Can generic paediatric mortality scores calculated 4 hours after admission be used as inclusion criteria for clinical trials?
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INTRODUCTION: Two generic paediatric mortality scoring systems have been validated in the paediatric intensive care unit (PICU). Paediatric RISk of Mortality (PRISM) requires an observation period of 24 hours, and PRISM III measures severity at two time points (at 12 hours and 24 hours) after admission, which represents a limitation for clinical trials that require earlier inclusion. The Paediatric Index of Mortality (PIM) is calculated 1 hour after admission but does not take into account the stabilization period following admission. To avoid these limitations, we chose to conduct assessments 4 hours after PICU admission. The aim of the present study was to validate PRISM, PRISM III and PIM at the time points for which they were developed, and to compare their accuracy in predicting mortality at those times with their accuracy at 4 hours. METHODS: All children admitted from June 1998 to May 2000 in one tertiary PICU were prospectively included. Data were collected to generate scores and predictions using PRISM, PRISM III and PIM. RESULTS: There were 802 consecutive admissions with 80 deaths. For the time points for which the scores were developed, observed and predicted mortality rates were significantly different for the three scores (P < 0.01) whereas all exhibited good discrimination (area under the receiver operating characteristic curve >or=0.83). At 4 hours after admission only the PIM had good calibration (P = 0.44), but all three scores exhibited good discrimination (area under the receiver operating characteristic curve >or=0.82). CONCLUSIONS: Among the three scores calculated at 4 hours after admission, all had good discriminatory capacity but only the PIM score was well calibrated. Further studies are required before the PIM score at 4 hours can be used as an inclusion criterion in clinical trials. (+info)
Childhood mortality among former Mozambican refugees and their hosts in rural South Africa.
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BACKGROUND: It is important to monitor health differentials between population groups to understand how they are generated. Internationally displaced people represent one potentially disadvantaged group. We investigated differentials in mortality between children from former Mozambican refugee and host South African households in a rural sub-district in the north-east of South Africa. METHODS: Open prospective cohort of 30 276 children (80 462 person years of follow-up) followed from 1 January 1992 to 31 October 2000 in Limpopo Province, South Africa. Exposure and outcomes data came from the Agincourt Health and Demographic Surveillance System (DSS). RESULTS: There was no difference in infant mortality between children from former Mozambican refugee households and those from South African homes (adjusted rate ratio [RR] = 1.02, 95% CI: 0.79, 1.32), but mortality levels were higher among former Mozambican refugee children during the next 4 years (adjusted RR = 1.91, 95% CI: 1.50, 2.42). Increased mortality levels were also seen among children from larger households and whose mother died, while children born to mothers aged >40 years or with higher education were at lower risk. Measured maternal, household, and health service utilization characteristics could not explain the difference in mortality between children from former Mozambican refugee and South African households. Former Mozambican refugee children residing in refugee settlements had higher mortality rates than those residing in more established villages. CONCLUSIONS: This study demonstrates higher childhood, but not infant, mortality rates among children from former Mozambican refugee households compared with those from host South African households in rural South Africa. The lack of legal status and lower wealth of many former Mozambican refugees may partly explain this disparity. (+info)
Monitoring trends in under-5 mortality rates through national birth history surveys.
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BACKGROUND: We assessed whether Demographic and Health Surveys (DHS), a large and high-quality source of under-5 mortality estimates in developing countries, would be able to detect reductions in under-5 mortality as established in global child health goals. METHODS AND RESULTS: Mortality estimates from 41 DHS conducted in African countries between 1986 and 2002, for the interval of 0-4 years preceding each survey (with a mean time lag of 2.5 years), were reviewed. The median relative error on national mortality rates was 4.4%. In multivariate regression, the relative error decreased with increasing sample size, increasing fertility rates, and increasing mortality rates. The error increased with the magnitude of the survey design effect, which resulted from cluster sampling. With levels of precision observed in previous surveys, reductions in all-cause under-5 mortality rates between two subsequent surveys of 15% or more would be detectable. The detection of smaller mortality reductions would require increases in sample size, from a current median of 7060 to over 20,000 women. Across the actual surveys conducted between 1986 and 2002, varying mortality trends were apparent at a national scale, but only around half of these were statistically significant. CONCLUSIONS: The interpretation of changes in under-5 mortality rates between subsequent surveys needs to take into account statistical significance. DHS birth history surveys with their present sampling design would be able to statistically confirm under-5 mortality reductions in African countries if true reductions were 15% or larger, and are highly relevant to tracking progress towards existing international child health targets. (+info)
Relation between increased numbers of safe playing areas and decreased vehicle related child mortality rates in Japan from 1970 to 1985: a trend analysis.
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OBJECTIVES: To examine vehicle related mortality trends of children in Japan; and to investigate how environmental modifications such as the installation of public parks and pavements are associated with these trends. DESIGN: Poisson regression was used for trend analysis, and multiple regression modelling was used to investigate the associations between trends in environmental modifications and trends in motor vehicle related child mortality rates. SETTING: Mortality data of Japan from 1970 to 1994, defined as E-code 810-23 from 1970 to 1978 and E810-25 from 1979 to 1994, were obtained from vital statistics. Multiple regression modelling was confined to the 1970-1985 data. Data concerning public parks and other facilities were obtained from the Ministry of Land, Infrastructure, and Transport. SUBJECTS: Children aged 0-14 years old were examined in this study and divided into two groups: 0-4 and 5-14 years. MAIN RESULTS: An increased number of public parks was associated with decreased vehicle related mortality rates among children aged 0-4 years, but not among children aged 5-14. In contrast, there was no association between trends in pavements and mortality rates. CONCLUSIONS: An increased number of public parks might reduce vehicle related preschooler deaths, in particular those involving pedestrians. Safe play areas in residential areas might reduce the risk of vehicle related child death by lessening the journey both to and from such areas as well as reducing the number of children playing on the street. However, such measures might not be effective in reducing the vehicle related mortalities of school age children who have an expanded range of activities and walk longer distances. (+info)
Childhood mortality and probable causes of death using verbal autopsy in Niakhar, Senegal, 1989-2000.
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BACKGROUND: In African rural settings, medically certified information on causes of death is largely lacking. The authors applied the verbal autopsy to identify causes of death before 15 years old in a rural area of Senegal where a demographic surveillance system is operating. METHODS: Between 1989 and 2000, a postmortem interview was conducted using a standardized questionnaire which was independently reviewed by two physicians who assigned the probable underlying cause of death. Discordant diagnoses were discussed by a panel of physicians. Causes of death were grouped into a few categories; cause-specific mortality rates and fractions were generated. RESULTS: Between 1989 and 1997, all-cause mortality fluctuated. Diarrhoeal diseases, malaria and acute respiratory infections explained between 30% and 70% of the mortality before 10 years of age. In children 1-9 years old, malaria death rate increased between 1989 and 1994 and thereafter did not change. The 1998-2000 years were marked by a peak in mortality, attributed to a meningitis outbreak in children more than one year old paralleled by an increase in death rate from fever of unknown origin, diarrhoeal diseases, and acute respiratory infections in children under 5 years. CONCLUSIONS: Verbal autopsy provided useful information on the mortality structure responsible for the 1998-2000 peak in mortality. It underlined that, outside outbreak situations, malaria was a leading cause of death for 1-9 year old children and that diarrhoea, acute respiratory infections, or fever from unknown origin accounted for up to 50% of the deaths among the children under 5 years. (+info)
BCG vaccination scar associated with better childhood survival in Guinea-Bissau.
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BACKGROUND: Recent studies have suggested that Bacille Calmette-Guerin (BCG) vaccination may have a non-specific beneficial effect on infant survival and that a BCG scar may be associated with lower child mortality. No study has previously examined the influence of BCG vaccination on cause of death. METHODS: Two cohorts (A and B) were used to describe the mortality pattern for children with and without BCG scar and to determine specific causes of death. In cohort A (n = 1813), BCG scar was assessed at 6 months of age and as previously described children with a BCG scar had lower mortality over the next 12 months than children with no BCG scar. In cohort B, 1617 children aged 3 months to 5 years of age had their BCG scar status assessed in a household-based survey and mortality was assessed during a 12-month period. Causes of death were determined by verbal autopsy (VA) and related to BCG scar status in a cause-specific hazard function. RESULTS: Controlling for background factors associated with mortality, there was lower mortality for children with a BCG scar than without in cohort B, the mortality ratio (MR) being 0.45 (95% CI 0.21-0.96). Exclusion of children exposed to TB did not have any impact on the result. In a combined analysis of cohorts A and B, the MR was 0.43 (95% CI 0.28-0.65) controlling for background factors. There were no large differences in distribution of the five major causes of death (malaria, pneumonia, acute diarrhoea, chronic diarrhoea, and meningitis/encephalitis) according to BCG scar status in the two cohorts. Having a BCG scar significantly reduced the risk of death from malaria [MR 0.32 (95% CI 0.13-0.76)]. CONCLUSIONS: A BCG scar is a marker of better survival among children in countries with high child mortality. BCG vaccination may affect the response to several major infections including malaria. (+info)
Equitable child health interventions: the impact of improved water and sanitation on inequalities in child mortality in Stockholm, 1878 to 1925.
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Today, many of the 10 million childhood deaths each year are caused by diseases of poverty--diarrhea and pneumonia, for example, which were previously major causes of childhood death in many European countries. Specific analyses of the historical decline of child mortality may shed light on the potential equity impact of interventions to reduce child mortality. In our study of the impact of improved water and sanitation in Stockholm from 1878 to 1925, we examined the decline in overall and diarrhea mortality among children, both in general and by socioeconomic group. We report a decline in overall mortality and of diarrhea mortality and a leveling out of socioeconomic differences in child mortality due to diarrheal diseases, but not of overall mortality. The contribution of general and targeted policies is discussed. (+info)
OBJECTIVE: More than 10 million children die each year mostly from preventable causes and particularly in developing countries. WHO guidelines for the Integrated Management of Childhood Illness (IMCI) are intended to reduce childhood mortality and are being implemented in Ethiopia. As well as specific clinical interventions, the role of the community in understanding and acting on childhood sickness is an important factor in improving survival. This trial sought to assess the effect on survival of community-based health promotion activities. METHODS: Two districts in northern Ethiopia were studied, each with a random sample of more than 4000 children less than 5 years old. Regular six-monthly visits were made to document deaths among children. After the first year, communities in one district were educated about issues of good childcare and caring for sick children while the other district received this information only after the trial ended. FINDINGS: Although overall mortality was higher in the post-intervention period, most of the increase was seen in the control area. A Cox proportional hazards model gave an adjusted hazard ratio of 0.66 (95% confidence interval = 0.46-0.95) for the intervention area compared with the control area in the post-intervention period, with no significant pre-intervention difference. Significant survival advantages were found for females, children of younger fathers, those with married parents, those living in larger households, and those whose nearest health facility was a health centre. For all of the children who died, only 44% of parents or caregivers had sought health care before the child's death. CONCLUSION: This non-specific community-based public health intervention, as an addition to IMCI strategies in local health facilities, appears to have significantly reduced childhood mortality in these communities. The possibility that such interventions may not effectively reach certain social groups (for example single parents) is an important consideration for implementation of similar strategies in future. The synergy between community awareness and the availability of effective peripheral health services is also an issue that needs further exploration. (+info)