Time trends. Nine (50%) of 18 studies that examined multiple years of data reported decreasing mortality trends during their study periods [23, 27, 29, 30, 35, 36, 37, 38, 47] . For example, a seven-year study in Shandong province found that the case fatality rate for pneumonia decreased from 1.94% to 0.50% from 1995 to 2001, mortality decreased from 421 to 119 deaths from pneumonia per 100,000 population, and mortality per 1000 live births decreased from 2.50 to 1.07 [26] . However, another nine studies did not show a clear declining trend [21, 33, 40, 41, 42, 43, 44, 45, 46] . For example, a separate study in Shandong province found that while the mortality rate was lowest in the most recent year of the 11-year study (0.14 deaths per 1000 live births in children ,5 years in 2006), there was no clear decrease in mortality over the previous decade [31] . No studies showed increasing mortality.