternal bereavement? How does the intergenerational clustering of maternal bereavement vary across countries and cohorts? To answer these questions, we make use of Demographic and Health Survey Program data from 50 low- and middle-income countries, encompassing data on 1.05 million women and their mothers spanning three decadal birth cohorts. Descriptive results demonstrate that maternal bereavement is increasingly patterned intergenerationally across cohorts, with most women experiencing the same fate as their mothers. Multivariable hazard models further show that, on average, women whose mothers were maternally bereaved have significantly increased odds of losing a child themselves. In most countries, the association is stable across cohorts; however, in select countries, the risk associated with having a bereaved mother is shrinking among more recent birth cohorts.

Incidence density mortality rate among HIV-positive children on antiretroviral therapy in Ethiopia: a systematic review and meta-analysis.

BACKGROUND: Human Immunodeficiency Virus (HIV) continues to be the major cause of childhood deaths, particularly in the sub-Saharan African region. In Ethiopia, though several primary studies have been conducted on the incidence of HIV-related child mortality, the pooled incidence density mortality rate among HIV-positive children is unknown. Therefore, this systematic review and meta-analysis aimed to estimate the pooled incidence density mortality rate among HIV-positive children and identify its associated factors in Ethiopia. METHODS: We browsed PubMed, HINARI, Science Direct, Google Scholar, African Journals Online, and cross-references using different search terms to identify articles. Quality appraisal was done using the Joanna Briggs Institute checklist. Meta-package was used to estimate the pooled incidence of mortality and hazard ratio (HR) of predictors. Heterogeneity was tested using the I-square statistics. Publication bias was tested using a funnel plot visual inspection and Egger's test. Data was presented using forest plots and tables. The random effect model was used to compute the pooled estimate. RESULTS: The overall pooled incidence density mortality rate among HIV-positive children was 2.52 (95% CI: 1.82, 3.47) per 100 child years. Advanced HIV disease (hazard ratio (HR): 3.45, 95% CI (Confidence Interval): 2.64, 4.51), tuberculosis co-infection (HR: 3.19, 95% CI: 2.08, 4.88), stunting (3.22, 95% CI: 2.46, 4.22), underweight (HR: 2.71, 95% CI: 1.72, 4.26), wasting (HR: 4.14, 95% CI: 2.27, 7.58), didn't receive Isoniazid preventive therapy (HR: 3.33, 95% CI: 2.22, 4.99), anemia (HR: 3.03, 95% CI: 2.52, 3.64), fair or poor antiretroviral therapy adherence (HR: 4.14, 95% CI: 3.28, 5.28) and didn't receive cotrimoxazole preventive therapy (HR: 3.82, 95% CI: 2.49, 5.86) were factors associated with a higher hazard of HIV related child mortality. CONCLUSIONS: The overall pooled incidence density mortality rate among HIV-positive children was high in Ethiopia as compared to the national strategy target. Therefore, counseling on antiretroviral therapy adherence should be strengthened. Regular monitoring of hemoglobin levels and assessment of nutritional status should be done for all children living with HIV. Moreover, healthcare professionals should follow the national HIV treatment guidelines and provide cotrimoxazole preventive therapy and Isoniazid preventive therapy up on the guidelines for children living with HIV. REGISTRATION: Registered in PROSPERO with ID: CRD42023486902.

Timely access to secondary pediatric services in Korea: a key to reducing child and adolescent mortality.

OBJECTIVES: Geographic disparities in access to secondary pediatric care remain a significant issue in countries with universal health coverage, including Korea. This study investigated the link between geographic access to secondary pediatric care and mortality rates in children and adolescents (0-19 years) in Korea. METHODS: We analyzed district-level data to assess the percentage of those aged 0-19 years residing outside of a 60-minute travel radius from the nearest secondary pediatric care provider (accessibility vulnerability index, AVI). RESULTS: The AVI ranged from 0% to 100% across the districts for the study period. The confidence interval (CI) was -0.30 (95% CI, -0.41 to -0.19) in 2017 and -0.41 (95% CI, -0.52 to -0.30) in 2021, indicating that the proportion of those who could not access care within 60 minutes was disproportionately higher in districts with lower socioeconomic status. We found 8% rise in mortality rates among individuals aged 0-19 years for every 10% increase in AVI (95% CI, 1.06 to 1.10). CONCLUSIONS: The study highlights disparities in pediatric care access and their impact on child survival, emphasizing the need for improved access to achieve true universal health coverage.

Levels, trends and inequalities in mortality among 5-19-year-olds in Tanzania: Magu Health and Demographic Surveillance Study (1995-2022).

Background: For the past two decades, health priorities in Tanzania have focussed on children under-five, leaving behind the older children and adolescents (5-19 years). Understanding mortality patterns beyond 5 years is important in bridging a healthy gap between childhood to adulthood. We aimed to estimate mortality levels, trends, and inequalities among 5-19-year-olds using population data from the Magu Health and Demographic Surveillance Site (HDSS) in Tanzania and further compare the population level estimates with global estimates. Methods: Using data from the Magu HDSS from 1995 to 2022, from Kaplan Meir survival probabilities, we computed annual mortality probabilities for ages 5-9, 10-14 and 15-19 and determined the average annual rate of change in mortality by fitting the variance weighted least square regression on annual mortality probabilities. We compared 5-19 trends with younger children aged 1-4 years. We further disaggregated mortality by sex, area of residence and wealth tertiles, and we computed age-stratified risk ratios with respective 95% confidence intervals (CIs) using Cox proportional hazard model to determine inequalities. We further compared population-level estimates in all-cause mortality with global estimates from the United Nations Inter-agency Group for Child Mortality Estimation and the Global Burden of Disease study by computing the relative differences to the estimates. Results: Mortality declined steadily among the three age groups from 1995 to 2022, whereby the average annual rate of decline increased with age (2.2%, 2.7%, and 2.9% for 5-9-, 10-14-, and 15-19-year-old age groups, respectively). The pace of this decline was lower than that of younger children aged 1-4 years (4.8% decline). We observed significant mortality inequalities with boys, those residing in rural areas, and those from poorest wealth tertiles lagging behind. While Magu estimates were close to global estimates for the 5-9-year-old age group, we observed divergent results for adolescents (10-19 years), with Magu estimates lying between the global estimates. Conclusion: The pace of mortality decline was lower for the 5-19-year-old age group compared to younger children, with observable inequalities by socio-demographic characteristics. Determining the burden of disease across different strata is important in the development of evidence-based targeted interventions to address the mortality burden and inequalities in this age group, as it is an important transition period to adulthood.

Clinicopathological discrepancies in the diagnoses of childhood causes of death in the CHAMPS network: An analysis of antemortem diagnostic inaccuracies.

INTRODUCTION: Determining aetiology of severe illness can be difficult, especially in settings with limited diagnostic resources, yet critical for providing life-saving care. Our objective was to describe the accuracy of antemortem clinical diagnoses in young children in high-mortality settings, compared with results of specific postmortem diagnoses obtained from Child Health and Mortality Prevention Surveillance (CHAMPS). METHODS: We analysed data collected during 2016-2022 from seven sites in Africa and South Asia. We compared antemortem clinical diagnoses from clinical records to a reference standard of postmortem diagnoses determined by expert panels at each site who reviewed the results of histopathological and microbiological testing of tissue, blood, and cerebrospinal fluid. We calculated test characteristics and 95% CIs of antemortem clinical diagnostic accuracy for the 10 most common causes of death. We classified diagnostic discrepancies as major and minor, per Goldman criteria later modified by Battle. RESULTS: CHAMPS enrolled 1454 deceased young children aged 1-59 months during the study period; 881 had available clinical records and were analysed. The median age at death was 11 months (IQR 4-21 months) and 47.3% (n=417) were female. We identified a clinicopathological discrepancy in 39.5% (n=348) of deaths; 82.3% of diagnostic errors were major. The sensitivity of clinician antemortem diagnosis ranged from 26% (95% CI 14.6% to 40.3%) for non-infectious respiratory diseases (eg, aspiration pneumonia, interstitial lung disease, etc) to 82.2% (95% CI 72.7% to 89.5%) for diarrhoeal diseases. Antemortem clinical diagnostic specificity ranged from 75.2% (95% CI 72.1% to 78.2%) for diarrhoeal diseases to 99.0% (95% CI 98.1% to 99.6%) for HIV. CONCLUSIONS: Antemortem clinical diagnostic errors were common for young children who died in areas with high childhood mortality rates. To further reduce childhood mortality in resource-limited settings, there is an urgent need to improve antemortem diagnostic capability through advances in the availability of diagnostic testing and clinical skills.