CHERG-WHO methods and data

sources for child causes of death

2000-2013

Department of Health Statistics and Information Systems (WHO, Geneva)

and WHO-UNICEF Child Health Epidemiology Reference Group (CHERG)
September 2014

Global Health Estimates Technical Paper WHO/HIS/HSI/GHE/2014.6.2

Acknowledgments
This Technical Paper is an update to Global Health Estimates Technical Paper WHO/HIS/HSI/
GHE/2014.6, which was written by Daniel Hogan, Li Liu and Colin Mathers with inputs and assistance
from Wahyu Retno Mahanani, Jessica Ho and Doris Ma Fat. This update (2014.6.2) involved extending
previous child cause of death estimates for 2000-2012 to year 2013, and including updated all-cause
mortality estimates from UN-IGME. Country estimates of child deaths by cause for years 2000-2013
were primarily prepared by Li Liu, Shefali Oza, Bob Black, Simon Cousens, Joy Lawn and Jamie Perin, of
the Child Health Epidemiology Reference Group (CHERG), and Dan Hogan, Doris Ma Fat and Colin
Mathers (from the Mortality and Burden of Disease Unit in the WHO Department of Health Statistics
and Information Systems), with advice and inputs from other members of CHERG, WHO Departments,
collaborating UN Agencies, and other WHO expert advisory groups and academic collaborators.
The Child Health Epidemiology Reference Group has been supported by a grant from the Bill & Melinda
Gates Foundation to the US Fund for UNICEF for CHERG.
These estimates make considerable use of the all-cause mortality estimates developed by the
Interagency Group on Child Mortality Estimation (UN-IGME), and births estimates from the UN
Population Division, as well as inputs for certain vaccine-preventable diseases developed under the
oversight of the WHO Quantitative Immunization and Vaccines Related Research (QUIVER) Advisory
Group. While it is not possible to name all those who provided advice, assistance or data, both inside
and outside WHO, we would particularly like to note the assistance and inputs provided by Leontine
Alkema, Ties Boerma, Cynthia Boschi-Pinto, Tony Burton, Richard Cibulskis, Marta Gacic-Dodo, Peter
Ghys, Mie Inoue, Robert Jakob, Prabhat Jha, Hope Johnson, Mary Mahy, Igor Rudan, Peter Strebel, Tessa
Wardlaw, and Danzhen You.
Estimates and analysis are available at:
http://www.who.int/gho/mortality_burden_disease/en/index.html
For further information about the estimates and methods, please contact: healthstat@who.int.
In this series
1. WHO methods and data sources for life tables 1990-2011 (Global Health Estimates Technical Paper
WHO/HIS/HSI/GHE/2013.1)
2. CHERG-WHO methods and data sources for child causes of death 2000-2011 (Global Health Estimates
Technical Paper WHO/HIS/HSI/GHE/2013.2)
3. WHO methods and data sources for global causes of death 2000-2011 (Global Health Estimates
Technical Paper WHO/HIS/HSI/GHE/2013.3)
4. WHO methods and data sources for global burden of disease estimates 2000-2011 (Global Health
Estimates Technical Paper WHO/HIS/HSI/GHE/2013.4)
5. WHO methods for life expectancy and healthy life expectancy (Global Health Estimates Technical
Paper WHO/HIS/HSI/GHE/2014.5)
6. CHERG-WHO methods and data sources for child causes of death 2000-2012 (Global Health Estimates
Technical Paper WHO/HIS/HSI/GHE/2014.6)
7. WHO methods and data sources for country-level causes of death 2000-2012 (Global Health Estimates
Technical Paper WHO/HIS/HSI/GHE/2014.7)
i

Table of Contents
Acknowledgments.......................................................................................................................................... i
Table of Contents .......................................................................................................................................... ii
1 Introduction... .......................................................................................................................................... 1
2 All-cause mortality and population estimates for years 2000-2013 ....................................................... 2
2.1 Estimation of neonatal and under-5 mortality rates ....................................................................... 2
2.2 Population size and births estimates ............................................................................................... 2
2.3 Mortality shocks epidemics, conflicts and disasters ..................................................................... 2
3 Child mortality by cause .......................................................................................................................... 2
3.1 Death registration data .................................................................................................................... 3
3.2 Modeling causes of neonatal death (ages 0-27 days) ..................................................................... 4
3.3 Modeling causes of postneonatal deaths (ages 1-59 months) ........................................................ 5
3.5 Causes of child death for China and India ....................................................................................... 6
4 Methods for cause-specific revisions and updates.................................................................................. 7
4.1 HIV/AIDS........................................................................................................................................... 7
4.2 Malaria ............................................................................................................................................. 7
4.3 Whooping cough .............................................................................................................................. 8
4.4 Measles ............................................................................................................................................ 8
4.5 Conflict and natural disasters .......................................................................................................... 9
5 Uncertainty of estimates ......................................................................................................................... 9
References .................................................................................................................................. 10
Annex Table A. Methods used for estimation of child causes of death, by country, 2000-2013 .............. 12
Annex Table B. First-level categories for analysis of child causes of death............................................... 17

ii

Introduction

This document, Global Health Estimates Technical Paper WHO/HIS/HSI/GHE/2014.6.2, is a minor update
to the original document Global Health Estimates Technical Paper WHO/HIS/HSI/GHE/2014.6, which
described estimation methodology for child causes of death for 2000-2012. This updated version
(2014.6.2) is edited to reflect an update to those estimates in which child causes of death are estimated
for years 2000-2013 and include the latest available all-cause mortality estimates from the United
Nations Inter-agency Group for Child Mortality Estimation (UN-IGME), which were released in September
2014 (1). The underlying methodological approaches are unchanged from those used to derive child COD
estimates for years 2000-2012, which were published in May 2014.
Cause-specific estimates of deaths for children under age 5 were estimated for 15 cause categories for
years 2000-2013 using methods similar to those described elsewhere by Liu et al. (2) and on the WHO
website (3). These estimates were prepared by the WHO Department of Health Statistics and
Information Systems and the Child Health Epidemiology Reference Group (CHERG), with inputs and
assistance from other WHO Departments and UN Agencies. These child cause of death estimates for
years 2000-2013 supersede previously published estimates for child causes of death for years 20002012. The estimation framework for the 2000-2012 (and 2000-2013) estimates is similar to that used for
the 2000-2010 estimates, although several methodological components have been improved along with
updated inputs for child mortality levels (1) as well as cause-specific estimates for HIV, malaria, measles
and pertussis deaths (as described in Section 4). Inputs to the multivariate cause composition models
were also updated as described below in Section 3.
These estimates of child deaths by cause represent the best estimates of WHO and CHERG, based on the
evidence available to them up until September 2014, rather than representing the official estimates of
Member States, and have not necessarily been endorsed by Member States. They have been computed
using standard categories, definitions and methods to ensure cross-national comparability and may not
be the same as official national estimates produced using alternate, potentially equally rigorous
methods. The following sections of this document provide explanatory notes about data sources and
methods for preparing child mortality estimates by cause. Data files and statistical code that allow
interested readers to replicate the child cause of death estimates can be found at
http://www.who.int/healthinfo/global_burden_disease/ChildCOD_2000_2013.zip.

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All-cause mortality and population estimates for years 2000-2013

2.1

Estimation of neonatal and under-5 mortality rates

Methods for estimating time series of neonatal (0-27 days), infant (0-365 days) and under-5 mortality
rates have been developed and agreed upon within the Inter-agency Group for Child Mortality
Estimation (UN-IGME) which is made up of WHO, UNICEF, UN Population Division, World Bank and
academic groups. UN-IGME annually assesses and adjusts all available surveys, censuses and vital
registration data to estimate country-specific trends in under-five mortality per 1000 live births (U5MR)
over the past few decades (1). All data sources and estimates are documented on the UN-IGME
website.1 For countries with complete recording of child deaths in death registration systems, these are
used as the source of data for the estimation of trends in neonatal, infant and child mortality. For
countries with incomplete death registration, all available census and survey data sources that meet
quality criteria are used. UN-IGME methods are documented in a series of papers published in a
collection in 2012 (4).
Under-five and infant mortality rates are estimated from data inputs using a multi-level penalized spline
regression model that accommodates sources of bias across input data sources. Neonatal mortality
rates (NMR) are then estimated in a second estimation process which models NMR as a function of
U5MR using paired observations of these from death registration data and surveys (6). For countries
where child mortality is strongly affected by HIV, U5MR and NMR are estimated initially using neonatal
and child mortality observations for non-AIDS deaths, calculated by subtracting from total death rates
the estimated HIV death rates in the neonatal and 1-59 month periods respectively, and then AIDS
deaths are added back on to the non-HIV deaths to compute the total estimated U5MR and NMR.

2.2

Population size and births estimates

Total deaths by age and sex were estimated for each country by applying the UN-IGME estimates of
neonatal and under 5 mortality rates to the estimated total births and de facto resident population
estimates for children under age 5 prepared by the United Nations Population Division in its World
Population Prospects 2012 (5). They may thus differ slightly from official national estimates for
corresponding years.

2.3

Mortality shocks epidemics, conflicts and disasters

Country-specific estimates of deaths for organized conflicts and major natural disasters were prepared
for years 1990-2013 using data and methods as described below in Section 4.5. For country-years where
total all-age death rates from these conflicts and disasters exceeded 1 per 10,000 population, neonatal
and child mortality rates were adjusted by adding the estimated age-specific components of the conflict
and disaster deaths.
As described in Section 4.4, deaths due to measles outbreaks were identified and also added to the
smoothed all-cause envelopes estimated from the UN-IGME estimates for neonatal and under 5 deaths.

Child mortality by cause

Final cause of death estimates for children under 5 are the result of separate estimation processes for
causes of death during the neonatal (0-27 days) and postneonatal (1 to 59 months) periods (2). New for

www.childmortality.org

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this estimation round, the neonatal period was further divided into two periods, 0-6 days and 7-27 days,
to allow for more accurate modeling within these time periods, between which cause of death
distributions can change significantly in many countries (6). The approach used for estimating cause of
death distributions for early neonatal, late neonatal, and postneonatal periods varied depending on a
countrys data availability and under-five mortality rate. Three general estimation strategies were
employed. First, for countries with high-quality vital registration (VR) data, cause distributions were
estimated directly from the vital registration data. Second, for lower mortality countries lacking highquality vital registration data, cause of death distributions were predicted from a regression fit to data
from countries with high-quality VR data. Third, for higher mortality countries without high-quality VR
data, cause of death distributions were predicted from a regression fit to data assembled from studies
of causes of death in high-mortality countries, which typically relied on verbal autopsy. These
approaches are augmented by UN program estimates of certain diseases, such as HIV and measles. The
following sections explain the methodological details of the estimation process.

3.1

Death registration data

Cause-of-death statistics are reported to WHO on an annual basis by country, year, cause, age and sex.
Most of these statistics can be accessed in the WHO Mortality Database (7). The number of countries
reporting data using the 10th revision of the International Classification of Diseases (ICD-10) (8) has
continued to increase.
Death registration data were used directly for estimating cause fractions of neonatal and postneonatal
child deaths for countries with high-quality vital registration data and population coverage of >80%. VR
data were considered to be high quality if the following criteria were met: (a) reasonable distribution of
deaths by cause were reported without excessive use of implausible codes or certain codes, and (b)
sufficient details of the coding was provided so that deaths could be grouped into appropriate
categories used in the analysis. For these estimates, VR data was used for directly estimating cause of
death distributions in the neonatal period for 65 countries and in the postneonatal period for 67
countries (Annex Table A).
Annual data from 2000 to the latest available year were incorporated for country estimates. For small
countries with a population of less than 1 million and fewer than 50 neonatal or postneonatal annual
deaths, a three-year moving average was computed to obtain a more stable estimate of mortality by
cause. In cases where data on causes of death were missing for some years, local logistic regressions fit
to a countrys cause of death time series were used to impute missing numbers of deaths by cause. A
few countries (Canada, Portugal and Switzerland) reporting mortality data to WHO do not provide the
breakdown for the neonatal period across all years. In these cases, 1-59 months deaths by cause were
imputed from totals for 0-4 years, using information on the average cause-specific ratio of neonatal to
postneonatal deaths from other parts of the countrys time series and data from other countries in the
same region. Neonatal cause distributions for these countries were estimated with a multi-cause model
(see Section 3.2).
The category Preterm includes all the specific codes for complications of preterm birth and the related
obstetric causes codes for preterm labour as cause of death. Less than 1% of these deaths were
attributed to term small for gestational age (SGA) as cause of death. Almost all (99%) deaths in this
category were coded as due to complications of preterm birth. This is in line with data reported from
industrialized countries.
Respiratory distress syndrome (RDS) with ICD-10 codes P22 and P27 and intraventricular haemorrhage
code P52 were assigned to preterm birth since they are almost a distinctive characteristic of preterm
birth. In some developing countries, it has been noted that the proportion of neonatal deaths coded to
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RDS is relatively high compared to developed countries. This may be due to certification habits inherent
to the medical profession in these countries and the application of ICD-10 rules for the determination of
the underlying cause of death. One of these rules stipulates that when the death certificate has other
conditions listed together with prematurity, the coders should code to the other conditions including
RDS. (Reference ICD-10 rule P1, ICD-10 vol2 section 4.3.5.) Alternatively, this may be a real result of
limited intensive care for babies with RDS in some countries, especially transitional countries.
The ICD-10 provides a chapter on 'Congenital malformations, deformations and chromosomal
abnormalities' which captures most of the deaths among neonates due to congenital abnormalities. In
addition neonatal deaths classified in other chapters of the ICD-10 such as endocrine, nutritional and
metabolic diseases, and diseases of the nervous, digestive, circulatory, musculoskeletal and
genitourinary systems were reassigned to congenital abnormalities as these are consequences of
congenital malformations. Neonatal deaths classified to the diseases of the respiratory symptoms are
included in the acute respiratory infections for this analysis.
For the analyses of neonatal deaths, deaths that were reported as due to ill-defined causes (ICD-9
Chapter XVI , ICD-10 Chapter XVIII, on symptoms, signs and abnormal clinical and laboratory findings,
not elsewhere classified) as well as the codes P92, P95 and P96 were proportionately reassigned to
other defined causes including external causes of injuries. However for the analyses of the deaths aged
1-59 months of age, only those ill-defined causes coded to R codes were proportionately reassigned to
the natural causes.
Final country time series for 2000 to 2013 of the proportion of deaths by cause for neonatal and
postneonatal periods from high-quality VR data were multiplied by UN-IGME envelopes to obtain
estimates of numbers of deaths by cause.

3.2

Modeling causes of neonatal death (ages 0-27 days)

The CHERG neonatal working group undertook an extensive exercise to derive mortality estimates for
dominant causes of neonatal death, defined as deaths occurring at less than 28 days of age. These cause
categories are defined in Annex Table B. Estimates were derived separately for early (0-6 days) and late
(7-27 days) neonatal periods.
Low mortality countries
Death registration data were used to directly calculate cause of death distributions for 65 countries
considered to have reliable information as described in Section 3.1. Data from these 65 countries were
then used to fit a multinomial logistic regression model (separately for early and late neonatal periods),
which was then employed to predict cause distributions for 48 low mortality countries without highquality VR data. This vital registration multi-cause model (VRMCM) was used to estimate seven broad
cause categories in these 48 countries: complications of preterm birth (preterm), intrapartum-related
complications (intrapartum, which includes birth asphyxia and birth trauma), congenital disorders,
pneumonia, sepsis and other severe infections (sepsis), injuries, and other causes.
High mortality countries
For 80 high mortality countries the cause distribution was estimated using a multinomial model applied
to (largely) verbal autopsy (VA) data from research studies (1). A total of 112 data points from 36
countries in high mortality populations met the inclusion criteria. The high mortality, verbal-autopsy
based multinomial model (VAMCM) was used for countries that were classified as high mortality based
on an average U5MR>35 from 2000-2010 in the previous estimation round (2). The VAMCM model was
used to estimate eight cause categories for the 80 high mortality countries (separately for early and late

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neonatal periods): preterm, intrapartum, congenital disorders, pneumonia, diarrhea, neonatal tetanus,
sepsis, and other causes.
Covariates for each for the four models (VRMCM and VAMCM for early and late neonatal periods) were
selected separately via cross-validation. The final set of covariates included in at least one of the four
models was: female literacy, Gini coefficient, neonatal mortality rate, infant mortality rate, under 5
mortality rate, low birth weight, GNI per capita (PPP, $international), antenatal care coverage,
percentage of births with skilled birth attendance, general fertility rate, BGC vaccine coverage, DTP3
vaccine coverage, PAB vaccine coverage, and indicator variables for world regions. Linear, quadratic and
restricted cubic spline formulations were considered for each covariate with the regression. See
supplementary appendix in (6) for details.
The estimated proportional distribution of causes of death predicted from the models were then
combined with information on causes of death from WHO program estimates as described in Section 4,
and applied to numbers of neonatal deaths derived from UN-IGME estimates of neonatal mortality
rates. For modeled countries, it was assumed that 74% of neonatal deaths occurred in the early period
and 26% occurred in the late period (9).

3.3

Modeling causes of postneonatal deaths (ages 1-59 months)

Low mortality countries

For 48 low mortality countries without available vital registration data on postneonatal causes of death,
the cause distribution was estimated using a multinomial logistic regression model applied to death
registration data from countries with reliable VR information. The multinomial model applied to death
registration data was generally used for countries that were classified as low mortality based on an
average U5MR<35 from 2000-2010 in the previous estimation round (2).
The multinomial logistic regression model was developed using death registration data from countries
with >80% complete cause of death certification for the year closest to 2008 to estimate the proportion
of deaths due to pneumonia, diarrhea, meningitis, injuries, perinatal, congenital anomalies, other noncommunicable diseases (NCDs) and other causes. The model included the following covariates, which
were previously identified as being predictive of cause of death distributions for the postneonatal period
(2,10): under five mortality rates (U5MRs), under five population size, GNI per capita (PPP,
$international), human development index (HDI), Gini coefficient, an education index, percentage of
births with skilled birth attendance, percent urbanization, percent with access to an improved drinkingwater, DTP3 vaccine coverage, Hib3 vaccine coverage, year, and WHO region. The proportional
distribution of causes of death predicted from the model was then applied to UN-IGME mortality
envelope for children 1-59 months of age, after removing some program specific causes (see Section 4).
Key revisions to the previous VRMCM model used for the 2000-2010 estimates (2) include the use of
death registration data for the years 1990 to 2012, which includes a total of 997 country-year
observations from 56 countries, and updated covariate time series.
High mortality countries
For 81 high mortality countries the cause of death distribution was estimated using a multinomial model
applied to (largely) verbal autopsy data from research studies (2,10,11). For these estimates for years
2000-2013, the multicause model for deaths at ages 1-59 months (2) was further updated to include
recent community-based VA studies published between June 2, 2010 and May 27, 2013, as well as
national VA surveys. A total of 128 sets of data points from 95 VA studies and 37 countries that met the
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inclusion criteria2 were included. Among them 47 data points were either new or updated from the last
round. These studies were predominantly from lower income high mortality countries. Mortality
estimates for eight cause categories of postneonatal death were derived: pneumonia, diarrhea, malaria,
meningitis, injuries, congenital malformations, causes arising in the perinatal period (prematurity, birth
asphyxia and trauma, sepsis and other conditions of the newborn), and other causes. Malnutrition
deaths were included in the other cause of death category. Deaths due to measles, unknown causes,
and HIV/AIDS were excluded from the multinomial model. Measles and HIV/AIDS deaths were
separately estimated as described in Section 4.
Covariates for the postneonatal VAMCM were selected via cross-validation. The final model included the
following covariates: under five mortality rate, percentage of births with skilled birth attendance,
percent child stunting, percent urbanization, measles vaccine coverage, CHERG malaria index, and year.
Estimates of deaths by cause were adjusted for intervention coverage (pneumonia and meningitis
estimates adjusted for the use and effectiveness of Hib vaccine; malaria estimates adjusted for the use
and effectiveness of insecticide treated mosquito nets (ITNs)) (2). Final cause-specific estimates for the
proportion of deaths due to each cause were multiplied by the estimated 1-59 month death envelopes
(excluding HIV and measles deaths) for corresponding years to obtain estimates of number of deaths by
cause.

3.5

Causes of child death for China and India

In order to estimate trends in under 5 causes of death for India, previously developed subnational
analyses were further refined and used to develop national estimates for years 2000-2013 (2). For
neonatal causes of death, Indian states were modeled separately within the high mortality, verbal
autopsy multi-cause model described in Section 3.2. The resulting cause-specific proportions were
applied to the estimated number of neonatal deaths to obtain the estimated number of deaths by cause
at state level prior to summing to obtain national estimates.
For children who died between ages 1-59 months, an updated systematic review was conducted to
identified new studies published between June 2, 2010 and May 27, 2013, which identified 27 new study
data points based on a set of inclusion criteria (10). In addition, cause of death distribution derived from
the Million Death Studies were also included for each of the 22 major states (12). A set of cause-specific
covariates were abstracted for each of a total of 49 study data points either from the studies themselves
or from other sub-national data sources, such as the National Family and Health Survey (NFHS) and the
District-Level Health Survey (DLHS). Based on these study-level data, a multi-cause model was
constructed applying a multinomial logistic regression framework (2,11,12). The parameterized model
was subsequently applied to a set of state-level cause-specific covariates for years 2000-2013 to derive
cause of death estimates for all 35 states for the 13-year period. Finally, the state-level estimates were
collapsed to obtain the national child cause of death distribution for 2000-2013 for eight causes of
postneonatal death, including pneumonia, diarrhea, malaria, meningitis, injuries, congenital
malformations, causes arising from the neonatal period, and other causes.
For China, updated IGME U5MR estimates in 2000-2013 were applied to the VA-based national causespecific models developed by Rudan and colleagues (13), which were extended to 2013, to derive cause2

Studies conducted in year 1980 or later, a multiple of 12 months in study duration, cause of death available for
more than a single cause, with at least 25 deaths in children <5 years of age, each death represented once, and less
than 25% of deaths due to unknown causes were included. Studies conducted in sub-groups of the study population
(e.g. intervention groups in clinical trials) and verbal autopsy studies conducted without use of a standardized
questionnaire or the methods could not be confirmed were excluded from the analysis.

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fractions annually in this period. Together with cause-specific inputs from WHO technical programmes
and UNAIDS for measles, meningitis, malaria and AIDS, the resulting cause-specific inputs for China were
adjusted to match the estimated total deaths at ages 0-1 month and 1-59 months, respectively.

Methods for cause-specific revisions and updates

4.1

HIV/AIDS

For countries with death registration data that met the usability criteria in Section 3.2, HIV/AIDS
mortality estimates were generally based on the most recently available vital registration. For other
countries, estimates were based on UNAIDS estimates of HIV/AIDS mortality (14). It was assumed based
on advice from UNAIDS that 1% of HIV deaths under age 5 occurred in the neonatal period.

4.2

Malaria

Countries outside the WHO African Region and low transmission countries in Africa3.
Estimates of the number of malaria cases were made by adjusting the reported number of malaria cases
for completeness of reporting, the likelihood that cases are parasite-positive and the extent of health
service use. The procedure, which is described in the World Malaria Report 2013 (15), combines data
reported by National Malaria Control Programs (reported cases, reporting completeness, likelihood that
cases are parasite positive) with those obtained from nationally representative household surveys on
health service use. If data from more than one household survey was available for a country, estimates
of health service use for intervening years were imputed by linear regression. If only one household
survey was available then health service use was assumed to remain constant over time; analysis
summarized in the World Malaria Report 2008 (16) indicated that the percentage of fever cases seeking
treatment in public sector facilities varies little over time in countries with multiple surveys. Such a
procedure results in an estimate with wide uncertainty intervals.
The number of deaths was estimated by multiplying the estimated number of P. falciparum malaria
cases by a fixed case fatality rate for each country as described in the World Malaria Report 2013 (15).
This method is used for all countries outside the African Region and for countries within the African
Region where estimates of case incidence were derived from routine reporting systems and where
malaria causes less than 5% of all deaths in children under 5. A case fatality rate of 045% is applied to
the estimated number of P. falciparum cases for countries in the African Region and a case fatality rate
of 03% for P. falciparum cases in other Regions. In situations where the fraction of all deaths due to
malaria is small, the use of a case fatality rate in conjunction with estimates of case incidence was
considered to provide a better guide to the levels of malaria mortality than attempts to estimate the
fraction of deaths due to malaria.
South Sudan and high transmission countries in the WHO African Region.
Child malaria deaths were estimated using the verbal autopsy-based multi-cause model described in
Section 3.3. The VAMCM derives mortality estimates for malaria, as well as 7 other causes (pneumonia,
diarrhea, congenital malformation, causes arising in the perinatal period, injury, meningitis, and other
causes) using multinomial logistic regression methods to ensure that all 8 causes are estimated
simultaneously with the total cause fraction summing to 1. Malaria deaths were retrospectively adjusted
for coverage of ITNs (1).
3

Botswana, Cabo Verde, Eritrea, Madagascar, Namibia, Swaziland, South Africa, and Zimbabwe

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4.3

Whooping cough

In an effort to better characterize the global burden of pertussis, the World Health Organization has
developed a series of global pertussis models. Recognizing the limited data to support model inputs, in
2009, the World Health Organizations Department of Immunization Vaccines and Biologicals
Quantitative Immunization and Vaccines Related Research (QUIVER), recommended that a revised
pertussis model be developed to specifically address uncertainty in the model inputs and parameter
values. Inputs to the current model are country- and year-specific estimates of population by single year
of age (17) and estimated pertussis immunization coverage (18). Age-, country-, and immunization
history- specific estimates of the probability of initial infection, probability that an infected individual
develops typical symptoms of a case of pertussis and the probability that a case of pertussis will die
were estimated using structured expert judgment (19-21). Annual deaths attributable to pertussis
infection during the neonatal period (5% of estimated pertussis deaths 0-11 months of age), from age 111 months of age (estimated as 95% of deaths 1-11 months of age) and 12-59 months of age were
estimated for each country for the years 2000 2012, and rates were assumed constant from 2012 to
2013.

4.4

Measles

In May 2010, WHO established targets for measles vaccine coverage, incidence and mortality as
milestone towards measles eradication. This created a requirement to report annually on these statistics,
and to address this need WHO has worked with technical experts and its QUIVER advisory group (22) to
develop an improved statistical model that firstly estimates measles cases by country and year using
surveillance data. The estimation uses the Kalman Filter method in order to make explicit projections
about dynamic transitions over time as well as overall patterns in incidence (23). The cases are then
stratified by age classes based on a model fitted to data stratified by national GDP and vaccine coverage.
The results are applied to age-specific case fatality ratios for each country (24-26) and then aggregated
again to produce overall measles deaths. Uncertainty is estimated by bootstrap sampling from the
distribution of incidence and age distribution estimates. This method was published in the Lancet in
2012 (27). The estimates used here are from an update to those in (27) that take into account trends in
case notifications and vaccine coverage up to and including the year 2012, with rates held constant to
extend to 2013.
Inclusion of measles deaths within the all-cause envelope for child mortality
Estimated measles deaths in countries experiencing measles outbreaks can vary substantially from yearto-year, whereas the all-cause mortality envelopes for deaths at ages 1-59 months vary smoothly from
year to year due to the use of regression smoothing techniques applied to the available under 5
mortality observations (28). For countries without good death registration data, child mortality
observations from surveys and censuses can have considerable variability which may reflect real
changes (such as due to a measles outbreak) or be mainly due to measurement errors and variations in
survey sampling and quality. In order to include the measles deaths within the all-cause envelope
without creating fluctuations in death rates for other causes, the measles deaths for each country were
split into "outbreak" deaths and a smoothly varying endemic measles component. The latter was
estimated by fitting Loess regression (29) with an alpha=1.0 to a countrys time series of measles deaths,
after removing observations that were highly divergent from the underlying trend.
For high mortality countries, the endemic measles mortality component and HIV deaths were subtracted
from all-cause deaths in the age range 1-59 months in order to estimate the HIV- and measles-free
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envelope to which the verbal autopsy based multi-cause model cause fractions were applied. The
outbreak deaths were then added back to the measles deaths, and all-cause deaths.

4.5

Conflict and natural disasters

For the majority of countries, deaths attributable to conflicts and disasters are assumed to be included
within the estimates of total deaths due to injuries. Estimated deaths for major natural disasters were
obtained from the CRED International Disaster Database (30) and the under 5 proportion estimated as
described elsewhere (31). Child deaths due the Haiti earthquake in 2010 and the Japanese tsunami in
2011 were added to the smoothed estimates of total under 5 deaths for Haiti and Japan. Estimated
conflict deaths under age 5 were also added for Syria for 2011 and 2012.

Uncertainty of estimates

Country-level all-cause mortality envelope uncertainty for neonatal and postneonatal periods was
simulated from the confidence intervals for neonatal mortality rates and posterior draws for under-five
mortality rates as produced by IGME. It was assumed that estimation error in neonatal and under-five
mortality rates was positively correlated within a county, with postneonatal mortality rates computed as
the difference between the under-five and neonatal rates. This procedure produced correlated draws of
neonatal and postneonatal mortality rates, and once combined with live births, numbers of deaths.
To estimate uncertainty by cause within the neonatal and postneonatal envelopes, a bootstrap
procedure was used to compute 95% confidence intervals around predicted cause fractions from each
of the multi-cause models for neonatal and 1-59 month deaths. These bootstrapped draws were
combined with draws obtained for program estimates (e.g., HIV/AIDS and measles) to simulate posterior
distributions for all 15 cause fractions, which were in turn applied to the simulated draws for the
envelopes. Uncertainty around cause fractions for countries with high-quality VR data was simulated
using poisson distributions.

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Page 9

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Annex Table A. Methods used for estimation of child causes of death, by

country, 2000-2013
Country

Neonatal method

Postneonatal Method

Afghanistan

VAMCM

VAMCM

Albania

VRMCM

VRMCM

Algeria

VAMCM

VAMCM

Andorra

VRMCM

VRMCM

Angola

VAMCM

VAMCM

Antigua and Barbuda

VR data

VR data

Argentina

VR data

VR data

Armenia

VRMCM

VRMCM

Australia

VR data

VR data

Austria

VR data

VR data

Azerbaijan

VAMCM

VAMCM

Bahamas

VR data

VR data

Bahrain

VR data

VR data

Bangladesh

VAMCM

VAMCM

Barbados

VR data

VR data

Belarus

VRMCM

VRMCM

Belgium

VR data

VR data

Belize

VR data

VR data

Benin

VAMCM

VAMCM

Bhutan

VAMCM

VAMCM

Bolivia (Plurinational State of)

VAMCM

VAMCM

Bosnia and Herzegovina

VRMCM

VRMCM

Botswana

VAMCM

VAMCM

Brazil

VR data

VR data

Brunei Darussalam

VRMCM

VRMCM

Bulgaria

VR data

VR data

Burkina Faso

VAMCM

VAMCM

Burundi

VAMCM

VAMCM

Cambodia

VAMCM

VAMCM

Cameroon

VAMCM

VAMCM

Canada

VRMCM

VR data

Cabo Verde

VRMCM

VRMCM

Central African Republic

VAMCM

VAMCM

Chad

VAMCM

VAMCM

Chile

VR data

VR data

China

Single cause models

Single cause models

Colombia

VR data

VR data

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Comoros

VAMCM

VAMCM

Congo

VAMCM

VAMCM

Cook Islands

VRMCM

VRMCM

Costa Rica

VR data

VR data

Croatia

VR data

VR data

Cuba

VR data

VR data

Cyprus

VRMCM

VRMCM

Czech Republic

VR data

VR data

Cte d'Ivoire

VAMCM

VAMCM

Democratic People's Republic of Korea

VAMCM

VAMCM

Democratic Republic of the Congo

VAMCM

VAMCM

Denmark

VR data

VR data

Djibouti

VAMCM

VAMCM

Dominica

VR data

VR data

Dominican Republic

VAMCM

VAMCM

Ecuador

VRMCM

VRMCM

Egypt

VRMCM

VRMCM

El Salvador

VRMCM

VRMCM

Equatorial Guinea

VAMCM

VAMCM

Eritrea

VAMCM

VAMCM

Estonia

VR data

VR data

Ethiopia

VAMCM

VAMCM

Fiji

VRMCM

VRMCM

Finland

VR data

VR data

France

VR data

VR data

Gabon

VAMCM

VAMCM

Gambia

VAMCM

VAMCM

Georgia

VRMCM

VRMCM

Germany

VR data

VR data

Ghana

VAMCM

VAMCM

Greece

VR data

VR data

Grenada

VR data

VR data

Guatemala

VAMCM

VAMCM

Guinea

VAMCM

VAMCM

Guinea-Bissau

VAMCM

VAMCM

Guyana

VR data

VR data

Haiti

VAMCM

VAMCM

Honduras

VRMCM

VRMCM

Hungary

VR data

VR data

Iceland

VR data

VR data

India

VAMCM state level

VAMCM state level

Indonesia

VAMCM

VAMCM

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Iran (Islamic Republic of)

VAMCM

VAMCM

Iraq

VAMCM

VAMCM

Ireland

VR data

VR data

Israel

VR data

VR data

Italy

VR data

VR data

Jamaica

VRMCM

VRMCM

Japan

VR data

VR data

Jordan

VRMCM

VRMCM

Kazakhstan

VAMCM

VAMCM

Kenya

VAMCM

VAMCM

Kiribati

VAMCM

VAMCM

Kuwait

VR data

VR data

Kyrgyzstan

VAMCM

VAMCM

Lao People's Democratic Republic

VAMCM

VAMCM

Latvia

VR data

VR data

Lebanon

VRMCM

VRMCM

Lesotho

VAMCM

VAMCM

Liberia

VAMCM

VAMCM

Libya

VRMCM

VRMCM

Lithuania

VR data

VR data

Luxembourg

VR data

VR data

Madagascar

VAMCM

VAMCM

Malawi

VAMCM

VAMCM

Malaysia

VRMCM

VRMCM

Maldives

VRMCM

VRMCM

Mali

VAMCM

VAMCM

Malta

VR data

VR data

Marshall Islands

VAMCM

VAMCM

Mauritania

VAMCM

VAMCM

Mauritius

VR data

VR data

Mexico

VR data

VR data

Micronesia (Federated States of)

VAMCM

VAMCM

Monaco

VRMCM

VRMCM

Mongolia

VAMCM

VAMCM

Montenegro

VR data

VR data

Morocco

VAMCM

VAMCM

Mozambique

VAMCM

VAMCM

Myanmar

VAMCM

VAMCM

Namibia

VAMCM

VAMCM

Nauru

VAMCM

VAMCM

Nepal

VAMCM

VAMCM

Netherlands

VR data

VR data

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New Zealand

VR data

VR data

Nicaragua

VRMCM

VRMCM

Niger

VAMCM

VAMCM

Nigeria

VAMCM

VAMCM

Niue

VRMCM

VRMCM

Norway

VR data

VR data

Oman

VRMCM

VRMCM

Pakistan

VAMCM

VAMCM

Palau

VRMCM

VRMCM

Panama

VR data

VR data

Papua New Guinea

VAMCM

VAMCM

Paraguay

VRMCM

VRMCM

Peru

VRMCM

VRMCM

Philippines

VAMCM

VAMCM

Poland

VR data

VR data

Portugal

VRMCM

VR data

Qatar

VRMCM

VRMCM

Republic of Korea

VR data

VR data

Republic of Moldova

VR data

VR data

Romania

VR data

VR data

Russian Federation

VRMCM

VRMCM

Rwanda

VAMCM

VAMCM

Saint Kitts and Nevis

VR data

VR data

Saint Lucia

VR data

VR data

Saint Vincent and the Grenadines

VR data

VR data

Samoa

VRMCM

VRMCM

San Marino

VRMCM

VRMCM

Sao Tome and Principe

VAMCM

VAMCM

Saudi Arabia

VRMCM

VRMCM

Senegal

VAMCM

VAMCM

Serbia

VR data

VR data

Seychelles

VRMCM

VRMCM

Sierra Leone

VAMCM

VAMCM

Singapore

VR data

VR data

Slovakia

VR data

VR data

Slovenia

VR data

VR data

Solomon Islands

VAMCM

VAMCM

Somalia

VAMCM

VAMCM

South Africa

VR data

VAMCM

South Sudan

VAMCM

VAMCM

Spain

VR data

VR data

Sri Lanka

VRMCM

VRMCM

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Sudan

VAMCM

VAMCM

Suriname

VR data

VR data

Swaziland

VAMCM

VAMCM

Sweden

VR data

VR data

Switzerland

VRMCM

VR data

Syrian Arab Republic

VRMCM

VRMCM

Tajikistan

VAMCM

VAMCM

Thailand

VRMCM

VRMCM

The former Yugoslav Republic of Macedonia

VR data

VR data

Timor-Leste

VAMCM

VAMCM

Togo

VAMCM

VAMCM

Tonga

VRMCM

VRMCM

Trinidad and Tobago

VR data

VR data

Tunisia

VRMCM

VRMCM

Turkey

VRMCM

VRMCM

Turkmenistan

VAMCM

VAMCM

Tuvalu

VRMCM

VRMCM

Uganda

VAMCM

VAMCM

Ukraine

VRMCM

VRMCM

United Arab Emirates

VRMCM

VRMCM

United Kingdom

VR data

VR data

United Republic of Tanzania

VAMCM

VAMCM

United States of America

VR data

VR data

Uruguay

VR data

VR data

Uzbekistan

VAMCM

VAMCM

Vanuatu

VRMCM

VRMCM

Venezuela (Bolivarian Republic of)

VR data

VR data

Viet Nam

VRMCM

VRMCM

Yemen

VAMCM

VAMCM

Zambia

VAMCM

VAMCM

Zimbabwe
VAMCM
VR data = tabulations of vital registration data from WHO Mortality Database
VRMCM = multi-cause model based on vital registration data
VAMCM = multi-cause model based on verbal autopsy studies

World Health Organization

VAMCM

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Annex Table B. First-level categories for analysis of child causes of

death
GBD cause name

ICD-10 code

ICD-9 code

All causes

A00-Y89

001-999

I.

Communicable, maternal,
perinatal and nutritional
conditionsa

A00-B99, D50-D53, D64.9, E00-E02,

E40-E64, G00-G09, H65-H66, J00J22, J85, N30, N34, N390, N70-N73,
O00-P96, U04

001-139, 243, 260-269, 279.5-279.6,

280, 281, 285.9, 320-326, 381-382,
460-466, 480-487, 513, 614-616, 630676, 760-779

HIV/AIDS

B20-B24

279.5-279.6, 042

Diarrhoeal diseases

A00-A09

001-009

Pertussis

A37

033

Tetanus

A33-A35

037, 771.3

Measles

B05

055

Meningitis/encephalitis

A20.3, A32.1, A39.1, G00G09

036, 320, 322-326

Malaria

B50-B54, P37.3, P37.4

084

Acute respiratory infections

H65-H66, J00-J22, J85, P23, U04

460-466,
770.0

Prematurity

P01.0, P01.1, P07, P22, P25-P28,

P52, P61.2, P77

761.0-761.1, 765, 769, 770.2-770.9,

772.1, 774.2, 776.6, 777.5-777.6,

Birth asphyxia & birth traumab

P01.7-P02.1, P02.4-P02.6, P03, P10P15, P20-P21, P24, P50, P90-P91

761.7-762.1, 762.4-762.6, 763, 767768, 770.1, 772.2, 779.0-779.2

Sepsis and other infectious

conditions of the newborn

P35-P39 (exclude P37.3, P37.4)

Other Group I

Remainder

Remainder

C00-C97, D00-D48, D55-D64 (exclude

D64.9), D65-D89, E03-E34, E65-E88,
F01-F99, G10-G98, H00-H61, H68H93, I00-I99, J30-J84, J86-J98, K00K92, L00-L98, M00-M99, N00-N28,
N31-N32, N35-N64 (exclude N39.0),
N75-N98, Q00-Q99

140- 242, 244-259, 270-279, 282-285,

286-319, 330-380, 383-459, 470-478,
490- 512, 514-611, 617- 629, 680- 759
(exclude 279.5-279.6, 285.9)

Congenital anomalies

Q00-Q99

740-759

Other Group II

Remainder

Remainder

V01-Y89

E800-E999

II. Noncommunicable
diseasesa

III. Injuries

480-487,

381-382,

513,

771.0-771.2, 771.4-771.8

Deaths coded to Symptoms, signs and ill-defined conditions (780-799 in ICD-9 and R00-R99 in ICD-10) are distributed proportionately to all for
neonatal deaths, but exclusively to Group I and Group II for the postneonatal deaths.
b
Also referred to as intrapartum-related complications

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