Deaths of older children: what do the data tell us?
Authors: Colin Mathers
Journal: The Lancet Global Health (2015)

In The Lancet Global Health, Kenneth Hill and colleagues1Hill K Zimmerman L Jamison DT Mortality risks in children aged 5–14 years in low-income and middle-income countries: a systematic empirical analysis.Lancet Glob Health. 2015; (published online Aug 6.)http://dx.doi.org/10.1016/S2214-109X(15)00044-3Google Scholar present the first empirical analysis of global mortality levels and numbers of deaths in children aged 5–14 years. Assessments of mortality in this age range have been neglected until recently, because this is when human mortality risks reach their minimum levels through the lifespan. However, interest in older children and adolescence has increased,2Patton GC Coffey C Sawyer SM et al.Global patterns of mortality in young people: a systematic analysis of population health data.Lancet. 2009; 374: 881-892Summary Full Text Full Text PDF PubMed Scopus (802) Google Scholar, 3Viner R Coffey C Mathers C et al.50-year mortality trends in children and young people: a study of 50 low-income, middle-income, and high-income countries.Lancet. 2011; 377: 1162-1174Summary Full Text Full Text PDF PubMed Scopus (183) Google Scholar because evidence exists that mortality rates in this age range have not declined as fast as for the under-5 age range.3Viner R Coffey C Mathers C et al.50-year mortality trends in children and young people: a study of 50 low-income, middle-income, and high-income countries.Lancet. 2011; 377: 1162-1174Summary Full Text Full Text PDF PubMed Scopus (183) Google Scholar Age 5–14 years represents an important period of social and educational development and the onset of puberty, and the older adolescent age group 15–19 years is also the period of transition to adult risk exposures (eg, driving, alcohol and drugs, reproductive risks, workplace risks, etc). Both WHO and UNICEF have published major reports about adolescent health and mortality.4WHOHealth for the World's adolescents. World Health Organization, Geneva2014http://www.who.int/maternal_child_adolescent/topics/adolescence/second-decade/en/Google Scholar, 5UNICEFProgress for children: a report card on adolescents (no 10). United Nations Children's Fund, New York2012Google Scholar, 6UNICEFHidden in plain sight: a statistical analysis of violence against children. United Nations Children's Fund, New York2014Google Scholar Existing global estimates rely heavily on model life-tables that are calibrated with mortality rates from children (<5 years) and adults (15–59 years) as inputs, so the Article by Hill and colleagues1Hill K Zimmerman L Jamison DT Mortality risks in children aged 5–14 years in low-income and middle-income countries: a systematic empirical analysis.Lancet Glob Health. 2015; (published online Aug 6.)http://dx.doi.org/10.1016/S2214-109X(15)00044-3Google Scholar that compares these global estimates (which underpin estimates of deaths and causes of deaths in older children from the UN and the Institute for Health Metrics and Evaluation [IHME]) with the empirical evidence from a very large amount of survey data plus census data for China, is of substantial interest. The investigators extend the analysis of birth-history data obtained in 194 Demographic and Health Surveys in 84 countries to estimate mortality risks for children in the age groups 5–9 and 10–14 years. Hill and colleagues' estimate that, globally, about 1·5 million (95% CI 1·2–1·8) children aged 5–14 years died in 2010. This finding is somewhat higher than the total estimated by the UN of 1·3 million,7UN Population DivisionWorld Population Prospects–the 2012 revision. United Nations, New York2013Google Scholar although the UN estimate is within the investigators' CI. However, their estimate is 87% higher than the total deaths estimated in the IHME Global Burden of Disease (GBD) study 20108Wang H Dwyer-Lindgren L Lofgren KT et al.Age-specific and sex-specific mortality in 187 countries, 1970–2010: a systematic analysis for the Global Burden of Disease Study 2010.Lancet. 2012; 380: 2071-2094Summary Full Text Full Text PDF PubMed Scopus (640) Google Scholar of 0·82 million for 2010. Hill and colleagues conclude that their analysis of the empirical evidence broadly provides support for the UN estimates, but is almost double that of the data underpinning GBD 2010. The GBD relational model life-table system, which is fitted to the probability of dying aged younger than 5 years and the probability of dying between ages 15 and 60 years, seems to underestimate older child deaths. GDB has published updated mortality estimates for the years up to 20139GBD 2013 Mortality and Causes of Death CollaboratorsGlobal, regional, and national age-sex specific all-cause and cause-specific mortality for 240 causes of death, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013.Lancet. 2014; 385: 117-171PubMed Google Scholar and continues to estimate substantially lower numbers of deaths in the age range 5–14 years than the UN. We have compared GBD's estimates for year 2013, with those from WHO life tables that are based mainly on UN life-table analyses for developing countries without adequate death registration systems (table).TableComparison of the number of global deaths estimated by the Global Burden of Disease and WHO (thousands) for 2013GBD 2013WHOGBD/WHO fraction0–4627062850·995–94718770·5410–143545460·6515–195977290·8220–249089570·9525–44513849931·0345–6411 77111 6191·0165–7914 82016 1040·9280+14 42313 9611·03All ages54 75356 1760·97Data are stratified by age group (years). GBD=Global Burden of Disease. Open table in a new tab Data are stratified by age group (years). GBD=Global Burden of Disease. As shown, the largest discrepancy between GBD and WHO estimates of number of deaths is between those for ages 5–14 years. The GBD 2013 estimates for older child deaths in this age range are similar to those of their earlier 2010 estimates, and are 600 000 deaths lower than those estimated by WHO for the same year.10WHOWorld Health Statistics 2015. World Health Organization, Geneva2015http://www.who.int/gho/publications/world_health_statistics/en/Google Scholar At their meeting in May, 2015, the technical advisory group of the UN Interagency Group on Mortality Estimates (UN-IGME) discussed possible approaches to the estimation of death rates for older children aged 5–14 and adolescents aged 15–19 years. The UN-IGME prepares annual updates of estimates and trends in mortality for neonates, infants, and children for more than 195 countries, based on data from full and summary birth histories in surveys and censuses, and from analyses of available data for death registrations. The group agreed to explore the extension of the birth-history analysis to the 5–14 year age group, and to investigate the feasibility of expanding the scope of UN-IGME to also address this age group. They also discussed data availability to assess mortality rates in the 15–19 years age group, but this assessment will involve use of data for sibling histories and deaths in households from surveys and censuses, for which a substantial amount of research is needed to identify their usefulness.11Masquelier B Adult mortality from sibling survival data: a reappraisal of selection biases.Demography. 2013 Feb; 50: 207-228Crossref PubMed Scopus (36) Google Scholar Hill and colleagues1Hill K Zimmerman L Jamison DT Mortality risks in children aged 5–14 years in low-income and middle-income countries: a systematic empirical analysis.Lancet Glob Health. 2015; (published online Aug 6.)http://dx.doi.org/10.1016/S2214-109X(15)00044-3Google Scholar are to be commended for their pioneering efforts in undertaking this systematic empirical analysis of the available evidence on levels of older child mortality in developing countries. We hope that their analysis leads to improved estimates for levels and trends of older child mortality in both UN and GBD mortality assessments. Additionally, we share their recommendations that global policy emphasis on reduction of mortality should be broadened to include older children and adolescents. I am a staff member of WHO. I am responsible for the views expressed in this Comment, which do not necessarily represent the decisions, policies, or views of WHO. I declare no competing interests. Mortality risks in children aged 5–14 years in low-income and middle-income countries: a systematic empirical analysisOur analysis suggests that mortality risks nowadays in the age range 5–14 years in low-income and middle-income countries are rather higher (relative to mortality in children younger than 5 years) than would be expected on the basis of historical evidence. Our findings broadly lend support for the UN WPP mortality estimates, but are almost double those underpinning GBD 2010. Global policy emphasis on reduction of mortality in children younger than 5 years should be broadened to include older children and adolescents. Full-Text PDF Open Access