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Snakebite envenoming is an important public health issue in many tropical and subtropical countries, where the burden of morbidity and mortality falls particularly on impoverished rural communities. Children are an especially vulnerable group. This scoping review provides an overview of the extent, type and content of peer-reviewed evidence regarding factors associated with mortality in snakebite-envenomed children. A comprehensive literature search of MEDLINE and the Global Index Medicus yielded 623 articles, of which 15 met the criteria for inclusion; 67% of studies were conducted in India, with the remaining studies taking place in Papua New Guinea, Morocco and The Gambia. There was a notable scarcity of eligible studies from sub-Saharan Africa and Latin America despite the high burden of envenoming in these regions. The risk factors for mortality that were identified by the greatest number of studies were younger patient age (n=4), delay in administration of antivenom (n=4) and acute kidney injury (n=3). Identification of poor prognostic factors can assist clinicians in making timely referrals to centres with paediatric critical care capability. Future research must address the lack of studies from key geographical regions so that evidence-based improvements to the care of this vulnerable group can be implemented. [ABSTRACT FROM AUTHOR]

Background: This study aimed to investigate overall and sex-specific excess all-cause mortality since the inception of the COVID-19 pandemic until August 2020 among 22 countries.Methods: Countries reported weekly or monthly all-cause mortality from January 2015 until the end of June or August 2020. Weekly or monthly COVID-19 deaths were reported for 2020. Excess mortality for 2020 was calculated by comparing weekly or monthly 2020 mortality (observed deaths) against a baseline mortality obtained from 2015-2019 data for the same week or month using two methods: (i) difference in observed mortality rates between 2020 and the 2015-2019 average and (ii) difference between observed and expected 2020 deaths.Results: Brazil, France, Italy, Spain, Sweden, the UK (England, Wales, Northern Ireland and Scotland) and the USA demonstrated excess all-cause mortality, whereas Australia, Denmark and Georgia experienced a decrease in all-cause mortality. Israel, Ukraine and Ireland demonstrated sex-specific changes in all-cause mortality.Conclusions: All-cause mortality up to August 2020 was higher than in previous years in some, but not all, participating countries. Geographical location and seasonality of each country, as well as the prompt application of high-stringency control measures, may explain the observed variability in mortality changes. [ABSTRACT FROM AUTHOR]

Background: Studies on the association between smoke haze (hereafter 'haze') and adverse health effects have increased in recent years due to extreme weather conditions and the increased occurrence of vegetation fires. The possible adverse health effects on under-five children (U5Y) is especially worrying due to their vulnerable condition. Despite continuous repetition of serious haze occurrence in Southeast Asia, epidemiological studies in this region remained scarce. Furthermore, no study had examined the association accounting for three important aspects (time lag, duration and intensity) concurrently.Objective: This study aimed to examine the association between haze and U5Y mortality in Malaysia, considering time lag, duration and intensity of exposure.Methods: We performed a time-stratified case-crossover study using a generalized additive model to examine the U5Y mortality related to haze in 12 districts in Malaysia, spanning from 2014 to 2016. A 'haze day' was characterized by intensity [based on concentrations of particulate matter (PM)] and duration (continuity of haze occurrence, up to 3 days).Results: We observed the highest but non-significant odds ratios (ORs) of U5Y mortality at lag 4 of Intensity-3. Lag patterns revealed the possibility of higher acuteness at prolonged and intensified haze. Stratifying the districts by the 95th-percentile of PM distribution, the 'low' category demonstrated marginal positive association at Intensity-2 Duration-3 [OR: 1.210 (95% confidence interval: 1.000, 1.464)].Conclusions: We found a null association between haze and U5Y mortality. The different lag patterns of the association observed over different duration and intensity suggest consideration of these aspects in future studies. [ABSTRACT FROM AUTHOR]

A contemporary, age-specific model for the distribution of burn mortality in children has not been developed for over a decade. Using data from TriNetX, a global federated health research network, and the American Burn Association's Nation Burn Repository (NBR), we investigated nonsurvival distributions for pediatric burns in the United States. Pediatric burn patients aged 0 to 20 between 2010 and 2020 were identified in TriNetX from 41 Healthcare Organizations using ICD-10 codes (T.20-T.30) and identified as lived/died. These were compared to the nonsurvival data from 90 certified burn centers in the NBR database between 2016 and 2018. The patient population was stratified by age into subgroups of 0 to 4, 5 to 9, 10 to 14, and 15 to 20 years. Overall, mortality rates for pediatric burn patients were found to be 0.62% in NBR and 0.52% in TrinetX. Boys had a higher incidence of mortality than girls in both databases (0.34% vs 0.28% NBR, P = .13; 0.31% vs 0.21% TriNetX, P < .001). Comparison of ethnic cohorts between 2010 to 2015 and 2016 to 2020 subgroups showed that nonsurvival rates of African American children increased relative to white children (TriNetX, P < .001); however, evidence was insufficient to conclude that African American children die more frequently than other ethnicities (NBR, P = .054). When analyzing subgroups in TriNetX, burned children aged 5 to 9 had significantly increased frequency of nonsurvival (P < .001). However, NBR data suggested that children aged 0 to 4 experience the highest frequency of mortality (P < .001). The nonsurvival distributions between these two large databases accurately reflect nonsurvival rates in burned children. [ABSTRACT FROM AUTHOR]

Background Globally, pneumonia is the leading cause of death among children. Few data exist regarding the effect of Haemophilus influenzae type b (Hib) vaccine and 13-valent pneumococcal conjugate vaccine (PCV-13) on the burden of childhood pneumonia in African settings. Methods We collected data on children aged 1 to 59 months at 3 hospitals in Botswana. Hib vaccine and PCV-13 were introduced in Botswana in November 2010 and July 2012, respectively. We compared pneumonia hospitalizations and deaths prevaccine (January 2009 to October 2010) with postvaccine (January 2013 to December 2017) using seasonally adjusted, interrupted time-series analyses. Results We identified 6943 pneumonia hospitalizations and 201 pneumonia deaths. In the prevaccine period, pneumonia hospitalizations and deaths increased by 24% (rate, 1.24; 95% CI,.94–1.64) and 59% (rate, 1.59; 95% CI,.87–2.90) per year, respectively. Vaccine introduction was associated with a 48% (95% CI, 29–62%) decrease in the number of pneumonia hospitalizations and a 50% (95% CI, 1–75%) decrease in the number of pneumonia deaths between the end of the prevaccine period (October 2010) and the beginning of the postvaccine period (January 2013). During the postvaccine period, pneumonia hospitalizations and deaths declined by 6% (rate,.94; 95% CI,.89–.99) and 22% (rate,.78; 95% CI,.67–.92) per year, respectively. Conclusions Pneumonia hospitalizations and deaths among children declined sharply following introduction of Hib vaccine and PCV-13 in Botswana. This effect was sustained for more than 5 years after vaccine introduction, supporting the long-term effectiveness of these vaccines in preventing childhood pneumonia in Botswana. [ABSTRACT FROM AUTHOR]

Background: The third dose of diphtheria-tetanus-pertussis vaccine (DTP3) is used to monitor immunization programs. DTP has been associated with higher female mortality.Methods: We updated previous literature searches for DTP studies of mortality by sex. We examined the female/male (F/M) mortality rate ratio (MRR) with increasing number of doses of DTP and for subsequent doses of measles vaccine (MV) after DTP and of DTP after MV.Results: Eight studies had information on both DTP1 and DTP3. The F/M MRR was 1.17 (95% confidence interval [CI], .88-1.57) after DTP1 and increased to 1.66 (95% CI, 1.32-2.09) after DTP3. Following receipt of MV, the F/M MRR declined to 0.63 (95% CI, .42-.96). In 11 studies the F/M MRR increased to 1.73 (95% CI, 1.33-2.27) when DTP-containing vaccine was administered after MV.Conclusions: F/M MRR increased with increasing doses of DTP. After MV, girls had lower mortality than boys. With DTP after MV, mortality increased again for girls relative to boys. No bias can explain these changes in F/M MRR. DTP does not improve male survival substantially in situations with herd immunity to pertussis and higher F/M MRR after DTP may therefore reflects an absolute increase in female mortality. [ABSTRACT FROM AUTHOR]

Background: Wealth inequalities are increasing in many countries, but their relationship to health is little studied. We investigated the association between individual wealth and mortality across the adult life course in Sweden.Methods: We studied the Swedish adult population using national registers. The amount of wealth tax paid in 1990 was the main exposure of interest and the cohort was followed up for 18 years. Relative indices of inequality (RII) summarize health inequalities across a population and were calculated for all-cause and cause-specific mortality for six different age groups, stratified by sex, using Poisson regression. Mortality inequalities by wealth were contrasted with those assessed by individual and household income. Attenuation by four other measures of socio-economic position and other covariates was investigated.Results: Large inequalities in mortality by wealth were observed and their association with mortality remained more stable across the adult life course than inequalities by income-based measures. Men experienced greater inequalities across all ages (e.g. the RII for wealth was 2.58 [95% confidence interval (CI) 2.54-2.63) in men aged 55-64 years compared with 2.29 (95% CI 2.24-2.34) for women aged 55-64 years), except among the over 85s. Adjustment for covariates, including four other measures of socio-economic position, led to only modest reductions in the association between wealth and mortality.Conclusions: Wealth is strongly associated with mortality throughout the adult life course, including early adulthood. Income redistribution may be insufficient to narrow health inequalities-addressing the increasingly unequal distribution of wealth in high-income countries should be considered. [ABSTRACT FROM AUTHOR]

Background: Life course epidemiology suggests that early life circumstances affect adult mortality, but most of the evidence is based on cohorts born in the beginning of the 20th century. It remains unclear whether and how the influences of early life circumstances on mortality have changed in later birth cohorts.Methods: Analyses rely on 10% register-based samples of households drawn from the 1950 and the 1975 Finnish censuses, with consistent follow-up of socioeconomic and housing-related characteristics and early mid-life mortality (at ages 30-55 years). We estimate survival models for the associations between childhood circumstances and all-cause, internal and external mortality for cohorts born in 1936-50 and 1961-75 adjusting for attained social characteristics. We estimate sibling intraclass correlations as summary measures of all early life and familial influences.Results: Adverse childhood social circumstances were typically associated with about 10-30% excess cause-specific mortality. These associations were almost fully attenuated by adjustment for achieved later life social characteristics. Early life influences have grown over time for mortality from external causes, particularly as related to home ownership and family type. Differentials have remained stable for internal causes. The intraclass correlations further confirmed the increasing association of early life circumstances on external-cause mortality.Conclusions: Our analyses show that the associations between childhood characteristics and mid-life mortality are substantial and almost fully mediated by achieved adult social characteristics. The increase in the contribution of childhood circumstances to mid-life mortality is driven by ever stronger associations with external causes of death. [ABSTRACT FROM AUTHOR]

Background: There is increasing knowledge of antimicrobial usage in children yet limited availability of nationally representative paediatric-specific data on antimicrobial resistance.Objectives: Paediatric data from this national surveillance programme are presented to explore differences between childhood and adult bloodstream infections and antimicrobial resistance surveillance.Methods: Using information collected from a prospective coordinated antimicrobial resistance surveillance programme, children ≤18 years and adults >18 years with a positive blood culture for Staphylococcus aureus, Enterococcus spp. or Gram-negative spp. presenting to one of 34 Australian hospitals during 2013-16 were evaluated. Consistent methodologies for key sepsis pathogens were employed and a comparative analysis between children and adults was conducted.Results: There are stark contrasts between children and adults in this national antimicrobial resistance (AMR) data set. Notable differences include lower rates of AMR, different clinical and molecular phenotypes and lower mortality amongst children. The burden of Gram-negative resistance is disproportionately experienced in children, with higher odds of death with an ESBL versus non-ESBL bacteraemia in comparison with adults.Conclusions: These data support that children are not just 'little adults' in the AMR era, and analyses by age group are important to detect differences in antibiotic susceptibility, clinical phenotype and genetic virulence factors. Antimicrobial surveillance incorporated into routine laboratory practice is vital to inform an array of wider applications including antimicrobial guidelines, stewardship and direction for prioritization of novel antimicrobial development. [ABSTRACT FROM AUTHOR]

Background and Hypothesis Maternal priming might enhance the beneficial nonspecific effects (NSEs) of live measles vaccination (MV). Children with a bacillus Calmette-Guérin (BCG) vaccine scar have a lower mortality rate than those without a scar that is not explained by protection against tuberculosis. We examined the hypothesis that BCG scarring would have a stronger effect on a child if the mother also had a BCG scar. Methods In a randomized controlled trial (RCT) of early MV in children aged 4.5 months, the BCG-scar status of the children and their mother were registered at enrollment at 4.5 months of age. The children were followed up until they were 36 months of age. Using a Cox proportional hazards model, we compared mortality rate ratios according to maternal and child BCG-scar status after adjusting for where the BCG vaccine was given (the national hospital or elsewhere). We censored for other interventions that have immunomodulating effects on child survival, including neonatal vitamin A supplementation and early MV. Results A total of 2213 children had not received neonatal vitamin A supplementation and early MV; 83% of these children and 44% of the mothers had a BCG scar. Children whose mother had a BCG scar were not more likely to have a BCG scar than those whose mother did not have a BCG scar (risk ratio, 1.01 [95% confidence interval (CI), 0.98–1.05]). Among the children, having a BCG scar was associated with a 41% (95% CI, 5%–64%) lower mortality between the ages of 4.5 and 36 months. The reduction in mortality was 66% (95% CI, 33%–83%) if the mother also had a BCG scar but only 8% (95% CI, −83% to 53%) if the mother had no BCG scar (test of interaction, P =.04). Conclusions Maternal BCG priming might be important for the effect of BCG vaccination on child survival. Ensuring better BCG vaccine scarring among mothers and children could have a considerable effect on child mortality levels. [ABSTRACT FROM AUTHOR]

Background: Although tetanus is a vaccine-preventable disease, reports indicate that it remains a significant cause of morbidity and mortality in both neonatal and post-neonatal periods especially in most developing countries.Aim: This study aimed to determine the prevalence and case fatality rates of post-neonatal tetanus among children managed at the Federal Medical Centre Asaba, Delta State, Nigeria over 8 years.Method: The study was a retrospective review of the records of the children above 1 month of age admitted into Federal Medical Centre, Asaba, with a clinical diagnosis of tetanus from January 2008 to May 2016. Data analysis was conducted on descriptive and inferential statistics using Statistical Package for Social Sciences version 22.0. Mean, standard deviation and other relevant parameters were calculated. Level of significance was set at p < 0.05.Results: During the study period, 32 out of 3693 admitted Paediatric patients had post-neonatal tetanus: giving a prevalence rate of 0.9%. The male : female ratio was 1.9 : 1 and patients' ages ranged from 2 to 15 years with a mean age 8.9 ± 3.1 years. Twenty-nine percent of them had complete immunization during infancy, but none had booster doses. Also, 60.9% of them presented with lower limb injuries as the portal of entry. Over 17.4% of the patients had very severe tetanus. Of the 32 patients studied, 62.5% resided in the neighbouring rural communities, while 50.0% were admitted for ≤10 days. The calculated case fatality rate was 50%.Conclusion: The prevalence and case fatality rates of post-neonatal tetanus are still relatively high in this clime. Given the prevalent nature of the disease in children aged 5 years and above, there is a need to include the booster doses of tetanus toxoid in the country's National Programme on Immunization schedule. [ABSTRACT FROM AUTHOR]

Background The offspring of parents with severe mental illness (SMI) are at higher risk of mortality and of developing certain somatic diseases. However, across the full spectrum of somatic illness, there remains a gap in knowledge regarding morbidity. Methods We conducted a register-based nationwide cohort study of all 2 000 694 individuals born in Denmark between 1982 and 2012. Maximum age of offspring at follow-up was 30 years. Information on parents' psychiatric diagnoses of schizophrenia, bipolar disorder, and unipolar depression was retrieved from the Psychiatric Central Register. We estimated incidence rate ratio (IRR), cumulative incidence percentage and mortality rate ratio of first hospital contact for a broad spectrum of somatic illnesses according to the International Statistical Classification of Diseases and Related Health Problems. Analyses were adjusted for important confounders. Results Offspring of individuals with SMI had higher risk of somatic hospital contacts IRR: 1.17 (95% CI: 1.16–1.18) with maternal depression being associated with the highest IRR (1.22, 95% CI: 1.20–1.24). Offspring of parents with SMI had higher risk within most broad diagnostic categories with highest IRRs for unclassified somatic diagnoses, infections and endocrine diseases ranging from 1.27 (95% CI: 1.25–1.28) to 1.26 (95% CI: 1.23–1.29) (all P <.0001). Morbidity was particularly increased in children aged 0–7 years. The mortality rate ratio associated with parental SMI was 1.31 (95% CI: 1.21–1.41) with excess mortality mainly due to unnatural causes. Conclusion Our findings indicate that offspring of parents with SMI experienced increased mortality and somatic morbidity warranting heightened vigilance and support for this population. [ABSTRACT FROM AUTHOR]

The Lives Saved Tool (LiST) has been used to estimate the impact of scaling up intervention coverage on undernutrition and mortality. Evidence for the model is largely based on efficacy trials, raising concerns of applicability to large-scale contexts. We modelled the impact of scaling up health programs in India between 2006 and 2016 and compared estimates to observed changes. Demographics, intervention coverage and nutritional status were obtained from National Family and Health Survey 2005-6 (NFHS-3) for the base year and NHFS-4 2015-16 for the endline. We used the LiST to estimate the impact of changes in coverage of interventions over this decade on child mortality and undernutrition at national and subnational levels and calculated the gap between estimated and observed changes in 2016. At the national level, the LiST estimates are close to the actual values of mortality for children <1 year and <5 years in 2016 (at 41 vs 42.6 and 50 vs 56.4, respectively, per 1000 live births). National estimates for stunting, wasting and anaemia at are also close to the actual values of NFHS-4. At the state level, actual changes were higher than the changes from the LiST projections for both mortality and stunting. The predicted changes using the LiST ranged from 33% to 92% of the actual change. The LiST provided national projections close to, albeit slightly below, actual performance over a decade. Reasons for poorer performance of state-specific projections are unknown; further refinements to the LiST for subnational use would improve the usefulness of the tool. [ABSTRACT FROM AUTHOR]

The Child Health and Mortality Prevention Surveillance (CHAMPS) program is a 7-country network (as of December 2018) established by the Bill & Melinda Gates Foundation to identify the causes of death in children in communities with high rates of under-5 mortality. The program carries out both mortality and pregnancy surveillance, and mortality surveillance employs minimally invasive tissue sampling (MITS) to gather small samples of body fluids and tissue from the bodies of children who have died. While this method will lead to greater knowledge of the specific causes of childhood mortality, the procedure is in tension with cultural and religious norms in many of the countries where CHAMPS works—Bangladesh, Ethiopia, Kenya, Mali, Mozambique, Sierra Leone, and South Africa. Participatory Inquiry Into Community Knowledge of Child Health and Mortality Prevention (PICK-CHAMP) is a community entry activity designed to introduce CHAMPS to communities and gather initial perspectives on alignments and tensions between CHAMPS activities and community perceptions and priorities. Participants' responses revealed medium levels of overall alignment in all sites (with the exception of South Africa, where alignment was high) and medium levels of tension (with the exception of Ethiopia, where tension was high). Alignment was high and tension was low for pregnancy surveillance across all sites, whereas Ethiopia reflected low alignment and high tension for MITS. Participants across all sites indicated that support for MITS was possible only if the procedure did not interfere with burial practices and rituals. [ABSTRACT FROM AUTHOR]

Background: Worldwide, reduction in under-five mortality has not sufficiently included neonates, who represent 45% of deaths in children of age under five years. The least progress has been observed in resource-limited settings.Methods: This mixed methods study conducted at a Cambodian non-governmental paediatric hospital described the key priorities of the ongoing neonatal service. Routinely collected data from the hospital and microbiology databases included the number of admissions, discharges and deaths and the number of cases of bacteraemias (2011-2016). Semi-structured interviews with the management staff explored the essential features of the service.Results: There were 2127 neonatal admissions and 247 deaths. The incidence of facility-based neonatal mortality decreased by 81%. Bacteraemic healthcare-associated infections decreased by 68%. A dedicated area for neonatal care was perceived as crucial, allowing better infection control and delivery of staff training.Conclusions: In this hospital, the neonatal service prioritized basic measures, particularly, having a dedicated neonatal area. Facility-based mortality and bacteraemic healthcare-associated infections decreased. [ABSTRACT FROM AUTHOR]

Background Socioeconomic inequality in child mortality highlights opportunities for policies to reduce child deaths. Methods We used singleton birth, death and maternity records from Scotland, 1981-2011, to examine mortality rate differences by age across deprivation quintiles over time. We measured the difference between the most and least deprived quintiles (Q5-Q1) and the slope index of inequality (SII) across all quintiles--measures of the absolute deprivation gap, providing an indication of the public health impact. Results Q5--Q1 remained relatively constant from 1990 onwards for early neonates, widened in the mid-2000s for late neonates, increased in the 1990 s then decreased in the 2000 s in the post-neonates and declined over time in early childhood. The trend over time in SII showed no significant change for early neonates (P = 0.440), significant decrease for post-neonates (P = 0.010) and early childhood (P = 0.043), and significant increase for late neonates (P = 0.011). Conclusions Over three decades, the absolute deprivation gap in mortality widened in late neonates but stabilized or declined at other ages. This may reflect improved survival beyond the early neonatal period of babies with conditions related to socioeconomic inequality such as prematurity. Monitoring birth cohort data could enhance understanding of this vulnerable group. [ABSTRACT FROM AUTHOR]

Background. Pneumococcal conjugate vaccines (PCVs) are highly effective in preventing invasive pneumococcal disease (IPD), but deaths due to IPD still occur. We aimed to describe children who died of IPD since PCV introduction in England and Wales. Methods. Public Health England conducts enhanced IPD surveillance in England and Wales. IPD cases in PCV-eligible children aged <5 years (born since 4 September 2004 and diagnosed between 4 September 2006 and 3 September 2014) were actively followed up by postal questionnaires and, for fatal cases, detailed information was requested prospectively from multiple sources. Results. During the 8-year period, there were 3146 IPD cases and 150 IPD-related deaths (case fatality rate, 4.8%). Overall, 132 isolates from fatal cases were serotyped (88%) and 35 distinct serotypes were identified, with no serotype predominance. Most deaths occurred in children aged <1 year (88/150 [59%]) and 1-year-olds (36/150 [24%]). One-third (53/150 [35%]) had a known risk factor for IPD. Clinical presentation varied with age but not by serotypes in the different conjugate vaccines. Meningitis was diagnosed in nearly half the fatal cases (71/150 [47%]). The IPD-related mortality rate declined after 7-valent PCV introduction from 1.25/100 000 children in 2006-2007 to 0.60/100 000 in 2009-2010, with a further reduction following 13-valent PCV introduction from April 2010 to 0.39/100 000 in 2013-2014 (14 deaths; incidence rate ratio, 0.31 [95% confidence interval, .16-.61]; P = .0003), when most deaths were due to nonvaccine serotypes or in neonates. Conclusions. Most fatal IPD cases are currently not vaccine-preventable. Additional strategies will be required to reduce childhood pneumococcal deaths in countries with established pneumococcal vaccination programs. [ABSTRACT FROM AUTHOR]

Background. Candidemia causes significant morbidity and mortality among children. Removal of a central venous catheter (CVC) is often recommended for adults with candidemia to reduce persistent and metastatic infection. Pediatric-specific data on the impact of CVC retention are limited. Methods. A retrospective cohort study of inpatients <19 years with candidemia at the Children's Hospital of Philadelphia between 2000 and 2012 was performed. The final cohort included patients that had a CVC in place at time of blood culture and retained their CVC at least 1 day beyond the blood culture being positive. A structured data collection instrument was used to retrieve patient data. A discrete time failure model, adjusting for age and the complexity of clinical care before onset of candidemia, was used to assess the association of CVC retention and 30-day all-cause mortality. Results. Two hundred eighty-five patients with candidemia and a CVC in place at the time of blood culture were identified. Among these 285 patients, 30 (10%) died within 30 days. Central venous catheter retention was associated with a significant increased risk of death on a given day (odds ratio, 2.50; 95% confidence interval, 1.06-5.91). Conclusions. Retention of a CVC was associated with an increased risk of death after adjusting for age and complexity of care at candidemia onset. Although there is likely persistence of unmeasured confounding, given the strong association between catheter retention and death, our data suggest that early CVC removal should be strongly considered. [ABSTRACT FROM AUTHOR]

Background: Cognitive capabilities in childhood and in late life are inversely associated with mortality rates. However, it is unclear if adult cognition, at a time still relatively free from comorbidity, is associated with subsequent mortality, and whether this explains the associations of early life factors with adult mortality.Methods: We used data from the MRC National Survey of Health and Development, a birth cohort study prospectively assessing 5362 participants born in 1946. The present analysis includes participants followed up from age 43 and undergoing cognitive assessment (verbal memory and search speed). Mortality outcomes were notified through linkage with a national register. Cox regression was used to estimate mortality hazards in relation to cognitive performance at age 43, adjusting for early life factors, socioeconomic position and health status.Results: Data were available on 3192 individuals. Univariable analyses indicated that adult verbal memory and search speed, parental factors, childhood cognition and educational attainment were associated with mortality. However, multivariable models showed that the mortality associations with earlier life factors were explained by adult cognitive capability. A standard deviation increase in verbal memory and search speed scores was associated with lower mortality rates [hazard ratio (HR) = 0.86, 95% confidence interval (CI) 0.77-0.97, P = 0.02; HR = 0.88, 95% CI 0.78-1.00, P = 0.05, respectively), after adjustment for adult health.Conclusions: Cognitive capability in early midlife was inversely associated with mortality rates over 25 years and accounted for the associations of family background, childhood cognitive ability and educational attainment with mortality. These findings, in a nationally representative cohort with long-term follow-up, suggest that building cognitive reserve may improve later life health and survival chances. [ABSTRACT FROM AUTHOR]

Background: Rates of child malnutrition and mortality in India remain high. We tested the hypothesis that rising food prices are contributing to India's slow progress in improving childhood survival.Methods: Using rounds 2 and 3 (2002-08) of the Indian District Level Household Survey, we calculated neonatal, infant and under-five mortality rates in 364 districts, and merged these with district-level food price data from the National Sample Survey Office. Multivariate models were estimated, stratified into 27 less deprived states and territories and 8 deprived states ('Empowered Action Groups').Results: Between 2002 and 2008, the real price of food in India rose by 11.7%. A 1% increase in total food prices was associated with a 0.49% increase in neonatal (95% confidence interval (CI): 0.13% to 0.85%), but not infant or under-five mortality rates. Disaggregating by type of food and level of deprivation, in the eight deprived states, we found an elevation in neonatal mortality rates of 0.33% for each 1% increase in the price of meat (95% CI: 0.06% to 0.60%) and 0.10% for a 1% increase in dairy (95% CI: 0.01% to 0.20%). We also detected an adverse association of the price of dairy with infant (b = 0.09%; 95% CI: 0.01% to 0.16%) and under-five mortality rates (b = 0.10%; 95% CI: 0.03% to 0.17%). These associations were not detected in less deprived states and territories.Conclusions: Rising food prices, particularly of high-protein meat and dairy products, were associated with worse child mortality outcomes. These adverse associations were concentrated in the most deprived states. [ABSTRACT FROM AUTHOR]

Background: Child labour is an important topic in contemporary society. In this study we have tried to explore the magnitude of injury problems among child labourers in Bangladesh using an injury surveillance system. Methods: An injury surveillance system (ISS) was performed under the Prevention of Child Injuries through Social intervention and Education (PRECISE) project in Bangladesh during 2006-2010 in three sub-districts covering a population of more than 700 000. We used the ISS for assessing child labour. Appropriate epidemiological methods were considered in the study. Results: Considering the reported main occupation of the children, 30% of children from the surveillance households were identified as child labourers. More than two thirds of child labourers were educated to primary or secondary level. The majority of boys worked as unskilled labourers and girls were employed in domestic work. The incidence of injury and deaths among child labourers was estimated as 24 per 100 000 children years. More than 19 injury related illnesses of moderate to severe intensity were found among 1000 child labourers in a year. Fractures, sprains, dislocations, cuts/wounds, animal bites, abrasions or lacerations, burns, head injuries and internal organ injuries are most common among child labourers. Conclusions:Working children are at risk of injury, death and illness in Bangladesh. Child labourers are now even more clearly tied to quantified morbidity and mortality. [ABSTRACT FROM AUTHOR]

Evidence-based approaches to preventing child death require evidence; without data on common causes of child mortality, taking effective action to prevent these deaths is difficult at best. Minimally invasive tissue sampling (MITS) is a potentially powerful, but nascent, technique to obtain gold standard information on causes of death. The Gates Foundation committed to further establishing the methodology and obtain the highest quality information on the major causes of death for children under 5 years. In 2018, the MITS Surveillance Alliance was launched to implement, refine, and enhance the use of MITS across high mortality settings. The Alliance and its members have contributed to some remarkable opportunities to improve mortality surveillance, and we have only just begun to understand the possibilities on larger scales. This supplement showcases studies conducted by MITS Surveillance Alliance members and represents a significant contribution to the cause-of-death literature from high mortality settings. [ABSTRACT FROM AUTHOR]

Background: Vitamin A deficiency (VAD) is associated with increased mortality. To prevent VAD, WHO recommends high-dose vitamin A supplementation (VAS) every 4-6 months for children aged between 6 months and 5 years of age in countries at risk of VAD. The policy is based on randomized clinical trials (RCTs) conducted in the late 1980s and early 1990s. Recent RCTs indicate that the policy may have ceased to be beneficial. In addition, RCTs attempting to extend the benefits to younger children have yielded conflicting results. Stratified analyses suggest that whereas some subgroups benefit more than expected from VAS, other subgroups may experience negative effects. Methods and Results: We reviewed the potential modifiers of the effect of VAS. The variable effect of VAS was not explained by underlying differences in VAD. Rather, the effect may depend on the sex of the child, the vaccine status and previous supplementation with vitamin A. Vitamin A is known to affect the Th1/Th2 balance and, in addition, recent evidence suggests that vitamin A may also induce epigenetic changes leading to down-regulation of the innate immune response. Thus VAS protects against VAD but has also important and long-lasting immunological effects, and the effect of providing VAS may vary depending on the state of the immune system. Conclusions: To design optimal VAS programmes which target those who benefit and avoid those harmed, more studies are needed. Work is ongoing to define whether neonatal VAS should be considered in subgroups. In the most recent RCT in older children, VAS doubled the mortality for males but halved mortality for females. Hence, we ur-gently need to re-assess the effect of VAS on older children in large-scale RCTs powered to study effect modification by sex and other potential effect modifiers, and with nested immunological studies. [ABSTRACT FROM AUTHOR]

The prevalence of vitamin A (VA) deficiency, which affects about one-third of children in developing countries, is falling only slowly. This is despite extensive distribution and administration of periodic (4– to 6-monthly) high-dose VA capsules over the past 20 years, now covering a reported 80% of children in developing countries. This massive programme was motivated largely by an expectation of reducing child mortality, stemming from findings in the 1980s and early 90s. Efficacy trials since 1994 have in most cases not confirmed a mortality impact of VA capsules. Only one large scale programme evaluation has ever been published, which showed no impact on 1–6–year-old mortality (the DEVTA trial, ending in 2003, in Uttar Pradesh, India). Periodic high-dose VA capsules may have less relevance now with changing disease patterns (notably, reductions in measles and diarrhoea). High-dose VA 6-monthly does not reduce prevalence of the deficiency itself, estimated by low serum retinol. It is proposed that: (i) there is no longer any evidence that intermittent high-dose VA programmes are having any substantial mortality effect, perhaps due to changing disease patterns; (ii) frequent intakes of vitamin A in physiological doses —e.g. through food-based approaches, including fortification, and through regular low-dose supplementation—are highly effective in increasing serum retinol (SR) and reducing vitamin A deficiency; (iii) therefore a policy shift is needed, based on consideration of current evidence. A prudent phase-over is needed towards increasing frequent regular intakes of VA at physiological levels, daily or weekly, replacing the high-dose periodic capsule distribution programmes. Moving resources in this direction must happen sooner or later: it should be sooner. [ABSTRACT FROM PUBLISHER]

Background Household characteristics are important influences on the risk of child death. However, little is known about this influence in HIV-endemic areas. We describe the effects of household characteristics on children’s risk of dying in rural South Africa.Methods We use data describing the mortality of children younger than 5 years living in the Agincourt health and socio-demographic surveillance system study population in rural northeast South Africa during the period 1994–2008. Using discrete time event history analysis we estimate children’s probability of dying by child characteristics and household composition (other children and adults other than parents) (N = 924 818 child-months), and household socio-economic status (N = 501 732 child-months).Results Children under 24 months of age whose subsequent sibling was born within 11 months experience increased odds of dying (OR 2.5; 95% CI 1.1–5.7). Children also experience increased odds of dying in the period 6 months (OR 2.1; 95% CI 1.2–3.6), 3–5 months (OR 3.0; 95% CI 1.5–5.9), and 2 months (OR 11.8; 95% CI 7.6–18.3) before another household child dies. The odds of dying remain high at the time of another child’s death (OR 11.7; 95% CI 6.3–21.7) and for the 2 months following (OR 4.0; 95% CI 1.9–8.6). Having a related but non-parent adult aged 20–59 years in the household reduces the odds (OR 0.6; 95% CI 0.5–0.8). There is an inverse relationship between a child’s odds of dying and household socio-economic status.Conclusions This detailed household profile from a poor rural setting where HIV infection is endemic indicates that children are at high risk of dying when another child is very ill or has recently died. Short birth intervals and additional children in the household are further risk factors. Presence of a related adult is protective, as is higher socio-economic status. Such evidence can inform primary health care practice and facilitate targeting of community health worker efforts, especially when covering defined catchment areas. [ABSTRACT FROM AUTHOR]

Celiac disease (CD) is associated with increased mortality rate and adverse pregnancy outcome, but little is known about offspring mortality rate. In this nationwide retrospective cohort study, we identified persons whose biopsy-verified CD was diagnosed in Sweden in 1969–2008. We compared mortality rates in children born to mothers with and without CD (n = 16,121 vs. n = 61,782) and children born to fathers with and without CD (n = 9,289 vs. n = 32,984). Median age of offspring at end of follow-up was 28.7 (range, 16.7–39.7) years. We also examined mortality rates in children born to mothers with undiagnosed CD (later CD diagnosis; n = 12,919) and diagnosed CD (n = 3,202) to determine if intrauterine exposures associated with CD could affect offspring mortality rate. We estimated hazard ratios for death by using Cox regression. Death rates were independent of maternal CD (60 deaths per 100,000 person-years in children of mothers with CD, vs. 54 in controls) and paternal CD (53 deaths per 100,000 person-years in children of fathers with CD, vs. 53 in controls). Corresponding adjusted hazard ratios were 1.09 (95% confidence interval: 0.95, 1.26) for maternal CD and 1.02 (95% confidence interval: 0.85, 1.23) for paternal CD. Death rates were similar in children born to mothers with undiagnosed CD and in children whose mothers had diagnosed CD during pregnancy. Parental CD does not seem to influence mortality rate in offspring, which suggests that neither genetic influences of CD nor intrauterine conditions have adverse effects on offspring mortality rate. [ABSTRACT FROM PUBLISHER]

Low rates of treatment failure and death in >6000 cases of children treated for severe pneumonia with oral antibiotics support supports the shift to management of severe pneumonia to outpatients and in the community.Background. Despite advances in childhood pneumonia management, it remains a major killer of children worldwide. We sought to estimate global treatment failure rates in children aged 2–59 months with World Health Organization–defined severe pneumonia.Methods. We pooled data from 4 severe pneumonia studies conducted during 1999–2009 using similar methodologies. We defined treatment failure by day 6 as death, danger signs (inability to drink, convulsions, abnormally sleepy), fever (≥38°C) and lower chest indrawing (LCI; days 2–3), LCI (day 6), or antibiotic change.Results. Among 6398 cases of severe pneumonia from 10 countries, 564 (cluster adjusted: 8.5%; 95% confidence interval [CI], 5.9%–11.5%) failed treatment by day 6. The most common reasons for clinical failure were persistence of fever and LCI or LCI or fever alone (75% of failures). Seventeen (0.3%) children died. Danger signs were uncommon (<1%). Infants 6–11 months and 2–5 months were 2- and 3.5-fold more likely, respectively, to fail treatment (adjusted OR [AOR], 1.8 [95% CI, 1.4–2.3] and AOR, 3.5 [95% CI, 2.8–4.3]) as children aged 12–59 months. Failure was increased 7-fold (AOR, 7.2 [95% CI, 5.0–10.5]) when comparing infants 2–5 months with very fast breathing to children 12–59 months with normal breathing.Conclusions. Our findings demonstrate that severe pneumonia case management with antibiotics at health facilities or in the community is associated with few serious morbidities or deaths across diverse geographic settings and support moves to shift management of severe pneumonia with oral antibiotics to outpatients in the community. [ABSTRACT FROM PUBLISHER]

Aim: As there is lack of information about what happens to children after recovery from severe acute malnutrition (SAM), we report their relapse, morbidity, mortality and referral during follow-up period. Methods: From February 2001 to November 2003, 180 children completing acute and nutrition rehabilitation (NR) phases of protocolized management were advised for 6-months follow-up. The mean (SD) age was 12 (5) months, 55% were infants, 53% were male and 68% were breast-fed. Results: The follow-up compliance rate dropped from 91% at first to 49% at tenth visit. The common morbidities following discharge included fever (26%), cough (24%) and diarrhoea (20%). Successful follow-up done in 124 children [68.9% (95% CI 61.8–75.2%)], partial follow-up in 45 [25% (95% CI 19.2–31.8%)], relapse in 32 [17.8% (95% CI 12.9–24%)] and 5 [2.8% (95% CI 1.2–6.3%)] died. Conclusion: Our findings highlight need for follow-up as part of overall management of SAM and recommend an effective community follow-up. [ABSTRACT FROM PUBLISHER]

Summary: Burkitt''s lymphoma (BL) is a major cause of death among Ugandan children. We studied clinical characteristics and outcomes of childhood BL over time at the Uganda Cancer Institute (UCI). A total of 1217 children (766 boys, 451 girls, mean age 6.69 years) diagnosed with BL between 1985 and 2005 were included. There were no significant changes in the proportion of boys and girls diagnosed, or in mean age at diagnosis. Facial tumor (n =945, 77.65%) and abdominal disease (n =842, 69.19%) were the most common presentations. The proportion of children presenting with hepatic mass, malignant pleocytosis, and advanced-stage (stage C and D) BL increased during the study period (P <0.01). A total of 1085 children out of 1206 (89.97%) received at least one cycle of chemotherapy, and 832 of 1099 (75.71%) demonstrated objective response (i.e. complete or partial remission). The most common symptoms at BL diagnosis were fever (n =621, 51.03%), anemia (n =593, 48.73%), and weight loss (n =588, 48.32%). Significant increases in the proportion of children with fever, and significant changes in the proportion of children with anemia, night sweats and severe infection were observed. HIV positivity was 3.87%, but no substantial differences in the proportion of HIV-positive children were observed. Mortality was not significantly different over time: it was similar in boys and girls, higher in older children (compared with younger ones), in those with advanced-stage BL, and HIV-positive children, but lower in children with facial tumors compared with other tumor presentations, and among those who received chemotherapy. [ABSTRACT FROM AUTHOR]

Abstract: With a mortality rate in the under-5s of 93 per 1000 live births reported in the 1996 Demographic and Health Survey (DHS), Papua New Guinea (PNG) was at the time one of only four countries with stalled progress in child survival, and seemed destined to fail its national Millennium Development Goal (MDG) 4 target. However, accurate estimates have shown reductions in under-5 and infant mortality rates of 19% and 17% respectively, over 10 years from 1996 to 2006. In that period PNG adopted an integrated and coordinated approach to child health that includes all the essential interventions outlined in the Lancet''s child survival series, under a framework consistent with the Western Pacific Regional Child Survival Strategy, associated with significant improvements in leadership and coordination of child health services by paediatricians at the provincial and national level. The reduction in child mortality since the mid-1990s is strong encouragement that such an approach can translate to real improvements. This paper outlines the recent advances in child health in PNG, identifying successful areas, and the challenges that lie ahead. There has been increased immunization coverage, introduction of vitamin A supplementation, bed-nets to prevent malaria, interventions to reduce mortality from acute respiratory infection, and improvements in the education of girls. These and improved leadership and coordination help to explain the recent significant gains in child survival. [Copyright &y& Elsevier]

Background: Pneumonia is a leading cause of hospitalization and death among children in Africa. We describe the clinical presentation of severe pneumonia among hospitalized children in a malaria endemic area with a high prevalence of HIV infection. Methods: As part of a 2-year prospective study of radiologically confirmed pneumonia, chest radiographs, malaria parasite counts and bacterial blood cultures were systematically performed for children 0-23 months admitted with severe pneumonia. Radiographs were interpreted according to WHO guidelines. HIV tests were performed during a 12-month period. Results: Severe pneumonia accounted for 16% of 4838 hospital admissions among children 0-23 months; 43% of episodes had endpoint consolidation, 15% were associated with bacteremia and 11% were fatal. Fever, cough >3 days, crepitations, hypoxemia and absence of malaria parasitemia were associated with radiologically confirmed pneumonia. Nineteen per cent of children with severe pneumonia and 27% with radiologically confirmed pneumonia had clinical malaria. HIV-prevalence was 26% among children hospitalized with severe pneumonia and HIV-testing results. HIV infection, anaemia, malnutrition, hypoxemia and bacteremia were associated with fatal episodes of severe pneumonia. Conclusion: Treatment of admitted children with severe pneumonia is complicated in settings with prevalent HIV and malaria. Children with severe pneumonia and clinical malaria require antibiotic and antimalarial treatment. In addition to vertical programs, integrated approaches may greatly contribute to reduction of pneumonia-related mortality. [ABSTRACT FROM AUTHOR]

Previous studies have lacked sufficient power to assess associations between early-life socioeconomic position and adult cause-specific mortality. The authors examined associations of parental social class at age 0–16 years with mortality among 1,824,064 Swedes born in 1944–1960. Females and males from manual compared with nonmanual childhood social classes were more likely to die from smoking-related cancers, stomach cancer, respiratory disease, cardiovascular disease, and diabetes. Males from manual compared with nonmanual social classes were more likely to die from unintentional injury, homicide, and alcoholic cirrhosis. The association with stomach cancer was little affected by adjustment for parental later-life and own adult social class or education. For other outcomes, educational attainment resulted in greater attenuation of associations than did adjustment for adult social class. Early-life social class was not related to suicide or to melanoma, colon, breast, brain, or lymphatic cancers or to leukemia. With the exception of stomach cancer, caused by Helicobacter pylori infection acquired in childhood, poorer social class in early life was associated with diseases largely caused by behavioral risk factors such as smoking, physical inactivity, and an unhealthy diet. Educational attainment may be important in reducing the health inequalities associated with early-life disadvantage. [ABSTRACT FROM PUBLISHER]

Background Candida is the most common cause of invasive fungal infection in healthcare settings and is associated with significant increases in healthcare resource utilization and attributable mortality. Methods This study was conducted in a pediatric tertiary care hospital from Turkey. We conducted a retrospective analysis in children ≤18 years with blood culture-proven candidaemia identified between December 2013 and November 2017. Sociodemographic variables,underlying condition, mortality, additional risk factors, origin of specimens were all recorded. Results A total of 236 episodes of candidaemia were identified over the study period. The median age of the patients was 600 days (4-6482). 106 specimens (44.9%) were cultured from patients under 1 year of age and 15 of 106 specimens were cultured from neonates. The most frequently isolated Candida spp. were C. albicans (42.%), followed by C. parapsilosis (30.5%), C. glabrata (7.6%), C. tropicalis (6.4%), C. krusei (2.5%), C. lusitaine (2.5%), C. dubliniensis (2.1%), C. kefir (0.8%), and C. pelliculosa (0.4%). In 11 of the 236 episodes (4.5%), two Candida sp p were cultured at the same time.The most common coinfection was C. albicans and C. parapsilosis. 112 of the 236 episodes (47.5%) was due to central venous catheter-related blood stream infection. 47.5% of these patients were receiving total parenteral nutrition at the time of candidemia. Concomitant coagulase negatif staphylococcus bacteremia was present in 50 of 236 candidemia episodes (21.2%). Of 236 isolates, 74 (31.4%) was cultured from peripheral blood culture only, 95 (40.3%) from central venous catheter only, 67 (28.4%) from both peripheral and central catheter blood culture.Trombocytopenia was noted in 117 episodes (49.6%) and neutropenia in 45 episodes (19.1 Of the 112 central venous catheter-related candidemia, 35 (31.3%) resulted in death within 30 days from the onset of candidaemia (Figure 1). In 49 (45.%) episodes of central venous catheter-related candidemia, catheter was not removed and 40% of these episodes resulted as death.Catheter removal, thrombocytopenia, total parenteral nutrion were found to be associated with increased mortality in children under 1 year of age (P < 0.001). Conclusion Clinicians must be aware of candidemia in children due to high risk of mortality. Disclosures All authors: No reported disclosures. [ABSTRACT FROM AUTHOR]

Background Acute respiratory illnesses are a leading cause of global morbidity and mortality in children. Coinfection with multiple respiratory viruses is common. Although the effects of each virus have been studied individually, the effects of coinfection on disease severity or healthcare seeking are less well-understood. Methods A secondary analysis was performed of a maternal influenza vaccine trial conducted between 2011 and 2014 in rural southern Nepal. Prospective weekly active household-based surveillance of infants was conducted from birth to 180 days of age. Mid-nasal swabs were collected and tested for respiratory syncytial virus (RSV), rhinovirus, influenza, human metapneumovirus (HMPV), coronavirus, parainfluenza (HPIV), and bocavirus by RT–PCR. Coinfection was defined as the presence of two or more respiratory viruses simultaneously detected as part of the same illness episode. Maternal vaccination status, infant age, prematurity, and number of children under 5 in the household were adjusted for with multivariate logistic regression. Results Of 1,730 infants with a respiratory illness, 327 (19%) had at least two respiratory viruses detected on their primary illness episode. Coinfection status did not differ by maternal vaccination status, infant age, premature birth, and number of children under 5 in the household. Of 113 infants with influenza, 23 (20%) had coinfection. Of 214 infants with RSV, 87 (41%) had coinfection. Overall, infants with coinfection had increased occurrence of fever lasting 4 or more days overall (OR 1.4, 95% CI: 1.1, 2.0), and in the subset of infants with influenza (OR 5.8, 95% CI: 1.8, 18.7). Coinfection was not associated with seeking further care (OR 1.1, 95% CI: 0.8, 1.5) or pneumonia (OR 1.2, 95% CI: 1.0, 1.6). Conclusion A high proportion of infants experiencing their first respiratory illness had multiple viruses detected. Coinfection with influenza was associated with longer duration of fever compared with children with influenza alone, but was not associated with increased illness severity by other measures. Disclosures All authors: No reported disclosures. [ABSTRACT FROM AUTHOR]

Recent research suggests that childhood cognitive performance is associated with various health outcomes, but the nature of the relation is not well understood. It is unclear whether the association occurs across the continuum of cognitive performance, and if it is independent of socioeconomic status. Prospective data from the Terman Life Cycle Study were used to evaluate the hypothesis of a monotonic relation between childhood intelligence quotient (IQ) and adult mortality and to determine whether there exists a threshold beyond which the protective effects of IQ are no longer evident. A total of 897 individuals of school age who scored 135 or higher on the Stanford-Binet IQ test were recruited in 1922. Cox proportional hazards regression was used to estimate survival over a 64-year period. A 15-point advantage in childhood IQ was significantly associated with a decreased risk of mortality (hazard ratio = 0.68, 95% confidence interval: 0.49, 0.93) for IQ scores up to 163; beyond that, the risk of death plateaued. Results were similar when the sample was limited to those participants whose fathers had nonmanual occupations. Childhood IQ, even at the upper end of the distribution, is a significant predictor of mortality, independent of childhood social position. [ABSTRACT FROM AUTHOR]

Background During 2002, there was an increase in reports of bacterial meningitis among people with cochlear implants in Europe and North America. One model of implant, which included a space-occupying ‘positioner’, was recalled. Implantation of a positioner was shown to be a risk factor for meningitis among children in the United States. The situation in the United Kingdom was not known. [ABSTRACT FROM PUBLISHER]

Presents a study that investigated social differentials in child mortality during the years 1885, 1891 and 1910 in one parish in Stockholm, Sweden. Methodology of the study; Discussion on the results of the study; Conclusion.

Objectives: To examine the relationship of anthropometrical indicators of fatness and muscularity with mortality in children in a rural African community.Background: A prospective cohort study was carried out in the rural health zone of Bwamanda, Northern Congo using a random cluster sample of 5167 children, aged 0-5 years.Main Outcome Measures: Short- and long-term mortality rates, being deaths within 3 months and deaths in 3-month periods observed 3-30 months after enrolment. Rates of all cause mortality and of mortality from kwashiorkor or marasmus, by level of baseline fatness and muscularity. Indicators of fatness and muscularity were obtained by correcting anthropometric arm fat and arm muscle areas for age, sex, weight and height.Results: The relationship of both the fatness and muscularity scores with short-term mortality was marked by a clear threshold (-0.5 SDS) below which there was a significant rise in mortality from all causes as well as from kwashiorkor and marasmus. These excess mortalities were also found in normal weight children. Fatness and muscularity scores remained significant determining factors of short-term mortality in a multiple logistic regression analysis with sex, age, season and weight-for-age. A ROC curve analysis showed that fat and muscularity scores had better predictive abilities than weight-for-age. Low fat status had a bad prognosis on the long-term in underweight children.Conclusions: Measures of current nutritional status should not be based on weight indices alone. Objective and/or clinical evaluation of fat and muscle status (also in normal weight children) should be added in order to detect a higher proportion of malnourished children and to more accurately evaluate mortality risk. [ABSTRACT FROM AUTHOR]

Data on measles incidence, acute case fatality, and delayed mortality were collected on 25,443 children aged 0–95 months during the course of a community-based, double-blind, placebo-controlled, randomized trial of vitamin A supplementation in rural, northern Ghana between 1989 and 1991. Measles vaccine coverage in these children was 48%. The overall estimated measles incidence rate was 24.3 per 1,000 child-years, and acute case fatality was 15.7%. There was not significantly increased mortality in survivors of the acute phase of measles compared with controls (rate ratio = 1.22, 95% confidence interval (Cl) 0.65–2.30). Reported incidence rates and case fatality were higher in families with low paternal education, in the dry season, and in unvaccinated children, and case fatality was higher in malnourished children. There was no sex difference in incidence, but acute case fatality was somewhat higher in girls than boys (adjusted odds ratio = 1,3, 95% Cl 0.9–2.1). Measles incidence was lower in vitamin A-supplemented groups (23.6 per 1,000 child-years) than in placebo groups (28.9 per 1,000 child-years), but this difference was not statistically significant (p = 0.33). Among 946 measles cases in clusters randomized to receive vitamin A or placebo, there was no marked difference in acute measles case fatality between vitamin A-supplemented and placebo groups (15.4% vs. 14.5%, respectively). The biologic effects of vitamin A supplementation on the subsequent clinical manifestations and severity of measles need further elucidation. [ABSTRACT FROM AUTHOR]

The epidemiology of measles has been investigated in Niakhar, a rural area of Senegal, during two periods, 1983–1986 and 1987–1990. Following a major increase in immunization coverage beginning in 1987, the case fatality ratio for all ages declined fourfold from the first to the second period (relative risk (RR) = 0.24, 95% confidence interval (Cl) 0.13–0.46). The measles incidence for children under 10 years of age declined by 69% (95% Cl 65–72) and the risk of dying of measles by 91 % (95% Cl 82–95). Vaccinated children who contracted measles had significantly lower case fatality ratio than unvaccinated children with measles (p = 0.038). Children infected by an immunized case tended to have lower case fatality ratio than those infected by an unimmunized index case (p = 0.104) and immunized index cases generated fewer secondary cases than unimmunized index cases (p ≪ 0.001). Respiratory complications were more common in secondary cases infected by an index case with respiratory complications than by an index case without such complications (RR = 1.60, 95% Cl 1.08–2.37), which suggests that severe cases give rise to further severe cases. As expected, there was a significant increase in the proportion of vaccinated cases in the second period (RR = 1.41, 95% Cl 1.00–1.98). Mean age at infection increased from 4 to 7 years between the two periods and the change in age structure accounted for 20% of the decline in case fatality ratio. Measles immunization may contribute to lower mortality directly through reduced incidence and indirectly through increases in age at infection, less severe infection for immunized cases and changes in transmission patterns leading to reduced severity of measles. Am J Epidemiol 1997;145:51–7. [ABSTRACT FROM AUTHOR]

To compare the effectiveness of treating malnourished children in different centers, the authors believe there is a need to have a simple method of adjusting mortality rates so that differences in the nutritional status of the children are taken into account. The authors compared different anthropometric indices based on weight and height to predict the risk of death among severely malnourished children. Anthropometric data from 1,047 children who survived were compared with those of 147 children who died during treatment in therapeutic feeding centers set up in African countries in 1993. The optimal ratio of weight to height determined by logistic regression was weight (kg)/height (m)1.74 (95% confidence interval of β estimate 1.65–1.84). The receiver operating curves (sensitivity vs. specificity) showed that the body mass index (weight (kg)/height (m)2), optimal ratio of weight to height, and weight/height index expressed as the percentage of the median of the National Center for Health Statistics' standard were equivalent and superior to the weight/height index expressed as the z score of the National Center for Health Statistics' standard to predict death. As the optimal ratio of weight to height is easier to calculate than the weight/height index expressed as the percentage of the median or z score and does not depend upon either standards or tables, the optimal ratio of weight to height could be conveniently used to adjust mortality rates for nutritional status in therapeutic feeding centers. Am J Epidemiol 1996; 144: 116–23. [ABSTRACT FROM AUTHOR]

A hospital-based follow-up study was conducted between 1986 and 1988 at Lwiro (South Kivu Province, Zaire). Of 1, 129 children in the study, three of four were severely mainourished, and 17.4% died. This study analyzes the mortality in hospital; its objectives are to evaluate the prognostic power of edema and anthropometric and biologic indicators and to seek indices that perform better. Receiver operating characteristic curves were established for each parameter under study and for each index constructed. Areas under receiver operating characteristic curves were highest for biologic indicators, and simple indices, obtained by counting the number of risk factors present, performed best. In the absence of biologic parameters, the authors suggest classifying children as at risk of dying when they present with edema and/or with arm circumference of less than 115 mm. When biologic measurements are possible, in addition to edema and arm circumference, the authors suggest taking serum albumin and transthyretin into account. For serum albumin and transthyretin, mortality risk is defined in terms of values of less than 16 g/liter and 6.5 mg/dl, respectively. Children will be classified as at risk of dying when they present with at least two of the four risk factors. The resulting diagnostic test has a high sensitivity (91.2%) and positive and negative predictive values of 40.8% and 97.9%, respectively. Am J Epidemiol 1996; 143: 1235–43. [ABSTRACT FROM AUTHOR]

Background IA remains a leading cause of morbidity and mortality in immunocompromised children, and our understanding regarding epidemiology and outcomes of IA are limited and based on adult studies. Methods We conducted a retrospective evaluation of cases of proven or probable IA according to the 2008 EORTC/MSG criteria cared for at Boston Children's Hospital from 2007 to 2019. We collected data including demographics, clinical characteristics, diagnosis modality, antifungal treatment, and survival. Survival curves over one year were estimated using the Kaplan–Meier method and univariate and multivariate Cox modeling was used to evaluate for risk factors for mortality. Results 67 patient cases were identified, 20 (30%) with proven IA and 47 (70%) with probable IA. The mean age at diagnosis was 11.9 years (6 months–28 years). Underlying conditions included hematopoietic-cell transplantation (HCT) in 45%, cancer in 21%, and solid-organ transplantation in 18%. Pulmonary IA was the most common (70.1%) presentation. Diagnostic modalities included positive microbiology alone (18%), fungal PCR alone (1.5%), galactomannan alone (28%), and multiple modalities for the remaining cases (52.5%). 44.8% of patients were neutropenic at diagnosis and 78.5% of patients with malignancies were receiving chemotherapy. Immunosuppressive drugs included glucocorticoids in 34.3%, calcineurin inhibitors in 31.3%, and IMDH inhibitors in 25.3%. Voriconazole was the most common treatment used (72%). Twenty-two (33%) deaths occurred in the cohort attributable to IA (6 of which underwent autopsies and 4 had histopathological confirmation) Most deaths occurred in the BMT patients (15 patients, 45% of deaths). The 6 week mortality was 18% while the 12 week mortality was 25.4%. No antifungal or immunosuppressive regimen had a statistically significant impact on mortality. Conclusion We demonstrate in our >10-year retrospective cohort analysis of immunocompromised hosts that IA is associated with 49% all-cause mortality with particular impact on the BMT population. No protective nor harmful association was also noted with a particular antifungal or immunosuppressive regimen. Disclosures All authors: No reported disclosures. [ABSTRACT FROM AUTHOR]

Background Patients undergoing hematopoietic stem cell transplantation and patients with hematologic malignancies are at increased risk for acquiring invasive fungal infection (IFI) due to immune system impairment from chemotherapy. Affected patients require prolonged antifungal therapy with the risk of associated toxicity and extended hospitalization due to delay of accurate diagnosis. There is a lack of effective serologic biomarkers and hesitancy to proceed with tissue diagnosis due to thrombocytopenia or other associated risks. Mortality in oncology patients with invasive mycoses is high, with pediatric mortality rates of 30–40% at 12 weeks following diagnosis. Methods All patients that were admitted to Lurie Children's Hospital between January 2014 and December 2018 and received voriconazole, ambisome, posaconazole and isavuconazole were identified. The following data were retrospectively collected: CT chest and sinus, (1,3)-β- d -Glucan and Aspergillus galactomannan, ANC and ALC at diagnosis, blood next-generation sequencing, tissue 18s rRNA, fungal culture, duration of neutropenia and lymphopenia, site of infection, time between underlying diagnosis and development of IFI, surgical intervention and associated mortality. Results A total of 94 unique patients that received voriconazole were identified. There were 8 proven cases of invasive Aspergillus infection the past 5 years, 50% male, mean age 14 years. Only 25% of patients had positive serum Aspergillus galactomannan and 37.5% had positive β- d -Glucan. Seven cases were due to Aspergillus fumigatus and one case was due to Aspergillus flavus. There were 9 patients with mucormycosis and all but one were culture positive. Three patients with Mucor had mold identification in blood next-generation sequencing prior to surgery. Mucor associated mortality was 22.2%. Conclusion The majority of pediatric patients with invasive aspergillosis did not have characteristic chest CT imaging findings and serum Aspergillus galactomannan was usually negative.The was no associated mortality in invasive Aspergillus cases, whereas the mortality rate of invasive mucormycosis was 22.2%. Although we have a small sample size, this is significantly lower compared with published literature. Disclosures All authors: No reported disclosures. [ABSTRACT FROM AUTHOR]

Background: The Lives Saved Tool (LiST) projects the magnitude of mortality reduction based on baseline coverage, demographic characteristics and coverage targets. As a validation exercise, we compared neonatal, post-neonatal, infant, child and under-5 mortality reductions as projected by LiST to changes in mortality measured through demographic surveys in Ghana and Mali as part of a recently completed, retrospective evaluation of a child survival programme.Methods: Using coverage and other information collected during the evaluation, we modelled the predicted mortality reduction, using logical assumptions to fill gaps if no data were available. We performed a sensitivity analysis on several indicators for which we used a proxy, using the results to examine model sensitivity and readdress our assumptions.Results: In Ghana, the modelled mortality reductions were within the 95% confidence boundaries of the measured reduction. In Mali LiST significantly underestimated the reduction. Several coverage indicators were found to influence the projection, specifically case management of serious neonatal illness in both countries and pneumonia treatment, vitamin A measles treatment and breastfeeding promotion in Mali.Conclusions: We consider LiST to be a useful tool given the limitations of the available data. Although the model was a good match in Ghana, we identified several limiting factors with the input data in the Mali projection. This exercise highlights the importance of continually improving the availability of sound demographic, epidemiological and intervention coverage data at district and national levels. More comparative studies are needed to fully assess the strengths and weaknesses of LiST. [ABSTRACT FROM AUTHOR]

Background Most diarrhoeal deaths can be prevented through the prevention and treatment of dehydration. Oral rehydration solution (ORS) and recommended home fluids (RHFs) have been recommended since 1970s and 1980s to prevent and treat diarrhoeal dehydration. We sought to estimate the effects of these interventions on diarrhoea mortality in children aged <5 years. [ABSTRACT FROM PUBLISHER]

Background: The Lives Saved Tool (LiST) uses estimates of the effects of interventions on cause-specific child mortality as a basis for generating projections of child lives that could be saved by increasing coverage of effective interventions. Estimates of intervention effects are an essential element of LiST, and need to reflect the best available scientific evidence. This article describes the guidelines developed by the Child Health Epidemiology Reference Group (CHERG) that are applied by scientists conducting reviews of intervention effects for use in LiST.Methods: The guidelines build on and extend those developed by the Cochrane Collaboration and the Working Group for Grading of Recommendations Assessment, Development and Evaluation (GRADE). They reflect the experience gained by the CHERG intervention review groups in conducting the reviews published in this volume, and will continue to be refined through future reviews. Presentation of the guidelines Expected products and guidelines are described for six steps in the CHERG intervention review process: (i) defining the scope of the review; (ii) conducting the literature search; (iii) extracting information from individual studies; (iv) assessing and summarizing the evidence; (v) translating the evidence into estimates of intervention effects and (vi) presenting the results.Conclusions: The CHERG intervention reviews represent an ambitious effort to summarize existing evidence and use it as the basis for supporting sound public health decision making through LiST. These efforts will continue, and a similar process is now under way to assess intervention effects for reducing maternal mortality. [ABSTRACT FROM AUTHOR]

Background: In the absence of planned efforts to target the poor, child survival programs often favour the rich. Further evidence is needed urgently about which interventions and programme approaches are most effective in addressing inequities. The Lives Saved Tool (LiST) is available and can be used to model mortality levels across economic groups based on coverage levels for child survival interventions.Methods: We used LiST to model neonatal and under-5 mortality levels among the highest and the lowest wealth quintiles in Bangladesh based on national and wealth-quintile-specific coverage of child survival interventions. The cause-of-death structure among children under-5 was also modelled using the coverage levels. Modelled rates were compared to the rates measured directly from the 2004 Bangladesh Demographic and Health Survey and associated verbal autopsies.Results: Modelled estimates of mortality within wealth quintiles fell within the 95% confidence intervals of measured mortality for both neonatal and post-neonatal mortality. LiST also performed well in predicting the cause-of-death structure for these two age groups for the poorest quintile of the population, but less well for the richest quintile.Conclusions: LiST holds promise as a useful tool for assessing socio-economic inequities in child survival in low-income countries. [ABSTRACT FROM AUTHOR]