Causes of Death Among Infants and Children in the Child Health and Mortality Prevention Surveillance (CHAMPS) Network

Abstract

Importance: The number of deaths of children younger than 5 years has been steadily decreasing worldwide, from more than 17 million annual deaths in the 1970s to an estimated 5.3 million in 2019 (with 2.8 million deaths occurring in those aged 1-59 months [53% of all deaths in children aged <5 years]). More detailed characterization of childhood deaths could inform interventions to improve child survival.

Objective: To describe causes of postneonatal child deaths across 7 mortality surveillance sentinel sites in Africa and Asia.

Design, setting, and participants: The Child Health and Mortality Prevention Surveillance (CHAMPS) Network conducts childhood mortality surveillance in sub-Saharan Africa and South Asia using innovative postmortem minimally invasive tissue sampling (MITS). In this cross-sectional study, MITS was conducted in deceased children aged 1 to 59 months at 7 sites in sub-Saharan Africa and South Asia from December 3, 2016, to December 3, 2020. Data analysis was conducted between October and November 2021.

Main outcomes and measures: The expert panel attributed underlying, intermediate, and immediate conditions in the chain of events leading to death, based on histopathologic analysis, microbiological diagnostics, clinical data, and verbal autopsies.

Results: In this study, MITS was performed in 632 deceased children (mean [SD] age at death, 1.3 [0.3] years; 342 [54.1%] male). The 6 most common underlying causes of death were malnutrition (104 [16.5%]), HIV (75 [11.9%]), malaria (71 [11.2%]), congenital birth defects (64 [10.1%]), lower respiratory tract infections (LRTIs; 53 [8.4%]), and diarrheal diseases (46 [7.2%]). When considering immediate causes only, sepsis (191 [36.7%]) and LRTI (129 [24.8%]) were the 2 dominant causes. An infection was present in the causal chain in 549 of 632 deaths (86.9%); pathogens most frequently contributing to infectious deaths included Klebsiella pneumoniae (155 of 549 infectious deaths [28.2%]; 127 [81.9%] considered nosocomial), Plasmodium falciparum (122 of 549 [22.2%]), and Streptococcus pneumoniae (109 of 549 [19.9%]). Other organisms, such as cytomegalovirus (57 [10.4%]) and Acinetobacter baumannii (39 [7.1%]; 35 of 39 [89.7%] considered nosocomial), also played important roles. For the top underlying causes of death, the median number of conditions in the chain of events leading to death was 3 for malnutrition, 3 for HIV, 1 for malaria, 3 for congenital birth defects, and 1 for LRTI. Expert panels considered 494 of 632 deaths (78.2%) preventable and 26 of 632 deaths (4.1%) preventable under certain conditions.

Conclusions and relevance: In this cross-sectional study investigating causes of child mortality in the CHAMPS Network, results indicate that, in these high-mortality settings, infectious diseases continue to cause most deaths in infants and children, often in conjunction with malnutrition. These results also highlight opportunities for action to prevent deaths and reveal common interaction of various causes in the path toward death.

Figure 1.. Sankey Diagram Illustrating the Pathways Linking the Different Steps (Underlying Causes, Pooled Morbid or Intermediate Conditions, and Immediate Causes) of the Causal Pathway Leading to Death

For the major causes, a more detailed breakdown of their characteristics is shown. Note that only cases with 2 or more events are shown in the Sankey diagram (ie, to avoid confusion); cases with only 1 event (ie, the underlying cause is the immediate cause) are not depicted. Data supporting this figure are available in eTable 5 in Supplement 1. As an example, in the left column (underlying causes), the different diagnoses related to malnutrition (E4* International Statistical Classification of Diseases and Related Health Problems, Tenth Revision [ICD-10] codes, pale yellow color) represent the largest proportion of underlying causes, linking to a myriad of morbid causes, but in particular with lower respiratory infections and sepsis (as morbid or immediate cause of death).

Figure 2.. Frequency of Occurrence of the Most Common 20 Diagnoses According to the Position in the Chain of Events

Data are shown for total (any location in causal chain), underlying, intermediate or comorbid (pooled), and immediate causes of death. Note that x-axis scales differ between the panels. Also note that all deaths are assigned an underlying cause; some may also have 1 immediate cause and from none to multiple intermediate causes (Figure 1).

Figure 3.. Relative Contribution of Different Pathogens to the Most Common Syndromes or Conditions

Common syndromes or conditions are identified as underlying causes (270 disease-pathogen pairs; A) and immediate causes (479 disease-pathogen pairs; B). The size of the bubble is proportional to the number of cases detected (see eTable 7 in Supplement 1 for details). Note that, according to coding practice, deaths with only 1 cause identified have that cause listed as the underlying cause and no immediate cause of death assigned.