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Child survival II
Gareth Jones, Richard W Steketee, Robert E Black, Zulfiqar A Bhutta, Saul S Morris, and the Bellagio Child Survival Study
Group*
This is the second of five papers in the child survival series. The first focused on continuing high rates of child
mortality (over 10 million each year) from preventable causes: diarrhoea, pneumonia, measles, malaria, HIV/AIDS, the
underlying cause of undernutrition, and a small group of causes leading to neonatal deaths. We review child survival
interventions feasible for delivery at high coverage in low-income settings, and classify these as level 1 (sufficient
evidence of effect), level 2 (limited evidence), or level 3 (inadequate evidence). Our results show that at least one
level-1 intervention is available for preventing or treating each main cause of death among children younger than
5 years, apart from birth asphyxia, for which a level-2 intervention is available. There is also limited evidence for
several other interventions. However, global coverage for most interventions is below 50%. If level 1 or 2 interventions
were universally available, 63% of child deaths could be prevented. These findings show that the interventions needed
to achieve the millennium development goal of reducing child mortality by two-thirds by 2015 are available, but that
they are not being delivered to the mothers and children who need them.
The first paper in this series on child survival presented an Our aim, then, is to assess the potential effect of
unacceptable picture: more than 10 million children dying translating current knowledge about child survival
every year, almost all in low-income countries or poor interventions into effective action. These questions take
areas of middle-income countries.1 90% of these deaths on added urgency in view of the millennium development
occurred in just 42 countries,2 most from one of a short goals, which were set in 2001 and adopted by the member
list of causes: diarrhoea, pneumonia, measles, malaria, states of the UN.4 One of these eight goals is to reduce
HIV/AIDS, and the underlying cause of undernutrition child mortality by two-thirds between 1990 and 2015.4
for deaths among children younger than 5 years, and We have just passed the halfway mark in this period, and
asphyxia, preterm delivery, sepsis, and tetanus for deaths unless there is substantial change, very soon, the target
among neonates.1 The assessment of deaths by cause will be out of reach.
provides a useful starting point for a stocktaking of
available child survival interventions. Identifying effective child survival
In this paper we review the state of the evidence for interventions
interventions to reduce child mortality for each of the Child mortality is the result of a complex web of
major direct and underlying causes of death in children determinants at many levels.5 Although we recognise the
younger than 5 years (under-5 deaths). The term important role played by distal determinants such as
intervention is used here in a limited sense to refer to a poverty and characteristics of the physical environment,
biological agent or action intended to reduce morbidity or we focus here on interventions addressing the more
mortality. Approaches used to reach children and mothers proximal determinants of child mortality and those that
with the interventions they need are referred to as delivery can be delivered mainly through the health sector.
strategies. We draw on existing research reports and Interventions that addressed more distal determinants, or
systematic reviews to document the efficacy or that would normally be implemented by sectors other
effectiveness of each intervention in reducing mortality than health, were not considered (eg, maternal education,
among children younger than 5 years, to summarise reduction of crowding). Interventions include preventive
current coverage with these interventions, and to estimate approaches that may reduce the exposure to the infection
how many child deaths could be prevented if proven or condition6 or reduce the likelihood of exposure that
interventions were delivered to all the children and leads to disease, and both preventive and treatment
mothers who need them. Delivery strategies are addressed approaches to reduce the likelihood that the disease or
in the next paper in the series.3
se s
is
on l te y
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relationship, because, for example:
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at ta
there was conflicting evidence from
l
e hy
ea nia
on de
eu a
Bi IDS
Pr asp
M les
Pn hoe
M mo
several studies; low-income countries
HI ria
A
s
a
r
r th
V/
ar
et
al
were not adequately represented in the
Di
Preventive interventions
1 1 1 studies, or there were too few studies
*Breastfeeding8,38–40
Insecticide-treated 1 1 to generalise globally; there were
materials 26–28,32,33 unresolved questions about the
Complementary feeding9 1 1 1 1 adequacy of the design, conduct, or
Water, sanitation, hygiene 10 1 interpretation of the studies or the
Hib vaccine22 1 intervention reduced morbidity or risk,
Zinc11,12 1 1 2 but a clear link to mortality had not
Vitamin A13–15 1 2 2 been established.
Antenatal steroids36 1 Level 3—inadequate evidence of
Newborn temperature 2 effect: the available data could not be
management12,41,47,48 interpreted as showing either the
Tetanus toxoid42–44 1 presence or absence of an effect on
Nevirapine and 1 under-5 mortality because of major
replacement feeding30,31 qualitative or quantitative limitations.
Antibiotics for premature rupture 2 2
Information was obtained from
of membranes46 published research studies and system-
Clean delivery12,37 1 1
atic reviews. 21 interventions support-
Measles vaccine25 1
1
ed by level 1 or level 2 evidence are
Antimalarial intermittent preventive
shown in figure 1.8–48 Zinc and vitamin
treatment in pregnancy34,35
A are effective both as preventive and
Treatment Interventions
therapeutic interventions, leading to a
Oral rehydration therapy16,17 1 total of 23 measures. The results of the
Antibiotics for pneumonia 23,24 1 review show that at least one level-1
Antimalarials29 1 intervention feasible for implement-
Antibiotics for sepsis 41 1 ation at high coverage in low-income
Newborn resuscitation41,45 2 countries is available to prevent or
Antibiotics for dysentery18,19 1 treat each of the main causes of under-
Zinc20,21 1 5 deaths, apart from birth asphyxia, for
Vitamin A13,14 1 which a level-2 intervention is
available.
1 Level 1 (sufficient) evidence Hib=Haemophilus influenzae type b Limited evidence of effect was
available for three interventions
2 Level 2 (limited) evidence * Exclusive breastfeeding in the first
addressing causes of death in the
6 months of life and continued
breastfeeding from 6 to 11 months neonatal period—newborn tempera-
ture management, antibiotics for
Figure 1: Child survival interventions with sufficient or limited evidence of effect on premature rupture of the membranes,
reducing mortality from the major causes of under-5 deaths and newborn resuscitation—showing
that neonatal deaths have only
condition will lead to death. We focus specifically on recently been identified as a global priority and that there
interventions that address deaths by cause for the is urgent need for further research in this area. There is
42 countries with 90% of worldwide under-5 deaths in sufficient or limited evidence that five of the studied
2000.2 interventions may be effective against more than one of
Feasibility for delivery at high levels of population the major causes of death. Further focused research
coverage is a central criterion for any intervention efforts can expand the list of interventions with sufficient
intended to reduce child mortality. What is feasible, evidence of effect to include those with limited evidence
however, varies widely even among low-income countries. of effect at present.
We have therefore focused on an essential set of Level-3 interventions, for which current levels of
interventions judged to be feasible for high levels of evidence were judged to be inadequate, include those that
implementation in low-income countries, assuming that hold promise of substantial effects on child mortality but
additional interventions can be added and further lives have not yet been fully assessed. Several of these
saved in countries with greater levels of resources and interventions are likely to be proven effective for wide
health-system capacity. scale, affordable use in the near future; these include
Each potential intervention was assigned to one of three rotavirus vaccine for diarrhoea prevention,49
50
levels based on the strength of the evidence for its effect pneumococcal vaccine and reduction of indoor air
on child mortality. Operational definitions for each level pollution for prevention of pneumonia;51 zinc for
were adapted from those used by the International treatment of pneumonia (Black RE, personal communi-
Association for Research on Cancer.7 cation); antimalarial intermittent preventive treatment in
Level 1—sufficient evidence of effect: the working infants;52 and advances in low-cost prevention and
group for this paper believed that a causal relationship had treatment of HIV in children.
been established between the intervention and reductions Additionally, several interventions were not considered
in cause-specific mortality among children younger than here because, although they are supported by various
5 years in developing countries. levels of evidence, they are not currently feasible for
Level 2—limited evidence of effect: the working group implementation at high coverage in low-income areas (eg,
believed that an effect was possible, but available data secondary care of newborns).
For personal use. Only reproduce with permission from The Lancet
CHILD SURVIVAL II
insecticide-treated materials (ITMs) we obtained data on The total proportion of deaths prevented, for any given
current national coverage levels and assumed that this cause, is independent of the sequencing of the
would increase to 99%. We then applied the efficacy of interventions. Although it may make intuitive sense to
ITMs to reduce malaria deaths, and calculated how many apply prevention interventions before therapeutic
of these deaths would be prevented in each country. For interventions, the summary estimate of effect from our
interventions that only apply to a subset of the population, model is independent of this sequence.
estimates of effect were restricted to these subsets. For Table 3 shows estimates of annual preventable deaths
example, vitamin A was assumed to have an effect only on by cause among the 9·7 million child deaths in the
children aged 6–59 months who were deficient in this 42 countries considered. About 5·5 million deaths (57%)
vitamin. Full details of methods and assumptions used in could be prevented by achieving universal coverage with
this exercise are available at http://www.childinfo.org/ interventions for which there is sufficient evidence
bellagio.htm.53 (level 1), and 63% if both the sufficient and limited
interventions (levels 1 and 2) were universally
Achievement of universal coverage with individual implemented.
interventions
Table 2 presents the numbers and proportions of child Universal coverage in countries with specific
deaths that could be prevented through application of each epidemiological profiles
intervention alone under two sets of conditions: The first paper in the series defined five different country
(1) applying only those interventions for which there is profiles on the basis of proportional distribution of causes
sufficient evidence of effect (level 1); and (2) also applying of child deaths.1 All these countries have substantial child
interventions for which there is limited evidence of effect mortality due to neonatal causes, diarrhoea, and
(levels 1 and 2). Two interventions—oral rehydration pneumonia. Countries were categorised as: profile 1
therapy and breastfeeding—were each estimated to prevent (accounting for 46% of child deaths)—low (less than
over 10% of deaths. Six further interventions could each 10%) AIDS and malaria and low (less than 40%)
prevent at least 5% of child deaths. These include ITMs, neonatal; profile 2 (27%)—low AIDS and high malaria;
improvement of complementary feeding, antibiotics for profile 3 (16%)—high neonatal; profile 4 (8%)—high
neonatal sepsis, antibiotics for pneumonia, antimalarial AIDS and malaria; and profile 5 (3%)—high AIDS and
treatment, and preventive zinc supplementation. low malaria. Figure 2 shows the proportion of under-5
Promotion of breastfeeding in countries with a high deaths that could be prevented within each of these
prevalence of HIV among women of reproductive age may profiles if the interventions we considered (with either
increase mother-to-child transmission of this virus. This sufficient or limited levels of evidence) were delivered at
drawback was taken into account in the modelling universal coverage levels. The estimate of preventable
exercise; otherwise, breastfeeding would have been deaths ranges from a 54% reduction in child deaths for
estimated to prevent 15% instead of 13% of child deaths. countries with profile 3 to a 73% reduction in profile-2
countries. The results show that remarkable progress
Universal coverage with multiple interventions could be made in all countries, regardless of their
We then estimated the number of child deaths, by cause, epidemiological profile, by use of the interventions that
that could be prevented if the full set of interventions for are available today and feasible for implementation in low-
each cause were delivered at universal coverage levels. To income countries.
avoid the unrealistic scenario of preventing the same death
through more than one intervention, the effect of each Universal coverage with specific groups of interventions
additional intervention was applied only to deaths not Thus far we have investigated the potential effects of
already prevented by the previously applied interventions. single interventions, of interventions directed at reducing
Therefore, the overall effect of applying multiple mortality from specific causes, and at the levels of effect
interventions does not equal the sum of individual that could be achieved in countries with specific
intervention effects presented in table 2, which exceeds epidemiological profiles. In the real world, however,
100%. interventions are often brought together based on the
For personal use. Only reproduce with permission from The Lancet
CHILD SURVIVAL II
in the hands of ministries of health and their partners in Conflict of interest statement
low-income and middle-income countries, through None declared.
expanded sensitivity analyses, and further technical
discussion and refinement of the assumptions. Issues Acknowledgments
Betty Kirkwood (London School of Hygiene and Tropical Medicine,
related to delivery, feasibility, cost, and sustainability of London, UK) provided important public health input, participated in the
interventions must be addressed, and much of this work conceptualisation of the approach, and reviewed the draft manuscript. Neff
is already under way.60,61 Walker (UNAIDS, Geneva, Switzerland) provided technical inputs related
Our estimates can only be as valid as the data on which to estimates of HIV prevalence and the effectiveness of various HIV/AIDS
interventions, and together with John Stover (The Futures Group,
they are based. Although great progress has been made Washington, DC, USA) contributed to the early conceptualisation of the
during the past decade in the measurement of coverage approach used to estimate deaths prevented and reviewed drafts of the
levels for child survival interventions through population- manuscript. Joy Lawn (Institute of Child Health, London, UK) contributed
based surveys,62,63 information about the relative efficacy technical assistance related to deaths in the neonatal period and the efficacy
of interventions to reduce these deaths. Simon Cousens (London School of
of such interventions has grown more slowly, and some of Hygiene and Tropical Medicine, London, UK) extensively revised the
the assumptions we have used are based on findings from calculations used in the statistical model.
only a few studies. Nevertheless, our overall mortality No specific funding was received by any author or institution for this
reduction estimate, based on the combination of several work. The Bill and Melinda Gates Foundation kindly permitted us to draw
on resources directed to the multi-country evaluation of IMCI effectiveness,
interventions, was very robust. Whenever we changed cost, and impact to support three working meetings. Two of these meetings
model parameters so that an intervention was saving were hosted by the Public Health Interventions and Research Unit of the
fewer lives, other interventions increased the number of London School of Hygiene and Tropical Medicine, and the third by the
deaths they prevented, leading to a fairly stable estimate Johns Hopkins Bloomberg School of Public Health. These groups had no
role in designing the analysis, interpreting the results, or writing the
of overall effect. manuscript.
Additionally, some interventions were not included in The views represented in this article are those of the individual authors
this exercise because sufficient evidence of their efficacy and do not represent the views of their institutions.
is not yet available, and in due time their inclusion may
contribute to saving an even larger proportion of lives. References
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