(Excerpted from LANCET 2003; 362 :65-71 . Accessed on www.thelancet.com)
Dr Santosh Singh

More than 10 million children are dying every year, almost all in low-income countries or poor areas of middle-income countries. 90% of these deaths occurred in just 42 countries, and were due to diarrhoea, pneumonia, measles, malaria, HIV/AIDS, and the underlying cause of undernutrition for deaths among children younger than 5 years, and asphyxia, preterm delivery, sepsis, and tetanus for deaths among neonates.

In this paper the state of the evidence for interventions to reduce child mortality is reviewed for each of the major direct and underlying causes of death in children younger than 5 years. The aim was to assess the potential effect of translating current knowledge about child survival interventions into effective action.

Interventions included preventive approaches that may reduce the exposure to the infection or condition or reduce the likelihood of exposure that leads to disease. The authors have focused on an essential set of interventions judged to be feasible for high levels of implementation in low-income countries.

Each potential intervention was assigned to one of three levels based on the strength of the evidence for its effect on child mortality.

Level 1 - sufficient evidence of effect: the working group for this paper believed that a causal relationship had been established between the intervention and reductions in cause-specific mortality among children younger than 5 years in developing countries.

Level 2 - limited evidence of effect: the working group believed that an effect was possible, but available data were not sufficient to establish a cause relationship

Level 3 - inadequate evidence of effect: the available data could not be interpreted as showing either presence or absence of an effect on under-5 mortality

21 interventions are supported by level 1 or level 2 evidence. Zinc and vitamin A are effective both as preventive therapeutic interventions, leading to a total of 23 measures. The results of review show that at least one level of intervention feasible for implementation at high coverage in low-income countries is available to prevent/treat each of the main causes of under 5 deaths. Limited evidence of effect was available for three interventions addressing causes of death in neonatal period-newborn namely temperature management, antibiotics for premature rupture of the membranes and newborn resuscitation. Level-3 interventions, for which current levels of that evidence were judged to be inadequate, include those that hold promise of substantial effects on child mortality that have not yet been fully assessed. Several of these interventions are likely to be proven effective for wide scale affordable use in the near future, these include rotavitus vaccine for diarrhoea, prevention with pneumococcal vaccine and reduction of indoor pollution for prevention of pneumonia; zinc for treatment of pneumonia; antimalarial intermittent preventive treatment in infants; and advances in low-cost prevention treatment of HIV in children. (see table 1)

Current coverage with effective child survival interventions

Coverage rates are fairly high for a few interventions (breastfeeding, measles vaccine), but for most countries and most interventions coverage is low or very low. Haemophilus influenzae type b (Hib) vaccine coverage was universally low and, with few exceptions, insecticide-treated net coverage rates in malarious areas were well below 5%.

Table 1 . Coverage estimates for child survival interventions for the 42 countries with 90% of worldwide child deaths in 2000

Data source: State of the World's Children 2003.2
* Where available. For interventions with no country-level coverage data a single estimate was used for all countries.
† The mean weight for age z score was used.

Achievement of universal coverage with individual interventions
Two interventions-oral rehydration therapy and breastfeeeding-were each estimated to prevent over 10% of deaths. Six further interventions could each prevent at least 5% of child deaths. These include insecticide treated material (ITMs), improvement of complementary feeding, antibiotics for neonatal sepsis, antibiotics for pneumonia, antimalarial treatment, and preventive zinc supplementation.

Universal coverage with multiple interventions
The authors then estimated the number of child deaths that could be prevented if the full set of interventions for each cause were delivered at universal coverage levels.

Table 3 . Under-5 deaths from specific causes that could be prevented in the 42 countries with 90% of worldwide child deaths in 2000 through child survival interventions addressing that cause

Universal coverage in countries with specific epidemiological profiles
Five different country profiles have been defined on the basis of proportional distribution of cause of child deaths. All these countries have substantial child mortality due to neonatal causes- diarrhoea and pneumonia. Countries were categorised as: profile 1(accounting for 46% of child deaths)-low (less than10%) AIDS and malaria and low (less than 40% neonatal; profile 2 (27%) - low AIDS and high malaria; profile 3 (16%)- high neonatal; profile 4 (8%) –high AIDS and malaria; and profile 5 (3%)-high AIDS and low malaria. Under-5 deaths that could be prevented within each of this profile if the interventions considered (with either sufficient or limited levels of evidence) were delivered at universal coverage levels. The estimate of preventing deaths ranges from a 54% reduction in child deaths for countries with profile-3 to a 73% reduction in profile-2 countries.

Universal coverage with specific groups of Interventions
Among children living in the 42 countries with 90% of child deaths, a group of effective nutrition interventions including breastfeeding, complementary feeding, vitamin A, and zinc supplementation could save about 2.4 million children each year (25% of total deaths). Effective and integrated case management of childhood infections (diarrhoea and dysentery, pneumonia, malaria, and neonatal sepsis) could save 3.2 million children each year (33% of total deaths). Interventions against deaths in the neonatal period could prevent 55% of these deaths (table 2), or 18% of all child deaths. Although skilled delivery care was not included in the model as a separate intervention, several of its components were considered separately, such as clean delivery, resuscitation, temperature management, and antibiotics for premature rupture of membranes. It is important to note that some of the most promising interventions may be delivered at the household level, with limited need for external material inputs; these include promotion of breastfeeding, oral rehydration therapy, education on complementary feeding, and insecticide-treated materials. These interventions could jointly prevent more than one-third of all deaths.

Conclusions
The findings of this article show that about two-thirds of child deaths could be prevented by interventions that are available today and are feasible for implementation in low income countries at high levels of population coverage. Published work on child mortality in low-income and middle-income countries over the past two decades confirms previous evidence of the efficacy and effectiveness of prevention and therapeutic interventions identified before that time, such as measles vaccine and the prevention of dehydration among children with diarrhea through oral rehydration therapy.


Last updated on 1-2-2007