IJE Advance Access originally published online on January 13, 2005
International Journal of Epidemiology 2005 34(1):61-68; doi:10.1093/ije/dyh378
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IJE vol.34 no.1 © International Epidemiological Association 2005; all rights reserved.
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Child mortality in relation to HIV infection, nutritional status, and socio-economic background
1 Department of Nutrition, Harvard School of Public Health, 665 Huntington Avenue, Boston, MA 02115, USA
2 Department of Epidemiology, Harvard School of Public Health, 677 Huntington Avenue, Boston, MA 02115, USA
3 Association of State and Territorial Health Officials, 1275 K. Street, NW, Suite 800, Washington, DC 20005, USA
4 Department of Pediatrics and Child Health, Muhimbili University College of Health Sciences, Dar es Salaam, Tanzania
* Corresponding author. Department of Nutrition, Harvard School of Public Health, 665 Huntington Avenue, Boston, MA 02115, USA. E-mail: evillamo{at}hsph.harvard.edu
Background The aims of this study were to examine the impact of child HIV infection on mortality and to identify nutritional and sociodemographic factors that increase the risk of child mortality independent of human immunodeficiency virus (HIV) infection.
Methods We conducted a prospective study in Dar es Salaam, Tanzania, among 687 children 6–60 months of age who were admitted to hospital with pneumonia. After discharge, children were followed up every 2 weeks during the first year and every 4 months thereafter. Sociodemographic characteristics were determined at baseline, and HIV status, haemoglobin, and malaria infection were assessed from a blood sample. During the first year of follow-up, we measured height, weight, and mid-upper arm circumference (MUAC) monthly. We estimated the risk of mortality according to HIV status and socio-economic characteristics using Cox proportional hazards models. Nutritional status variables (wasting and stunting) were examined as time-varying risk factors.
Results Mean age at enrolment was 18 months. A total of 90 children died during an average 24.7 months of follow-up. HIV infection was associated with an adjusted 4-fold higher risk of mortality [relative risk (RR) = 3.92, 95% confidence interval (CI) 2.34–6.55, P < 0.0001]. Other risk factors included child's age <24 months, stunting, low MUAC, anaemia, and lack of water supply in the household. In models with time-varying covariates, stunting and wasting during the previous month were both significant and independently related to increased risk of death. HIV infection appeared to be a stronger predictor of mortality among children who were wasted than among those who were not (P for interaction = 0.05).
Conclusions HIV infection is a strong predictor of death among children who have been hospitalized with pneumonia. Preventable conditions including inadequate water supply, child undernutrition, and anaemia contribute significantly to infant and child mortality independent of HIV infection.
Keywords Child mortality, infant mortality, HIV, stunting, wasting, anaemia, water
Accepted 19 October 2004
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