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International Health

Definitive Global Childhood Causes of Death Estimates Released by CHERG
Not on Track to Meet Millennium Development Goal 4  

Global causes of child deaths in 2010

Causes of Death 2010

Global, regional, and national causes of child mortality: an updated systematic analysis for 2010 with time trends since 2000. Liu, et al. The Lancet (May 11, 2012).

The Child Health Epidemiology Reference Group (CHERG), headquartered at the Department of International Health, released its latest gold-standard estimates of childhood causes of death in The Lancet. CHERG, an independent, multinational research group of WHO and UNICEF, provides technical expertise on maternal, child, and neonatal morbidity and mortality. The 2010 estimates (the most recent data available), show infectious diseases still account for nearly two-thirds of deaths. And neonatal deaths now account for 40 percent of all deaths under the age of 5. The study’s innovative global trend analysis does reveal a marked decline in the annual number of child deaths between 2000 and 2010. First author Assistant Scientist Li Liu warns, however, that the rate of decline is far from fast enough to reach the UN Millennium Development Goal of reducing under-five mortality by two-thirds between 1990 and 2015. Chair Robert Black, the study’s senior author, adds, “These national, regional and global estimates provide policy makers with the best evidence for effectively allocating scarce resources to meet global benchmarks in 2015 and beyond.”


Methodological Innovation
One of CHERG’s mandates is to constantly innovate and improve methods to produce the most reliable and accurate information on maternal, child and neonatal health interventions. This study highlights their ongoing resolve to advance their field so that resources are directed where they are most needed. 

A multi-cause model
CHERG has worked tirelessly to develop comprehensive multi-cause models for this analysis.  They believe this is ideal for cause estimates that must add up to 100 percent. Other efforts have employed a single-cause model, which typically produce a numerator that is larger than the denominator. The estimates then must be adjusted down in order not to sum over 100 percent.   

As Dr. Liu explains, “Single cause studies tend to overestimate the number of deaths due to that cause. A prime example is single-cause malaria studies which can easily misclassify a death as malaria if a fever is involved, thereby creating overestimates for the burden of malaria.” CHERG does use single-cause models only for causes of small numbers of deaths such as AIDS, measles and tetanus because they are not ideally estimated in a multi-cause model.

Trend analysis
The CHERG’s most challenging innovation in 2012 was the trend analysis for the 2000-2010 period. In the past, annual estimates were not strictly comparable due to slightly different methods used and data available at the time of individual studies. In 2012, the CHERG group addressed this shortcoming. Now, we can confidently compare numbers and evaluate the rate of change over the last 11 years for which data are available.

Global trends in burden of childhood deaths in 2000–10

Global Trends Child Mortality

Liu, et. al. The Lancet (May 11, 2012)

7.6 million children under the age of 5 died in 2010.  “The number is just too high, despite the 2 million drop between 2000 and 2010,” declares Dr. Black. “Over 3 million newborns died in 2010. That’s only a decline of 600,000 in 10 years. To make faster progress we must focus our resources on the major causes of death,” he adds.  The top three causes were:

  1. pneumonia (18 percent of all deaths)
  2. preterm birth complications (14 percent)
  3. diarrhea (11 percent)

For the first time, a neonatal cause of death ranks as high on the overall list, with preterm birth complications at second. Of the major causes, diarrhea declined the most and moved from the second to third spot. 

Regional Causes of Childhood Deaths in 2010

Sub-Saharan Africa



South Asia

South Asia

Liu, et. al. The Lancet (May 11, 2012).

Vast Regional Differences

Sub-Saharan Africa
More children died in sub-Saharan Africa than any other region (3.6 million), and the rate of improvement was slower there than the global average. Infectious disease caused nearly three-quarters of all child deaths compared to 64 percent globally. Nearly all of the malaria and AIDS deaths occurred in the region (96 percent and 90 percent, respectively).

South Asia
1.1 million newborns died in South Asia. And over half of all newborn deaths occurred in South Asia in 2010. Preterm birth complications was a higher proportion of overall deaths there than in any other region at 19 percent.

2015 Millennium Development Goals
“Pneumonia, measles and diarrhea contributed the most reduction between 2000 and 2010, however, the reduction was not significant enough to achieve Millennium Development Goal number 4,” says Dr. Liu. The annual rate of childhood mortality needed to decline by 4.4 percent a year during the 2000-2010 period; the current rate was only 2.6 percent. “To reach MDG 4, we will have to focus on the most common causes of death, especially pneumonia and preterm birth complications,” she adds.

Five countries accounted for nearly half of all the deaths of children under 5: India, Nigeria, Democratic Republic of Congo, Pakistan, and China. Scaling up child survival initiatives in these countries will also be critical to meet MDG 4.

Applications of CHERG Data
In 2 years, CHERG’s previous causes of death analysis (Black et al., 2010) has been cited over 400 times in the peer-reviewed literature. These new results are already in similar demand and are being fed directly into WHO’s World Health Statistics Database. The updated statistics, which are used by policy makers, governments and programs across the globe, should be available this summer.

Born Too SoonBorn Too Soon: The Global Action Report on Preterm Birth
March of Dimes, Save the Children, WHO, and the Partnership for Maternal, Newborn & Child Health
The Born Too Soon report provides the first-ever national, regional and global estimates of preterm birth, based in part on CHERG’s work. It also makes evidence-based recommendations for reducing the burden of neonatal mortality. The Department’s Assistant Scientist Jennifer Requejo and Professor Joanne Katz (also a CHERG member) authored the chapter entitled, Care during pregnancy and childbirth. This chapter utilizes much of the CHERG’s analysis on what can be done during pregnancy to prevent preterm birth.
Dr. Joy Lawn of Save the Children and CHERG is one of the two report editors, and Dr. Requejo was a member of the report’s core writing group. According to Requejo, “Two-thirds of the premature babies who die each year could be saved if current cost-effective interventions such as breastfeeding support, thermal care, and basic care for infections and breathing difficulties were made available to all.”

Lives Saved Tool (LiST)
LiST is a popular computer-based tool that allows users to set up and run scenarios to determine the estimated impact of health intervention packages and coverage levels for their countries, states or districts. The CHERG’s estimates provide the foundation for LiST’s scenarios that are used by governments and donor organizations across the globe in their planning processes. (See LiST article, page6.)

Planning for the Future
In June, USAID and UNICEF will host a Child Survival Summit during which priorities and goals for after 2015 will be discussed. Summit organizers are using CHERG’s cause of death numbers in their planning and agenda setting. The Summit is expected to announce new target goals for the future, including an ambitious under-five mortality rate of below 20 per 1,000 live births for all countries by 2035.

The CHERG causes of death estimates are now widely considered the standard. But as with all estimates, there are limitations, including the fact that only 3 percent of deaths worldwide were medically certified. As Dr. Black sums up, “These estimates allow us to make the best decisions about where our resources should be directed and what they should address. But, we also need to make sure that we continue to gather high-quality data so that our estimates remain the most accurate they can be for policy makers and programs.”

--May 2012, Brandon Howard

Global, regional, and national causes of child mortality: an updated systematic analysis for 2010 with time trends since 2000, by Li Liu, Hope L Johnson, Simon Cousens, Jamie Perin, Susana Scott, Joy E Lawn, Igor Rudan, Prof Harry Campbell, Richard Cibulskis, Mengying Li, Colin Mathers, Prof Robert E Black, for the Child Health Epidemiology Reference Group of WHO and UNICEF.  The Lancet, Early Online Publication, 11 May 2012.  doi:10.1016/S0140-6736(12)60560-1