Trends in cause-specific mortality among children aged 5-14 years from 2005 to 2016 in India, China, Brazil, and Mexico: an analysis of nationally representative mortality studies

A study protocol for predictors of post-discharge mortality among children aged 5-14 years admitted to tertiary hospitals in Tanzania: A prospective observational cohort study

INTRODUCTION

Globally, millions of children and adolescents die every year from treatable and preventable causes. Sub-Saharan Africa accounted for 55% of deaths of children aged 5-14 years in 2017. Despite this high burden, minimal effort has been directed toward reducing mortality among older children and adolescents in comparison to under-fives. Mortality rates of children post-discharge vary between 1-18% in limited-resource countries and are reported to exceed in-hospital mortality. In Tanzania, there is limited data regarding post-discharge mortality and its predictors among children aged 5-14 years.

OBJECTIVES

This study aims to determine the post-discharge mortality rate and its predictors among children aged 5-14 years admitted to pediatric wards at MNH, MOI, and JKCI.

METHODS AND ANALYSIS

This will be a prospective observational cohort study that will be conducted among children aged 5-14 years admitted to pediatric wards at Muhimbili National Hospital, Jakaya Kikwete Cardiac Institue, and Muhimbili Orthopedic Institue in Dar-Es-Salaam, Tanzania. Data will be collected using a structured questionnaire and will include socio-demographic characteristics, clinical factors, and patients' outcomes. Post-discharge follow-up will be done at months 1, 2, and 3 after discharge via phone call. Data will be analyzed using SPSS version 23. The association of demographic, social economic, and clinical factors with the outcome of all causes, 3 months post-discharge mortality will be determined by Cox regression, and survival rates will be displayed through Kaplan-Meier curves.

DISCUSSION

This study will determine post-discharge mortality among children aged 5-14 years and its predictors in Tanzania. This information is expected to provide baseline data that will be useful for raising awareness of clinicians on how to prioritize and plan a proper follow-up of children following hospital discharge. These data may also be used to guide policy development to address and reduce the high burden of older children and adolescent mortality and may be used for future studies including those aiming to develop prediction models for post-discharge mortality among older children and adolescents.

Overview of the Indigenous health of the Yanomami ethnic group in Brazil: A Public Health Emergency

INTRODUCTION

The Indigenous population of the Yanomami ethnic group in Brazil is currently facing a public health emergency due to the high number of deaths, mainly of children. Taking that into consideration, this study aims to analyze this crisis impact on the health of this population in the period between 2018 and 2022.

METHODS

The data presented were collected from the report called Yanomami Mission ("Missão Yanomami") published by the Brazilian Ministry of Health and, from it, a descriptive analysis of the Indigenous individuals' health was carried out for (i) the geographical distribution; ii) the number of deaths; (iii) the child death rate; (iv) the deaths of Indigenous individuals from preventable causes; (v) the causes of preventable diseases related to hygiene and basic sanitation, and the distribution of diarrheal diseases according to age groups; (vi) evaluation of the nutritional classification; vii) the percentage (%) of the complete vaccination scheme, and (viii) the coverage of prenatal appointments of Indigenous pregnant women.

RESULTS

The report included 31,017 individuals belonging to the Yanomami ethnic group, most of the participants were up to 39 years old (N = 26,377; 85.0%) and men (N = 15,836; 51.1%). During the period described in the report, the number of deaths reached 1285/31,017 (4.1%). When analyzing the deaths, the most representative age groups were those of children under 1 year old (505/1285; 39.9%), from 1 to 4 years old (178/1285; 13.8%), and the elderly from 60 to 79 years old (150/1285; 11.6%). The Indigenous individuals from this ethnic group presented a child death rate ~ 1.5 to 3.5 higher than that of the total Indigenous population in the country. Regarding the child death rate, the neonatal component represented 57.8% of the deaths and, in 2022, 93.0% of the pregnant women had less than six prenatal appointments. This population shows a high number of deaths due to preventable causes (N = 538) and cases of illnesses associated with hygiene and sanitation, for example (N = 35,103 cases/notifications). As for vaccination, the full vaccination scheme targeting children below 5 years old has not been met since 2018.

CONCLUSION

In the Indigenous population of the Yanomami ethnic group, a high number of deaths was observed, which affected mainly individuals under 1 year old. Among the factors associated with the deaths, mainly in children under 5 years old, most cases have preventable causes, which could be reduced by proper action promoting their health and preventing diseases.

Characteristic of school injuries in Asia: a cross-national, multi-center observational study

BACKGROUND

To prevent school injuries, thorough epidemiological data is an essential foundation. We aimed to investigate the characteristics of school injuries in Asia and explore risk factors for major trauma.

METHODS

This retrospective study was conducted in the participating centers of the Pan-Asian Trauma Outcome Study from October 2015 to December 2020. Subjects who reported "school" as the site of injury were included. Major trauma was defined as an Injury Severity Score (ISS) value of ≥16.

RESULTS

In total, 1305 injury cases (1.0% of 127,715 events) occurred at schools. Among these, 68.2% were children. Unintentional injuries were the leading cause and intentional injuries comprised 7.5% of the cohort. Major trauma accounted for 7.1% of those with documented ISS values. Multivariable regression revealed associations between major trauma and factors, including age, intention of injury (self-harm), type of injury (traffic injuries, falls), and body part injured (head, thorax, and abdomen). Twenty-two (1.7%) died, with six deaths related to self-harm. Females represented 28.4% of injuries but accounted for 40.9% of all deaths.

CONCLUSIONS

In Asia, injuries at schools affect a significant number of children. Although the incidence of injuries was higher in males, self-inflicted injuries and mortality cases were relatively higher in females.

IMPACT

Epidemiological data and risk factors for major trauma resulting from school injuries in Asia are lacking. This study identified significant risk factors for major trauma occurring at schools, including age, intention of injury (self-harm), injury type (traffic injuries, falls), and body part injured (head, thoracic, and abdominal injuries). Although the incidence of injuries was higher in males, the incidence of self-harm injuries and mortality rates were higher in females. The results of this would make a significant contribution to the development of prevention strategies and relative policies concerning school injuries.

Status and correlates of non-communicable diseases among children and adolescents in slum and non-slum areas of India's four metropolitan cities

The emergence of non-communicable diseases (NCDs) in childhood poses a serious risk to a healthy adult life. The present study aimed to estimate the prevalence of NCDs among children and adolescents in slums and non-slums areas of four metropolitan cities of India, and in rural areas of the respective states The study further, investigated the effect of the place residence as slum vs. non-slum and other risk factors of the NCDs. Nationally representative data from the Comprehensive National Nutrition Survey (CNNS) was used.. Estimates were based on children (5-9 years) and adolescents (10-19 years) for whom biomarkers predicting diabetes, high total cholesterol, high triglycerides and hypertension were determined. Weight, height and age data were used to calculate z-scores of the body mass index. Overweight and obesity was higher in urban areas than in rural areas among children and adolescents. Regional differences in the prevalence of diseases were observed; children in Delhi and Chennai had a higher likelihood of being diabetic while children in Kolkata were at a greater risk of high total cholesterol and high triglycerides. The risk of hypertension was strikingly high among non-slum children in Delhi. Children from slums were at a higher risk of diabetes compared to the children from non-slums, while children and adolecents from non-slums were at a greater risk of high triglycerides and hypertension respectively than their counterparts from slums. Male children and adolecents had a higher risk of diabetes and high cholesterol. Screening of children for early detection of NCDs should be integrated with the already existing child and adolescent development schemes in schools and the community can help in prevention and control of NCDs in childhood.

Effects of Child Life intervention on the symptom cluster of pain-anxiety-fatigue-sleep disturbance in children with acute leukemia undergoing chemotherapy

Objective

This study aims to explore the application effect of Child Life intervention on pain, anxiety, fatigue, and sleep disturbance in children with acute leukemia.

Methods

In a single-blinded, parallel-group randomized controlled trial, 96 children with acute leukemia were randomized to either the intervention group, which received Child Life intervention twice a week for 8 weeks, or the control group, which received routine care. Outcomes were evaluated at baseline and day 3 postintervention.

Results

All of the participants completed the study. Compared with the control group, the intervention group showed a significant reduction in pain, anxiety, fatigue, and sleep disturbance (P ​< ​0.001). However, no significant differences were observed in the disorders of excessive somnolence.

Conclusions

Child Life intervention can effectively improve pain, anxiety, fatigue, and sleep disturbance in children with acute leukemia undergoing chemotherapy. The results suggest that symptom cluster management intervention based on Child Life provided a promising approach for simultaneously treating multiple symptoms within a cluster.

Influencing factors of knowledge, attitude and behavior in children's palliative care among pediatric healthcare workers: a cross-sectional survey in China

BACKGROUND

Palliative care has become a key medical field worldwide. Although research relating to adult palliative care is well-established, less is known about children's palliative care (CPC). Therefore, this study investigated the knowledge, attitude and behavior of pediatric healthcare workers (PHWs) regarding CPC and analyzed the influencing factors for the implementation and development of CPC.

METHODS

A cross-sectional survey of 407 PHWs was carried out in a Chinese province from November 2021 to April 2022. The questionnaire consisted of two parts: a general information form and questions on the knowledge, attitude and behavior of PHWs about CPC. Data were analyzed using t-test, ANOVA and multiple regression analysis.

RESULTS

The total score of the PHWs' knowledge, attitude and behavior about CPC was 69.98, which was at a moderate level. PHWs' CPC knowledge, attitude, and behavior are positively correlated.The most important influencing factors were working years, highest education, professional title, job position, marital status, religion, grade of hospital (I, II or III), type of medical institution, experience of caring for a terminally ill child/kinsfolk and total hours of CPC education and training received.

CONCLUSIONS

In this study, PHWs in a Chinese province had the lowest scores on the knowledge dimension of CPC, with moderate attitude and behavior and various influencing factors. In addition to professional title, highest education and working years, it is also worth noting that the type of medical institution and marital status also affected the score. Continuing education and training of PHWs in CPC should be emphasized by the administrators of relevant colleges and medical institutions. Future research should start with the above-mentioned influencing factors and focus on setting up targeted training courses and evaluating the post-training effects.

Treating post-traumatic stress disorder in survivors of community and domestic violence using narrative exposure therapy: a case series in two public health centers in Rio de Janeiro/Brazil

Prevalence of violence in Brazil is high, which contributes to an increasing number of trauma-related disorders, especially post-traumatic stress disorder (PTSD). This study aims to present a case series of PTSD patients treated with narrative exposure therapy (NET) in two public health centers in Rio de Janeiro (Brazil). Health professionals were trained in a two-week workshop to deliver NET. Exposure to violence and other potentially traumatic events, as well as PTSD were assessed by interviewers before treatment and six months later in follow-up interviews conducted by blind assessors. Multiple traumatic events, including different types of childhood and sexual abuse, intimate partner violence and community violence were reported. Five patients were exposed to community violence, and one to domestic violence, during or after NET treatment. Treatment delivery was integrated into the routine of health centers. Eight patients completed NET and presented a substantial reduction in PTSD severity at six-month follow-up. NET is a feasible and effective treatment for PTSD patients exposed to ongoing violence, and can be integrated into established public health services.

Clinical features and risk factors for death in acute undifferentiated fever: A prospective observational study in rural community hospitals in six states of India

BACKGROUND

Acute undifferentiated fever (AUF) ranges from self-limiting illness to life-threatening infections, such as sepsis, malaria, dengue, leptospirosis and rickettsioses. Similar clinical presentation challenges the clinical management. This study describes risk factors for death in patients hospitalized with AUF in India.

METHODS

Patients aged ≥5 y admitted with fever for 2-14 d without localizing signs were included in a prospective observational study at seven hospitals in India during 2011-2012. Predictors identified by univariate analysis were analyzed by multivariate logistic regression for survival analysis.

RESULTS

Mortality was 2.4% (37/1521) and 46.9% (15/32) died within 2 d. History of heart disease (p=0.013), steroid use (p=0.011), altered consciousness (p<0.0001), bleeding (p<0.0001), oliguria (p=0.020) and breathlessness (p=0.015) were predictors of death, as were reduced Glasgow coma score (p=0.005), low urinary output (p=0.004), abnormal breathing (p=0.006), abdominal tenderness (p=0.023), leucocytosis (p<0.0001) and thrombocytopenia (p=0.001) at admission. Etiology was identified in 48.6% (18/37) of fatal cases.

CONCLUSIONS

Bleeding, cerebral dysfunction, respiratory failure and oliguria at admission, suggestive of severe organ failure secondary to systemic infection, were predictors of death. Almost half of the patients who died, died shortly after admission, which, together with organ failure, suggests that delay in hospitalization and, consequently, delayed treatment, contribute to death from AUF.

What do children aged 5 to 14 years die from in the state of Rio de Janeiro, Brazil? Trend analysis of the period 2000-2019

Abstract This study investigated the magnitude and trends of cause-specific mortality among children 5 to 14 years of age in the state of Rio de Janeiro (RJ) from 2000 to 2019. We performed an ecological study, using data from the Mortality Information System (MIS). We calculated mortality rates per 100,000 children by chapters, groups, and categories of causes of death (ICD-10). Trends were estimated by joinpoint regression. Mortality rates among children aged 10 to 14 years were higher than those among children 5 to 9. The five leading causes of death were the same in both age groups, but they ranked differently. The two leading ones were external causes and neoplasms (31% and 15% among children aged 5 to 9 years; 45% and 11% among children aged 10 to 14 years). Among children 5 to 9 years, the mortality trend showed an annual decline (8%) from 2011 to 2015. Among children aged 10 to 14 years, the annual decline was 1.3% from 2000 to 2019. Mortality due to external causes decreased in both age groups, except for the category “Assault by unspecified firearm” (boys, 10 to 14 years) and “Unspecified drowning and submersion” (boys, 5 to 9 years). Mortality caused by neoplasms remained steady in both age groups. Infectious and respiratory diseases decreased differently between the two groups. Most causes of death are preventable or treatable, indicating the need for health and intersectoral investments.

What do children aged 5 to 14 years die from in the state of Rio de Janeiro, Brazil? Trend analysis of the period 2000-2019

This study investigated the magnitude and trends of cause-specific mortality among children 5 to 14 years of age in the state of Rio de Janeiro (RJ) from 2000 to 2019. We performed an ecological study, using data from the Mortality Information System (MIS). We calculated mortality rates per 100,000 children by chapters, groups, and categories of causes of death (ICD-10). Trends were estimated by joinpoint regression. Mortality rates among children aged 10 to 14 years were higher than those among children 5 to 9. The five leading causes of death were the same in both age groups, but they ranked differently. The two leading ones were external causes and neoplasms (31% and 15% among children aged 5 to 9 years; 45% and 11% among children aged 10 to 14 years). Among children 5 to 9 years, the mortality trend showed an annual decline (8%) from 2011 to 2015. Among children aged 10 to 14 years, the annual decline was 1.3% from 2000 to 2019. Mortality due to external causes decreased in both age groups, except for the category "Assault by unspecified firearm" (boys, 10 to 14 years) and "Unspecified drowning and submersion" (boys, 5 to 9 years). Mortality caused by neoplasms remained steady in both age groups. Infectious and respiratory diseases decreased differently between the two groups. Most causes of death are preventable or treatable, indicating the need for health and intersectoral investments.

Development of a core dataset for child injury surveillance: a modified Delphi study in China

Background

Understanding the occurrence and severity of child injuries is the cornerstone of preventing child injuries. Currently, there is no standardized child injury surveillance dataset in China.

Methods

Multistage consultation by a panel of Chinese experts in child injury to determine items to include in the core dataset (CDS) was performed. The experts participated in two rounds of the modified Delphi method comprising a consultation questionnaire investigation (Round 1) and a face-to-face panel discussion (Round 2). Final consensus was established based on the opinions of the experts regarding the modified CDS information collection items. Enthusiasm and authority exhibited by the experts were evaluated by the response rate and using the expert authority coefficient, respectively.

Results

The expert panel included 16 experts in Round 1 and 15 experts in Round 2. The experts during both rounds had a high degree of authority, with an average authority coefficient of 0.86. The enthusiasm of the experts was 94.12%, and the proportion of suggestions reached 81.25% in Round 1 of the modified Delphi method. The draft CDS evaluated in Round 1 included 24 items, and expert panelists could submit recommendations to add items. Based on findings in Round 1, four additional items, including nationality, residence, type of family residence, and primary caregiver were added to the draft of the CDS for Round 2. After Round 2, consensus was reached on 32 items arranged into four domains-general demographic information, injury characteristics, clinical diagnosis and treatment, and injury outcome-to include in the final CDS.

Conclusion

The development of a child injury surveillance CDS could contribute to standardized data collection, collation, and analysis. The CDS developed here could be used to identify actionable characteristics of child injury to assist health policymakers in designing evidence-based injury prevention interventions.

Characteristics and temporal trends of mortality rates in children and adolescents in Mato Grosso and Brazil, 2009-2020

OBJECTIVE

to analyze the characteristics and temporal trend of mortality rates in the population aged 5 to 14 years in Mato Grosso state and in Brazil, from 2009 to 2020.

METHODS

this was an ecological time-series study, based on data taken from the Mortality Information System. Descriptive and trend analyses were performed, using the joinpoint regression model and calculating the average annual percentage change (AAPC).

RESULTS

in Brazil and in Mato Grosso state, deaths were predominantly male, preventable and due to external causes. A falling trend was identified for Brazil (5-9 years AAPC: -2.9; 95%CI -4.3;-1.6 and 10-14 years AAPC: -2.5; 95%CI -3.3;-1.8), while a stationary trend was found in Mato Grosso (5-9 years AAPC: -2.0; 95%CI -5.6;1.7 and 10-14 years AAPC: -0.1; 95%CI -5.9;6.1).

CONCLUSION

the stable trend of mortality at high levels demands urgent interventions to reduce it.

Comprehensive assessment of age-specific mortality rate and its incremental changes using a composite measure: A sub-national analysis of rural Indian women

Background

Diverse socio-economic and cultural issues contribute to adverse health outcomes and increased mortality rates among rural Indian women across different age categories. The present study aims to comprehensively assess age-specific mortality rates (ASMR) and their temporal trends using a composite measure at the sub-national level for rural Indian females to capture cross-state differences.

Materials and methods

A total of 19 states were included in the study to construct a composite age-specific mortality index for 2011 (base year) and 2018 (reference year) and examine the incremental changes in the index values across these years at the sub-national level in India. Sub-index values were calculated for each component age group and were subsequently used to compute the composite ASMR index using the geometric mean method. Based on the incremental changes, the performance of states was categorized into four different typologies.

Results

Improvement in mortality index scores in the 0-4 years age group was documented for all states. The mortality rates for the 60+ age group were recorded to be high for all states. Kerala emerged as the overall top performer in terms of mortality index scores, while Bihar and Jharkhand were at the bottom of the mortality index table. The overall mortality composite score has shown minor improvement from base year to reference year at all India level.

Conclusion

An overall reduction in the mortality rates of rural Indian women has been observed over the years in India. However, in states like Bihar and Jharkhand, mortality is high and has considerable scope for improvement. The success of public health interventions to reduce the under-five mortality rate is evident as the female rural mortality rates have reduced sizably for all states. Nevertheless, there is still sizable scope for reducing mortality rates for other component age groups. Additionally, there is a need to divert attention toward the female geriatric (60+ years) population as the mortality rates are still high.

National and sub-national levels and causes of mortality among 5-19-year-olds in China in 2004-2019: A systematic analysis of evidence from the Disease Surveillance Points System

Background

China accounts for 13% of the world’s 5-19-year-olds population. We estimated levels and trends of mortality by sex-age-cause among 5-19-year-olds at national and subnational levels in China annually from 2004 to 2019, to inform strategies for reducing child and adolescent mortality in China and other countries.

Methods

We used adjusted empirical data on levels and causes of deaths from the China Center for Disease Control and Prevention’s Disease Surveillance Point (DSP) system. We considered underreporting and surveillance sampling design, applied smoothing techniques to produce reliable time trends, and fitted age-specific deaths and population to national estimates produced by international agencies to allow for cross-national comparisons.

Results

The top leading causes for 54 594 deaths among 5-19-year-olds were neoplasms, road traffic injuries, and drowning. All-cause mortality in 5-19-year-olds has been declining steadily between 2004-2019, with evident yet narrowing geographical and gender disparities. Injury mortalities were one of the fastest declining causes, but widespread disparities were observed across subpopulations. Falling injuries and rising non-communicable diseases had the most pronounced epidemiological transition in the eastern region. Decrease in drowning fractions stalled for 15-19-year-olds in central/western rural areas. Suicide shares sustained or increased for 15-19-year-olds except among females in eastern rural areas.

Conclusions

China made significant improvements in child and adolescent survival since 2004. However, constant targeted investments are needed to maintain and accelerate progress. A sustainable sample registration system like the DSP is likely essential for supporting such a process.

Mortality Associated with Ambient PM2.5 Exposure in India: Results from the Million Death Study

BACKGROUND

Studies on the extent to which long-term exposure to ambient particulate matter (PM) with aerodynamic diameter ≤2.5μm (PM2.5) contributes to adult mortality in India are few, despite over 99% of Indians being exposed to levels that the World Health Organization (WHO) considers unsafe.

OBJECTIVE

We conducted a retrospective cohort study within the Million Death Study (MDS) to provide the first-ever quantification of national mortality from exposure to PM2.5 in India from 1999 to 2014.

METHODS

We calculated relative risks (RRs) by linking a total of ten 3-y intervals of satellite-based estimated PM2.5 exposure to deaths 3 to 5 y later in over 7,400 small villages or urban blocks covering a total population of 6.8 million. We applied using a model-based geostatistical model, adjusted for individual age, sex, and year of death; smoking prevalence, rural/urban residency, area-level female illiteracy, languages, and spatial clustering and unit-level variation.

RESULTS

PM2.5 exposure levels increased from 1999 to 2014, particularly in central and eastern India. Among 212,573 deaths at ages 15-69 y, after spatial adjustment, we found a significant RR of 1.09 [95% credible interval (CI): 1.04, 1.14] for stroke deaths per 10-μg/m3 increase in PM2.5 exposure, but no significant excess for deaths from chronic respiratory disease and ischemic heart disease (IHD), all nonaccidental causes, and total mortality (after excluding stroke). Spatial adjustment attenuated the RRs for chronic respiratory disease and IHD but raised those for stroke. The RRs were consistent in various sensitivity analyses with spatial adjustment, including stratifying by levels of solid fuel exposure, by sex, and by age group, addition of climatic variables, and in supplementary case-control analyses using injury deaths as controls.

DISCUSSION

Direct epidemiological measurements, despite inherent limitations, yielded associations between mortality and long-term PM2.5 inconsistent with those reported in earlier models used by the WHO to derive estimates of PM2.5 mortality in India. The modest RRs in our study are consistent with near or null mortality effects. They suggest suitable caution in estimating deaths from PM2.5 exposure based on MDS results and even more caution in extrapolating model-based associations of risk derived mostly from high-income countries to India. https://doi.org/10.1289/EHP9538.

Comparative treatment costs of risk-stratified therapy for childhood acute lymphoblastic leukemia in India

BACKGROUND

To evaluate the treatment cost and cost effectiveness of a risk-stratified therapy to treat pediatric acute lymphoblastic leukemia (ALL) in India.

METHODS

The cost of total treatment duration was calculated for a retrospective cohort of ALL children treated at a tertiary care facility. Children were risk stratified into standard (SR), intermediate (IR) and high (HR) for B-cell precursor ALL, and T-ALL. Cost of therapy was obtained from the hospital electronic billing systems and details of outpatient (OP) and inpatient (IP) from electronic medical records. Cost effectiveness was calculated in disability-adjusted life years.

RESULTS

One hundred and forty five patients, SR (50), IR (36), HR (39), and T-ALL (20) were analyzed. Median cost of the entire treatment for SR, IR, HR, and T-ALL was found to be $3900, $5500, $7400, and $8700, respectively, with chemotherapy contributing to 25%-35% of total cost. Out-patient costs were significantly lower for SR (p < 0.0001). OP costs were higher than in-patient costs for SR and IR, while in-patient costs were higher in T-ALL. Costs for non-therapy admissions were significantly higher in HR and T-ALL (p < 0.0001), representing over 50% of costs of in-patient therapy. HR and T-ALL also had longer durations of non-therapy admissions. Based on WHO-CHOICE guidelines, the risk-stratified approach was very cost effective for all categories of patients.

CONCLUSIONS

Risk-stratified approach to treat childhood ALL is very cost-effective for all categories in our setting. The cost for SR and IR patients is significantly reduced through decreased IP admissions for both, chemotherapy and non-chemotherapy reasons.

What is the state of children's participation in qualitative research on health interventions?: a scoping study

Background

Children are the focus of numerous health interventions throughout the world, yet the extent of children’s meaningful participation in research that informs the adaptation, implementation, and evaluation of health interventions is not known. We examine the type, extent, and meaningfulness of children’s participation in research in qualitative health intervention research.

Method

A scoping study was conducted of qualitative published research with children (ages 6–11 years) carried out as part of health intervention research. Following Arksey and O’Malley’s scoping study methodology and aligned with the PRISMA-ScR guidelines on the reporting of scoping reviews, the authors searched, charted, collated, and summarized the data, and used descriptive and content analysis techniques. Ovid MEDLINE was searched from 1 January 2007 to 2 July 2018 using the keywords children, health intervention, participation, and qualitative research. Study selection and data extraction were carried out by two reviewers independently.

Results

Of 14,799 articles screened, 114 met inclusion criteria and were included. The study identified trends in when children were engaged in research (e.g., post-implementation rather than pre-implementation), in topical (e.g., focus on lifestyle interventions to prevent adult disease) and geographical (e.g., high-income countries) focuses, and in qualitative methods used (e.g., focus group). While 78 studies demonstrated meaningful engagement of children according to our criteria, there were substantial reporting gaps and there was an emphasis on older age (rather than experience) as a marker of capability and expertise.

Conclusions

Despite evidence of children’s meaningful participation, topical, geographical, and methodological gaps were identified, as was the need to strengthen researchers’ skills in interpreting and representing children’s perspectives and experiences. Based on these findings, the authors present a summary reflective guide to support researchers toward more meaningful child participation in intervention research.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-022-03391-2.

What can work and how? An overview of evidence-based interventions and delivery strategies to support health and human development from before conception to 20 years

Progress has been made globally in improving the coverage of key maternal, newborn, and early childhood interventions in low-income and middle-income countries, which has contributed to a decrease in child mortality and morbidity. However, inequities remain, and many children and adolescents are still not covered by life-saving and nurturing care interventions, despite their relatively low costs and high cost-effectiveness. This Series paper builds on a large body of work from the past two decades on evidence-based interventions and packages of care for survival, strategies for delivery, and platforms to reach the most vulnerable. We review the current evidence base on the effectiveness of a variety of essential and emerging interventions that can be delivered from before conception until age 20 years to help children and adolescents not only survive into adulthood, but also to grow and develop optimally, support their wellbeing, and help them reach their full developmental potential. Although scaling up evidence-based interventions in children younger than 5 years might have the greatest effect on reducing child mortality rates, we highlight interventions and evidence gaps for school-age children (5-9 years) and the transition from childhood to adolescence (10-19 years), including interventions to support mental health and positive development, and address unintentional injuries, neglected tropical diseases, and non-communicable diseases.

Interventions for High-Burden Infectious Diseases in Children and Adolescents: A Meta-analysis

BACKGROUND

Approximately 2.2 million deaths were reported among school-age children and young people in 2019, and infectious diseases remain the leading causes of morbidity and mortality, especially in low and middle-income countries. We aim to synthesize evidence on interventions for high-burden infectious diseases among children and adolescents aged 5 to 19 years.

METHODS

We conducted a comprehensive literature search until December 31, 2020. Two review authors independently screened studies for relevance, extracted data, and assessed risk of bias.

RESULTS

We included a total of 31 studies, including 81 596 participants. Sixteen studies focused on diarrhea; 6 on tuberculosis; 2 on human immunodeficiency virus; 2 on measles; 1 study each on acute respiratory infections, malaria, and urinary tract infections; and 2 studies targeted multiple diseases. We did not find any study on other high burden infectious diseases among this age group. We could not perform meta-analysis for most outcomes because of variances in interventions and outcomes. Findings suggests that for diarrhea, water treatment, water filtration, and zinc supplementation have some protective effect. For tuberculosis, peer counseling, contingency contract, and training of health care workers led to improvements in tuberculosis detection and treatment completion. Continuation of cotrimoxazole therapy reduced the risk of tuberculosis and hospitalizations among human immunodeficiency virus-infected children and reduced measles complications and pneumonia cases among measles-infected children. Zinc supplementation led to a faster recovery in urinary tract infections with a positive effect in reducing symptoms.

CONCLUSIONS

There is scarcity of data on the effectiveness of interventions for high-burden infectious diseases among school-aged children and adolescents.

Prevention and Management of High-Burden Noncommunicable Diseases in School-Age Children: A Systematic Review

BACKGROUND AND OBJECTIVES

Noncommunicable diseases (NCDs) are chronic conditions requiring health care, education, social and community services, addressing prevention, treatment, and management. This review aimed to summarize and synthesize the available evidence on interventions from systematic reviews of high-burden NCDs and risk factors among school-aged children.

METHODS

The following databases were used for this research: Medline, Embase, The Cochrane Library, and the Campbell library. The search dates were from 2000 to 2021. We included systematic reviews that synthesized studies to evaluate intervention effectiveness in children aged 5 to 19 years globally. Two reviewers independently extracted data and assessed methodological quality of included reviews using the AMSTAR 2 tool.

RESULTS

Fifty studies were included. Asthma had the highest number of eligible reviews (n = 19). Of the reviews reporting the delivery platform, 27% (n = 16) reported outpatient settings, 13% (n = 8) home and community-based respectively, and 8% (n = 5) school-based platforms. Included reviews primarily (69%) reported high-income country data. This may limit the results' generalizability for school-aged children and adolescents in low- and middle- income countries.

CONCLUSIONS

School-aged children and adolescents affected by NCDs require access to quality care, treatment, and support to effectively manage their diseases into adulthood. Strengthening research and the capacity of countries, especially low- and middle- income countries, for early screening, risk education and management of disease are crucial for NCD prevention and control.

Sociodemographic Indicators of Child and Adolescent Mortality in Finland-A Nationwide Study of 310 Municipalities Covering Over 5,000,000 Inhabitants

Background: The reduction of child and adolescent deaths (defined as decedents aged 0–19 years) remains a crucial public health priority also in high-income countries such as Finland. There is evidence of a relationship between socioeconomic gradients and child mortality, but the association is considered complex and relatively poorly understood. Exploiting a Finnish dataset with nationwide coverage, the present study aimed to shed light on the sociodemographic predictors of child and adolescent mortality at the municipality level.

Methods: A public database of Statistics Finland was queried for municipality-level data on sociodemographic traits and child and adolescent deaths in Finland during the years 2011–2018. The sociodemographic indicators included total population size, child and adolescent population size, sex distribution, mean age, education, unemployment, median income, population density, rurality, percentage of individuals living in their birth municipality, household size, overcrowded households, foreign language speakers, divorce rate, car ownership rate, and crime rate. The sociodemographic indicators were modeled against child and adolescent mortality by means of generalized estimating equations.

Results: A total of 2,371 child and adolescent deaths occurred during the 8-year study period, yielding an average annual mortality rate of 26.7 per 100,000 individuals. Despite a fluctuating trend, the average annual decline in child and adolescent deaths was estimated to be 3% (95% confidence interval 1–5%). Of the sociodemographic indicators, population density was associated with higher child and adolescent mortality (rate ratio 1.03, 95% confidence interval 1.01–1.06), whereas the percentage of foreign language speakers was associated with lower child and adolescent mortality (0.96, 0.93–0.99).

Conclusion: Densely populated areas should be the primary focus of efforts to reduce child and adolescent mortality. Of note is also the apparently protective effect of foreign language speakers for premature mortality. Future studies are welcomed to scrutinize the mediating pathways and individual-level factors behind the associations detected in this study.

Implementation of a checklist to improve pediatric trauma assessment quality in a Brazilian hospital

BACKGROUND

Trauma is the leading cause of death among children and adolescents in Brazil. Measurement of quality of care is important, as well as interventions that will help optimize treatment. We aimed to evaluate adherence to standardized trauma care following the introduction of a checklist in one of the busiest Latin American trauma centers.

MATERIAL AND METHODS

A prospective, non-randomized interventional trial was conducted. Assessment of children younger than age 15 was performed before and after the introduction of a checklist for trauma primary survey assessment. Over the study period, each trauma primary survey was observed and adherence to each step of a standardized primary assessment protocol was recorded. Clinical outcomes including mortality, admission to pediatric intensive-care units, use of blood products, mechanical ventilation, and number of CT scans in the first 24 h were also assessed.

RESULTS

A total of 80 patients were observed (39 pre-intervention and 41 post-intervention). No statistically significant differences were observed between the pre- and post-intervention groups in regard to adherence to checklist by specialty (57.7% versus 50.5%, p = 0.115) and outcomes. No mortality was observed.

CONCLUSION

In our trauma center, the quality of the adherence to standardized trauma assessment protocols is poor among both surgical and non-surgical providers. The quality of this assessment did not improve after the introduction of a checklist. Further work aimed at organizing the approach to pediatric trauma including triage and trauma education specifically for pediatric providers is needed.

Evaluating the Need for Integrated Pediatric Palliative Care Services in a Pediatric Oncology Setting: A Retrospective Audit

Objectives:

Early integrated palliative care has shown to improve the quality of life in patients with cancer. During the past decade, pediatric palliative care has become an established area of medical expertise, however due to scant information available regarding the triggers for referral and referral practice very few children receive a formal palliative care consult.

Materials and Methods:

A retrospective audit of medical case records of pediatric oncology patients over a period of 1 year from September 30, 2019, to September 30, 2020, was conducted. Demographic details, diagnosis, staging, clinical parameters, reason for referral, and palliative care plan were captured in a predesigned pro forma.

Results:

Among 126 children with cancer, 27 (21.4%) patients were referred to palliative care. Majority 21 (77%) referrals were inpatient consults. Symptom management 17 (44.7%) was the most common trigger for referral followed by referrals for psychosocial support 12 (14.4%). Children with solid tumors 16 (59%) were more often referred than hematological malignancies. Among those needing end of life care, 8 (88.8%) out of 9 families preferred home than hospital.

Conclusion:

Low incidence of palliative care referral and presence of symptoms as a trigger for palliative care referral suggests gaps in the integrated approach. The study findings prompt a review of palliative care referral criteria and referral practice in a pediatric oncology setting.

Trends in maternal mortality in India over two decades in nationally representative surveys

OBJECTIVE

To assess national and regional trends and causes-specific distribution of maternal mortality in India.

DESIGN

Nationally representative cross-sectional surveys.

SETTING

All of India from 1997 to 2020.

SAMPLE

About 10 000 maternal deaths among 4.3 million live births over two decades.

METHODS

We analysed trends in the maternal mortality ratio (MMR) from 1997 through 2020, estimated absolute maternal deaths and examined the causes of maternal death using nationally representative data sources. We partitioned female deaths (aged 15-49 years) and live birth totals, based on the 2001-2014 Million Death Study to United Nations (UN) demographic totals for the country.

MAIN OUTCOME MEASURES

Maternal mortality burden and distribution of causes.

RESULTS

The MMR declined in India by about 70% from 398/100 000 live births (95% CI 378-417) in 1997-98 to 99/100 000 (90-108) in 2020. About 1.30 million (95% CI 1.26-1.35 million) maternal deaths occurred between 1997 and 2020, with about 23 800 (95% CI 21 700-26 000) in 2020, with most occurring in poorer states (63%) and among women aged 20-29 years (58%). The MMRs for Assam (215), Uttar Pradesh/Uttarakhand (192) and Madhya Pradesh/Chhattisgarh (170) were highest, surpassing India's 2016-2018 estimate of 113 (95% CI 103-123). After adjustment for education and other variables, the risks of maternal death were highest in rural and tribal areas of north-eastern and northern states. The leading causes of maternal death were obstetric haemorrhage (47%; higher in poorer states), pregnancy-related infection (12%) and hypertensive disorders of pregnancy (7%).

CONCLUSIONS

India could achieve the UN 2030 MMR goals if the average rate of reduction is maintained. However, without further intervention, the poorer states will not.

TWEETABLE ABSTRACT

We estimated that 1.3 million Indian women died from maternal causes over the last two decades. Although maternal mortality rates have fallen by 70% overall, the poorer states lag behind.

Patterns and trends in causes of child and adolescent mortality 2000-2016: setting the scene for child health redesign

The under-5 mortality rate has declined from 93 deaths per 1000 live births in 1990 to 39 per 1000 live births in 2018. This improvement in child survival warrants an examination of age-specific trends and causes of death over time and across regions and an extension of the survival focus to older children and adolescents. We examine patterns and trends in mortality for neonates, postneonatal infants, young children, older children, young adolescents and older adolescents from 2000 to 2016. Levels and trends in causes of death for children and adolescents under 20 years of age are based on United Nations Inter-agency Group for Child Mortality Estimation for all-cause mortality, the Maternal and Child Epidemiology Estimation group for cause of death among children under-5 and WHO Global Health Estimates for 5–19 year-olds. From 2000 to 2016, the proportion of deaths in young children aged 1–4 years declined in most regions while neonatal deaths became over 25% of all deaths under 20 years in all regions and over 50% of all under-5 deaths in all regions except for sub-Saharan Africa which remains the region with the highest under-5 mortality in the world. Although these estimates have great variability at the country level, the overall regional patterns show that mortality in children under the age of 5 is increasingly concentrated in the neonatal period and in some regions, in older adolescents. The leading causes of disease for children under-5 remain preterm birth and infectious diseases, pneumonia, diarrhoea and malaria. For older children and adolescents, injuries become important causes of death as do interpersonal violence and self-harm. Causes of death vary by region.

The injury mechanisms and injury pyramids among children and adolescents in Zhuhai City, China

BACKGROUND

The unclear mechanisms and severity of injuries in the injury pyramids for Chinese children and adolescents prevent the prioritization of interventions. This study aimed to describe the injury mechanisms and injury pyramids in this population to provide a priority for injury prevention strategies.

METHODS

Death, hospitalization, and outpatient/emergency department visit data from patients aged 0 ~ 17 years with injuries were obtained from January 1, 2013, to December 31, 2017, in Zhuhai City, China. The injury mechanism ratios were calculated, and the injury pyramid ratios were drawn in proportion using injury mortality and the incidence of both injury hospitalizations and outpatient/emergency department injury visits.

RESULTS

The top three mechanisms for injuries in children and adolescents treated in outpatient/emergency departments were falls (52.02%), animal bites (14.57%), and blunt injuries (10.60%). The top three mechanisms for injury hospitalizations were falls (37.33%), road traffic injuries (17.87%), and fire/burns (14.29%), while the top three mechanisms for injury deaths were drowning (32.91%), road traffic injuries (20.25%) and falls (13.92%). The incidence rate of outpatient/emergency department injury visits for children and adolescents was 11,210.87/100,000; the incidence rate of injury hospitalization was 627.09/100,000, and the injury death rate was 10.70/100,000. For each injury death, there were 59 injury hospitalizations and 1048 outpatient/emergency injury visits.

CONCLUSIONS

The injury mechanisms were different for injury-related outpatient/emergency department visits, hospitalizations, and deaths among children and adolescents. The injury mechanisms by sex at different stages of child development, and interventions should be formulated based on this finding. The ratios of the injury pyramids varied by age, sex, region, and injury mechanisms; minor nonfatal injuries were more common in children and adolescents. The differences in the severity and extent of the injuries suggested that injury interventions in children and adolescents still have a long way to go.

Psychosocial Factors Predicting Resilience in Family Caregivers of Children with Cancer: A Cross-Sectional Study

Chronic diseases in childhood can affect the physical and mental health of patients and their families. The objective of this study was to identify the sociodemographic and psychosocial factors that predict resilience in family caregivers of children with cancer and to define whether there are differences in the levels of resilience derived from these sociodemographic variables. Three hundred and thirty family caregivers of children with cancer, with an average age of 32.6 years were interviewed. The caregivers responded to a battery of tests that included a questionnaire of sociodemographic variables, the Measuring Scale of Resilience, the Beck Depression Inventory, the Inventory of Quality of Life, the Beck Anxiety Inventory, an interview of caregiver burden and the World Health Organization Well-Being Index. The main findings indicate that family caregivers of children with cancer reported high levels of resilience, which were associated positively with quality of life, psychological well-being and years of study and associated negatively with depression, anxiety and caregiver burden. The variables that predicted resilience in families of children with cancer were quality of life, psychological well-being, depression and number of children. Family caregivers who were married and Catholic showed higher resilience scores. We conclude that being a caregiver in a family with children with cancer is associated with symptoms of anxiety and with depressive episodes. These issues can be overcome through family strength, well-being, quality of life and positive adaptation processes and mobilization of family resources.

Trends and seasonality in cause-specific mortality among children under 15 years in Guangzhou, China, 2008-2018

BACKGROUND

This study analyzed the trends and seasonality in mortality among children aged 0-14 years in Guangzhou, China during 2008-2018. Understanding the epidemiology of this public health problem can guide policy development for children mortality prevention.

METHODS

A population-based epidemiological retrospective study was conducted. Seven thousand two hundred sixty-five individual data of children mortality were obtained from the Guangzhou Center for Disease Control and Prevention (CDC). The Poisson regression was used to quantify the annual average reduction rate and the difference in mortality rate between sex and age groups. Incidence ratio with 95% confidence interval (CI) was estimated to determine the temperaol variations in mortality by month, season, school term, day of the week and between holidays and other days.

RESULTS

Between 2008 and 2018, the children mortality rate in Guangzhou decreased from 54.0 to 34.3 per 100,000 children, with an annual reduction rate of 4.6% (95% CI: 1.1%-8.1%), especially the under-5 mortality rate decreased by 8.3% (95% CI: 4.8%-11.6%) per year. Decline trends varied by causes of death, even with an upward trend for the mortality of asphyxia and neurological diseases. The risk of death among males children was 1.33 times (95% CI: 1.20-1.47) of that of females. The distribution of causes of death differed by age group. Maternal and perinatal, congenital and pneumonia were the top three causes of death in infants and cancer accounted for 17% of deaths in children aged 1-14 years. Moreover, the injury-related mortality showed significant temporal variations with higher risk during the weekend. And there was a summer peak for drowning and a winter peak for asphyxia.

CONCLUSIONS

Guangzhou has made considerable progress in reducing mortality over the last decade. The findings of characteristics of children mortality would provide important information for the development and implementation of integrated interventions targeted specific age groups and causes of death.

Mortality and Causes of Death in Primary and Secondary School Students - China, 2018

WHAT IS ALREADY KNOWN ABOUT THIS TOPIC?

There were approximately 1.23 million deaths reported among individuals aged 5-19 years worldwide in 2017. Limited attention has been paid to current mortality among primary and secondary school students aged 6-18 years in China.

WHAT IS ADDED BY THIS REPORT?

In 2018, an estimated 28,519 deaths occurred among primary and secondary school students aged 6-18 years in China with an age-standardized mortality rate (ASMR) of 17.66 per 100,000. Substantial disparities existed among sexes, age groups, areas, and regions for different causes of death. Drowning, road traffic injuries, and leukemia were three leading causes of death.

WHAT ARE THE IMPLICATIONS FOR PUBLIC HEALTH PRACTICE?

Government support, legislation enforcement, multisectoral cooperation, and stakeholder engagement should be initiated to reduce premature deaths among primary and secondary school students in China, especially those due to injuries.

Brought in dead cases to a tertiary referral paediatric emergency department in India: a prospective qualitative study

OBJECTIVES

Brought in dead (BID) presentation is profoundly related to prehospital variables including disease-related determinants and social and system-related factors. Identifying these factors would help us recognise various gaps in health services.

SETTING

Tertiary paediatric emergency department (ED) in north India.

PATIENTS

Children aged 12 years or younger presented in cardiac arrest between April 2016 and March 2017 were prospectively enrolled irrespective of outcome of cardiopulmonary resuscitation (CPR). Data were collected from multiple sources including referral documents, direct interview from parents and field observations at the referring facility.

RESULTS

Of 100 BID cases enrolled, 55 were neonates. Low birth weight (n=43, 78%) and malnutrition (n=31, 69%) were respectively common in neonates and postneonatal children. The most frequent symptom was breathing difficulty (n=80). Common diagnoses included respiratory distress syndrome (n=21, 38%), birth asphyxia (n=19, 35%) and sepsis (n=11, 20%) in neonates, and pneumonia (n=11, 25%), congenital heart disease (n=6, 13%) and acute gastroenteritis (n=5, 11%) in postneonatal children. Eighty-nine cases were referred from another healthcare facility, majority after first healthcare contact (n=77, 87%). Progressive severity of illness (n=61, 71%) and lack of expertise for acute care (n=35, 39%) were the common reasons for referral. Ambulance (n=77) was the most common mode of transport; median (IQR) distance and duration of travel were 80 (25-111.5) km and 120 (60-180) min, respectively. Respiratory support during transport included supplemental nasal oxygen (n=41, 46%) and bag and tube ventilation (n=30, 34%). Clinical deterioration was recognised in 62 children during transport, only five received CPR en route. Ninety-five children underwent CPR at the referral centre, two had return of spontaneous circulation.

CONCLUSION

Social and system-related factors contribute to children presenting to ED in BID state. Streamlining the referral process and linking transport to hospital care could reduce decompensated referrals and thereby decrease child mortality.

Cost and cost-effectiveness of childhood cancer treatment in low-income and middle-income countries: a systematic review

INTRODUCTION

A major barrier to improving childhood cancer survival is the perception that paediatric oncology services are too costly for low-income and middle-income country (LMIC) health systems. We conducted a systematic review to synthesise existing evidence on the costs and cost-effectiveness of treating childhood cancers in LMICs.

METHODS

We searched multiple databases from their inception to March 2019. All studies reporting costs or cost-effectiveness of treating any childhood cancer in an LMIC were included. We appraised included articles using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist. Where possible, we extracted or calculated the cost per disability-adjusted life year (DALY) averted using reported survival and country-specific life expectancy. Cost/DALY averted was compared with per capita gross domestic product (GDP) as per WHO-Choosing Interventions that are Cost-Effective guidelines to determine cost-effectiveness.

RESULTS

Of 2802 studies identified, 30 met inclusion criteria. Studies represented 22 countries and nine different malignancies. The most commonly studied cancers were acute lymphoblastic leukaemia (n=10), Burkitt lymphoma (n=4) and Wilms tumour (n=3). The median CHEERS checklist score was 18 of 24. Many studies omitted key cost inputs. Notably, only 11 studies included healthcare worker salaries. Cost/DALY averted was extracted or calculated for 12 studies and ranged from US$22 to US$4475, although the lower-end costs were primarily from studies that omitted key cost components. In all 12, cost/DALY averted through treatment was substantially less than country per capita GDP, and therefore considered very cost-effective.

CONCLUSION

Many included studies did not account for key cost inputs, thus underestimating true treatment costs. Costs/DALY averted were nonetheless substantially lower than per capita GDP, suggesting that even if all relevant inputs are included, LMIC childhood cancer treatment is consistently very cost-effective. While additional rigorous economic evaluations are required, our results can inform the development of LMIC national childhood cancer strategies.

The Human Cost of Anthropogenic Global Warming: Semi-Quantitative Prediction and the 1,000-Tonne Rule

Greenhouse-gas emissions are indirectly causing future deaths by multiple mechanisms. For example, reduced food and water supplies will exacerbate hunger, disease, violence, and migration. How will anthropogenic global warming (AGW) affect global mortality due to poverty around and beyond 2100? Roughly, how much burned fossil carbon corresponds to one future death? What are the psychological, medical, political, and economic implications? Predicted death tolls are crucial for policy formulation, but uncertainty increases with temporal distance from the present and estimates may be biased. Order-of-magnitude estimates should refer to literature from diverse relevant disciplines. The carbon budget for 2°C AGW (roughly 10¹² tonnes carbon) will indirectly cause roughly 10⁹ future premature deaths (10% of projected maximum global population), spread over one to two centuries. This zeroth-order prediction is relative and in addition to existing preventable death rates. It lies between likely best- and worst-case scenarios of roughly 3 × 10⁸ and 3 × 10⁹, corresponding to plus/minus one standard deviation on a logarithmic scale in a Gaussian probability distribution. It implies that one future premature death is caused every time roughly 1,000 (300–3,000) tonnes of carbon are burned. Therefore, any fossil-fuel project that burns millions of tons of carbon is probably indirectly killing thousands of future people. The prediction may be considered valid, accounting for multiple indirect links between AGW and death rates in a top-down approach, but unreliable due to the uncertainty of climate change feedback and interactions between physical, biological, social, and political climate impacts (e.g., ecological cascade effects and co-extinction). Given universal agreement on the value of human lives, a death toll of this unprecedented magnitude must be avoided at all costs. As a clear political message, the “1,000-tonne rule” can be used to defend human rights, especially in developing countries, and to clarify that climate change is primarily a human rights issue.

Seasonal variation and etiologic inferences of childhood pneumonia and diarrhea mortality in India

Control of pneumonia and diarrhea mortality in India requires understanding of their etiologies. We combined time series analysis of seasonality, climate region, and clinical syndromes from 243,000 verbal autopsies in the nationally representative Million Death Study. Pneumonia mortality at 1 month-14 years was greatest in January (Rate ratio (RR) 1.66, 99% CI 1.51-1.82; versus the April minimum). Higher RRs at 1-11 months suggested respiratory syncytial virus (RSV) etiology. India's humid subtropical region experienced a unique summer pneumonia mortality. Diarrhea mortality peaked in July (RR 1.66, 1.48-1.85) and January (RR 1.37, 1.23-1.48), while deaths with fever and bloody diarrhea (indicating enteroinvasive bacterial etiology) showed little seasonality. Combining mortality at ages 1-59 months with prevalence surveys, we estimate 40,600 pneumonia deaths from Streptococcus pneumoniae, 20,700 from RSV, 12,600 from influenza, and 7200 from Haemophilus influenzae type b and 24,700 diarrheal deaths from rotavirus occurred in 2015. Careful mortality studies can elucidate etiologies and inform vaccine introduction.

Air Pollution and Suicide in Mexico City: A Time Series Analysis, 2000-2016

The association between air pollution and suicide has recently been under examination, and the findings continue to be contradictory. In order to contribute evidence to this still unresolved question, the objective of the present study was to evaluate the association between air quality and daily suicides registered in Mexico City (MC) between 2000 and 2016. Air quality was measured based on exposure to particulate matter under 2.5 and 10 micrometers (µm) (PM_2.5 and PM₁₀, respectively), ozone (O₃), nitrogen dioxide (NO₂), and sulfur dioxide (SO₂), adjusting for weather variables (air temperature and relative humidity), and holidays. To this end, an ecologic time series analysis was performed using a Poisson regression model conditioned by time and stratified by gender and age groups. Models were also generated to explore the lagged and accumulative effects of air pollutants, adjusted by weather variables. The effects of the pollutants were very close to the null value in the majority of the models, and no accumulative effects were identified. We believe these results, in this case, no evidence of a statistical association, contribute to the current debate about whether the association between air pollution and suicide reported in the scientific literature reflects an actual effect or an uncontrolled confounding effect.