D 1329
OULU 2015
UNIVERSITY OF OUL U P.O. Box 8000 FI-90014 UNIVERSITY OF OULU FINLA ND
U N I V E R S I TAT I S
O U L U E N S I S
ACTA
A C TA
D 1329
ACTA
U N I V E R S I T AT I S O U L U E N S I S
Marjo Lantto
University Lecturer Santeri Palviainen
Marjo Lantto
Professor Esa Hohtola
CHILDHOOD MORTALITY IN
FINLAND
Postdoctoral research fellow Sanna Taskila
Professor Olli Vuolteenaho
University Lecturer Veli-Matti Ulvinen
Director Sinikka Eskelinen
Professor Jari Juga
University Lecturer Anu Soikkeli
Professor Olli Vuolteenaho
Publications Editor Kirsti Nurkkala
ISBN 978-952-62-1023-0 (Paperback)
ISBN 978-952-62-1024-7 (PDF)
ISSN 0355-3221 (Print)
ISSN 1796-2234 (Online)
UNIVERSITY OF OULU GRADUATE SCHOOL;
UNIVERSITY OF OULU,
FACULTY OF MEDICINE
D
MEDICA
ACTA UNIVERSITATIS OULUENSIS
D Medica 1329
MARJO LANTTO
CHILDHOOD MORTALITY IN
FINLAND
Academic dissertation to be presented with the assent of
the Doctoral Training Committee of Health and
Biosciences of the University of Oulu for public defence in
Auditorium 12 of the Department of Paediatrics, on 11
December 2015, at 12 noon
U N I VE R S I T Y O F O U L U , O U L U 2 0 1 5
Copyright © 2015
Acta Univ. Oul. D 1329, 2015
Supervised by
Docent Marjo Renko
Professor Matti Uhari
Reviewed by
Docent Eero Kajantie
Docent Antti Malmivaara
Opponent
Professor Per Ashorn
ISBN 978-952-62-1023-0 (Paperback)
ISBN 978-952-62-1024-7 (PDF)
ISSN 0355-3221 (Printed)
ISSN 1796-2234 (Online)
Cover Design
Raimo Ahonen
JUVENES PRINT
TAMPERE 2015
Lantto, Marjo, Childhood mortality in Finland.
University of Oulu Graduate School; University of Oulu, Faculty of Medicine
Acta Univ. Oul. D 1329, 2015
University of Oulu, P.O. Box 8000, FI-90014 University of Oulu, Finland
Abstract
The aim of this work was to assess trends in childhood mortality in Finland over the period
1969–2004 and to identify the main preventable causes of death in childhood. Specific topics of
interest were childhood mortality due to infectious diseases and possible regional differences in
childhood mortality. As accidents are the most common cause of death in childhood, we also
analysed regional differences in accidental mortality in childhood between the years 1969 and
2013.
Annual neonatal mortality declined by 78%, from 11.13/1000 in 1969 to 2.46/1000 in 2004,
with perinatal disorders and congenital malformations the most common causes of death, while
childhood mortality declined by 65% during the same period, from 0.67/1000 to 0.23/1000, with
accidents the leading cause of death, followed by congenital malformations, tumours and
haematological diseases, and infectious diseases. Childhood mortality due to infectious diseases
decreased by 89%, from 0.12/1000 in 1969 to 0.013/1000 in 2004, and neonatal mortality from
similar causes by 69%, from 0.50/1000 to 0.16/1000. Pneumonia, central nervous system
infections and septicaemia were the most significant fatal infections in childhood. There were no
significant differences in childhood mortality between the university hospital districts, but notable
differences existed at the regional level between the central hospital districts. There were also
considerable regional differences in childhood accidental mortality, which showed a tendency to
persist with time, especially in the case of traffic accidents, suicides and homicides.
Childhood mortality in Finland has declined markedly, and the trend was a continuous one
throughout the period concerned. The differences between the central hospital districts, however,
suggest that paediatric care in Finland may need further centralization. Accidents represent the
main preventable cause of death in childhood, and further reductions in mortality could be
achieved, especially through local preventive measures.
Keywords: childhood, Finland, mortality, postneonatal
Lantto, Marjo, Suomalaisten lasten kuolleisuus.
Oulun yliopiston tutkijakoulu; Oulun yliopisto, Lääketieteellinen tiedekunta
Acta Univ. Oul. D 1329, 2015
Oulun yliopisto, PL 8000, 90014 Oulun yliopisto
Tiivistelmä
Tutkimuksen tarkoituksena oli tarkastella muutoksia lasten kuolleisuudessa Suomessa vuosina
1969–2004 ja selvittää tärkeimmät ehkäistävissä olevat kuolinsyyt lapsuudessa. Olimme kiinnostuneita erityisesti lasten infektiokuolleisuudesta ja mahdollisista alueellisista eroista lapsikuolleisuudessa. Koska tapaturmat ovat yleisin kuolinsyy lapsuudessa, analysoimme myös alueellisia eroja lapsuusiän tapaturmakuolleisuudessa vuosina 1969–2013.
Neonataalikuolleisuus laski vuosina 1969–2004 78%, 11.13/1000:sta 2.46/1000:een. Perinataaliset ongelmat ja synnynnäiset epämuodostumat olivat yleisin kuolinsyy. Lapsuusiän kuolleisuus laski samanaikaisesti 65%, 0.67/1000:sta 0.23/1000:een tapaturmien ollessa yleisin kuolinsyy. Epämuodostumat, syövät ja hematologiset sairaudet sekä infektiot olivat myös merkittäviä kuolinsyitä. Infektiokuolleisuus laski seuranta-aikana lapsuusiässä 89%, 0.12/1000:sta 0.013/
1000:een ja vastasyntyneisyyskaudella 69%, 0.50/1000:sta 0.16/1000:een. Keuhkokuume, keskushermostoinfektiot ja sepsikset olivat yleisimpiä kuolemaan johtavia infektioita lapsuudessa.
Yliopistollisten sairaanhoitopiirien välillä ei esiintynyt alueellisia eroja lapsikuolleisuudessa,
mutta pienempien sairaanhoitopiirien välillä havaittiin eroja. Myös tapaturmakuolleisuudessa
esiintyi merkittäviä alueellisia eroja, erityisesti liikenneonnettomuuksissa sekä itsemurhissa ja
henkirikoksissa. Erot säilyivät läpi seuranta-ajan.
Lapsikuolleisuus on laskenut Suomessa merkittävästi läpi seuranta-ajan. Koska lapsikuolleisuudessa esiintyy alueellisia eroja keskussairaaloiden välillä, lasten sairaanhoito voi vaatia jatkossa enemmän keskittämistä. Tapaturmat ovat tärkein ehkäistävissä oleva kuolinsyy lapsuudessa, ja kuolleisuutta niihin olisi mahdollista vähentää paikallisen ennaltaehkäisyn kautta.
Asiasanat: kuolleisuus, lapsuus, Suomi, vastasyntyneisyyskauden jälkeinen
To my loved ones
8
Acknowledgements
The work reported here was carried out at the Department of Paediatrics,
University of Oulu, and Oulu University Hospital, during the years 2007–2015.
I wish to express my deepest gratitude to my supervisors, Professor Matti
Uhari and Docent Marjo Renko for their dedicated and inspiring guidance and
invaluable encouragement during this project. Professor Uhari’s extensive
knowledge of medical research and Docent Renko’s endless optimism made it
possible for me to complete this thesis.
I am grateful to Professor Willy Serlo for his valuable expertise in paediatric
traumatology and for his significant contribution to Paper IV. I also wish to thank
Docent Päivi Tapanainen, Chief Physician of the Department of Paediatrics,
Professor Mikko Hallman, Professor Mika Rämet and Professor Riitta Veijola for
providing excellent conditions for research at Oulu University Hospital.
I sincerely thank the official referees of this thesis, Docent Eero Kajantie and
Docent Antti Malmivaara for their wise and constructive comments.
I am very grateful to Tytti Pokka, MSc, for her valuable help with the
statistical analyses, and I also warmly thank Malcolm Hicks, MA, for carefully
revising the English language of this thesis.
Many thanks go to my colleagues in the Departments of Paediatrics at Oulu
University Hospital and Lapland Central Hospital. I am especially grateful to
Pekka Valmari, Chief Physician in the Department of Paediatrics at Lapland
Central Hospital, for his understanding and flexibility during the time of finishing
this thesis.
I thank all my dear friends for being close to me during these years, and most
especially Anna-Kaisa Försti, Johanna Lahdenperä and Maria Harvio for their
invaluable friendship and their constant ability to share the joys and sorrows of
life.
I wish to thank my family, my parents Sinikka and Markku and my brother
Markus, for their love and support throughout my life. Finally, I thank with all my
heart my husband Juha and our lovely children Helmi and Vilho. Thank you,
Juha, for your love and encouragement through these years, and, you, Helmi and
Vilho, for bringing so much joy and happiness into my life. You mean everything
to me.
This work was supported financially by the Emil Aaltonen Foundation, the
Alma and K.A. Snellman Foundation, the University of Oulu Graduate School,
9
the Foundation for Paediatric Research and the Finnish Cultural Foundation,
Lapland Regional Fund, all of which are gratefully acknowledged.
October 2015
10
Marjo Lantto
Abbreviations
CNS
Hib
ICD
IPD
LRTI
NOPHO
RSV
SIDS
SND
central nervous system
Haemophilus influenzae type b
international classification of diseases
invasive pneumococcal disease
lower respiratory tract infection
Nordic Society of Paediatric Haematology and Oncology
respiratory syncytial virus
sudden infant death syndrome
standard normal deviate
11
12
List of original publications
This thesis is based on the following publications, which are referred to
throughout the text by their Roman numerals:
I
Lantto M, Renko M & Uhari M (2008) Trends in childhood mortality from 1969 to
2004 in Finland. Acta Paediatr 97(8): 1024–9.
II Lantto M, Renko M & Uhari M (2013) Changes in infectious disease mortality in
children during the past three decades. Pediatr Infect Dis J 32(9): e355–9.
III Lantto M, Renko M & Uhari M (2014) Regional differences in postneonatal
childhood mortality in Finland, 1985−2004. Acta Paediatr 104(5):466–72.
IV Lantto M, Serlo W, Uhari M & Renko M (2015) Regional differences in childhood
mortality due to accidents in Finland, 1969−2013. Manuscript.
13
14
Contents
Abstract
Tiivistelmä
Acknowledgements
9
Abbreviations
11
List of original publications
13
Contents
15
1 Introduction
17
2 Review of the literature
19
2.1 Historical aspects of childhood mortality................................................ 19
2.2 How to describe childhood mortality ...................................................... 20
2.3 Child mortality as a health indicator ....................................................... 21
2.4 Variations in childhood mortality ............................................................ 22
2.4.1 Accidents and other unnatural causes ........................................... 24
2.4.2 Infectious diseases ........................................................................ 26
2.4.3 Congenital malformations ............................................................ 27
2.4.4 Tumours and haematological diseases.......................................... 28
2.4.5 Sudden infant death syndrome ..................................................... 30
2.4.6 Regional differences in childhood mortality and the
impact of socioeconomic differences ........................................... 30
2.5 Validity of childhood mortality data ....................................................... 32
2.5.1 Comparability of the ICD revisions.............................................. 32
2.5.2 Validity of death certification ....................................................... 33
2.6 Possibilities for preventing childhood deaths.......................................... 34
2.6.1 Accidents ...................................................................................... 34
2.6.2 Infectious diseases ........................................................................ 36
2.6.3 Sudden infant death syndrome ..................................................... 38
2.6.4 The role of primary care in promoting children’s health .............. 39
3 Aims of the research
41
4 Materials and methods
43
4.1 Mortality due to infectious diseases (II).................................................. 44
4.2 Regional differences in childhood mortality (III) ................................... 45
4.3 Regional differences in childhood mortality due to accidents (IV)......... 47
5 Results
49
5.1 Trends in childhood mortality in Finland, 1969 – 2004 (I) ..................... 49
5.1.1 Neonatal mortality ........................................................................ 49
15
5.1.2 Childhood mortality...................................................................... 49
5.2 Changes in mortality due to infectious diseases (II) ............................... 53
5.2.1 Neonatal mortality from infections ............................................... 53
5.2.2 Childhood mortality due to infections .......................................... 54
5.3 Regional differences in childhood mortality (III) ................................... 59
5.3.1 University hospital districts .......................................................... 59
5.3.2 Central hospital districts ............................................................... 63
5.4 Regional differences in childhood mortality due to accidents (IV) ......... 66
6 Discussion
71
6.1 Trends in childhood mortality ................................................................. 71
6.2 Regional differences in childhood mortality ........................................... 76
6.3 What can be done to reduce childhood mortality in future?.................... 78
6.4 Strengths and limitations of the research ................................................ 83
7 Conclusions
87
References
89
Original papers
105
16
1
Introduction
Childhood mortality has decreased in Finland during the recent decades, as in
other high-income countries. In 1936 as many as 6579 children died before the
age of five years in Finland, a mortality rate of 95/1000 children (Korpi 2010),
with almost 1900 of these deaths attributable to birth injuries and congenital
malformations, 1000 to pneumonia, more than 600 to tuberculosis, more than 500
to gastroenteritis, approximately 450 to influenza, more than 400 to convulsions,
and approximately 250 to pertussis. By the 2000s, however, the total number of
deaths had diminished enormously, so that only 201 children died before their
fifth birthday in 2008 (a mortality rate of 3.4/1000) and the causes of death that
had been most significant during the 1930s, apart from congenital malformations,
had almost entirely disappeared (Korpi 2010).
These dramatic decreases in mortality were largely attributed to national
vaccination campaigns and enhanced general hygienic conditions (Korpi 2010), in
addition to which the status of children in society had improved greatly during the
20th century due to major social changes. The average number of children in a
family had diminished, and education had become possible for everyone, which
along with previous substantial changes such as urbanisation of the population
following industrialisation and the prohibition of child labour, contributed greatly
to the improvement in children’s living conditions (Korpi 2010).
Childhood mortality provides a robust and easily accessible measure of the
functioning and quality of social and health care systems. In a country with
accurate official statistics, such as Finland, childhood mortality data can be
exploited as a useful tool for organising paediatric care in the future and
preventing deaths during childhood. Without an understanding of why children in
highly developed countries occasionally die even today, it would not be possible
to make improvements in children’s living conditions and the health services and
social services available to them.
17
18
2
Review of the literature
2.1
Historical aspects of childhood mortality
Childhood mortality has decreased notably throughout the 20th century in the
developed countries. In England and Wales it declined markedly between the
years 1841 and 1943 in all age groups (Gale 1945), with mortality among children
older than one year beginning to fall from the mid-19th century onwards, whereas
the decrease in infant mortality did not begin until the 1900s. Specific mortality
rates were reported for the most common causes of death during childhood from
as early as the 1850s onwards, taking into account changes in medical knowledge
and methods of classifying diseases. Lung diseases, mainly bronchitis and
pneumonia, were the most common causes of death among younger children in
both the 1870s and the 1930s, and ’brain diseases’, mostly convulsions, also
caused high mortality among young children in the earlier period. Scarlet fever
was a significant cause of death during the earlier period, but no longer during the
latter. Other common infectious diseases, including tuberculosis and intestinal
infections, similarly decreased considerably as causes of death (Gale 1945).
The great decline in childhood mortality during the inter-war period was also
reported in more detail in England and Wales, with accompanying observations
that infant mortality was still almost twice as high as in New Zealand in 1935−39
and that the decline in infant mortality between 1920 and 1939 was slower than
that recorded in the United States (Martin 1945). This latter difference in the rate
of decline was thought to have resulted from improved maternal health in the
United States brought about by the antenatal and postnatal clinics and also from
the rise in the standards of medical care achieved through postgraduate training in
obstetrics and paediatrics for practising physicians. Despite the lack of suitable
statistics, the total attendance at child health clinics in England and Wales was
estimated to be low. A correlation was also sought between social class and infant
mortality in England and Wales. Since infant mortality was very low in the
Nordic countries at that time, i.e. 40/1000 in Norway and 43/1000 in Sweden, the
regional differences detected in England and Wales were not thought to be due to
geographical location. The improvement in childhood mortality had stemmed
mainly from a decrease in deaths from infectious diseases, whereas violent deaths
during the first year of life had increased in the course of time (Martin 1945).
19
Such reports on childhood mortality provide us with information on the
leading causes of death during childhood and help us to appreciate the potentially
preventable causes of death, especially when our increasing knowledge of the
natural courses of diseases and our understanding of the history of childhood
mortality simultaneously contribute to the development of measures for treating
and preventing diseases. It was still uncertain in the 1940s, for instance, whether
the marked decline in childhood mortality due to infectious diseases was
something that might prove reversible (Gale 1945). By analysing childhood
mortality we are able to assess the level and quality of the health care system as a
whole, and also the general path of development within society (Korpi 2010).
2.2
How to describe childhood mortality
Specific mortality rates are customarily calculated according to age at the time of
death. Perinatal mortality consists of stillbirths and deaths in the period from 24
weeks of gestation to the first week after live birth, while neonatal mortality
includes deaths before the age of 28 days after live birth, infant mortality deaths
from birth to one year of age and postneonatal mortality deaths at ages from 28
days to 365 days (Fraser et al. 2014). Perinatal mortality rates are mostly
calculated per 1000 total births, and the subsequent figures per 1000 live births.
International agencies such as UNICEF and the World Health Organization
(WHO) often report child mortality rates as under-five mortality, but age-specific
child mortality rates may be presented in different age bands, such as under one
year old (infant), 1−4 years, 5−9 years, 10−14 years and 15−19 years, respectively
(Fraser et al. 2014). Mortality is highest during infancy, very low in the middle
childhood years and rises again in adolescence (Fraser et al. 2014, Sidebotham et
al. 2014b). In the Finnish mortality data from the late-1980s, approximately two
thirds of the deaths during infancy occurred during the first 28 days of life, and
50% during the first seven days (early neonatal mortality) (Raivio 1990).
Likewise, 60% of the deaths during the early neonatal period occurred during the
first day of life.
Finnish population records can be traced back as far as the 17th century, and
the church records for Sweden, including the territory that later became Finland,
are some of the oldest to be found anywhere in Europe (Population Register
Centre 2013). The first population tables drawn up in Finland date from 1750,
while cause of death statistics were started in 1936 and were categorized
according to the WHO international classification of diseases current at that time
20
(Korpi 2010). However, as national statistics, even in high-income countries, vary
in terms of age cohorts, diagnostic details and data on socioeconomic factors, the
construction of detailed comparisons of child mortality between countries is
somewhat challenging (Fraser et al. 2014).
In any case, categorizations of deaths by main cause as published in national
vital statistics do not provide any explanation for why a child died of a certain
disease on a particular occasion (Sidebotham et al. 2014a). Only a systematic
review of child deaths will enable us to gather comprehensive mortality data and
identify potentially modifiable factors associated with childhood deaths such as
characteristics of the child, the family, and the environment and the prevailing
health-care services (Fraser et al. 2014). Such data could be exploited to make
recommendations for improvements in the system, where applicable.
2.3
Child mortality as a health indicator
Under-five mortality serves globally as an important indicator of child wellbeing,
including health and nutritional status, the coverage of child survival
interventions and levels of social and economic development (UN Inter-agency
Group for Child Mortality Estimation 2014). Factors affecting child mortality in
high-income countries include intrinsic ones, i.e. biological and psychological
factors, the physical and social environment and the provision of services
(Sidebotham et al. 2014a). Of these, it is socioeconomic differences that play the
most important role. Age, sex, genetics, ethnic origin and certain parental and
environmental characteristics are relatively fixed contributing factors, but many
environmental, social and health service factors are modifiable and amenable to
interventions in order to prevent future child deaths (Sidebotham et al. 2014a).
As child mortality reflects the functioning of the health care system in a
robust manner, analyses of the various first-contact and integrated-care models
existing in countries with low childhood mortality rates could provide insights
into how health-care services could be improved across community and hospital
boundaries (Sidebotham et al. 2014a). Although national policies, the
organization of health-care services and the individual health care specialists and
their training are the main service provider factors affecting childhood mortality,
factors inherent in the provision of other welfare services, such as welfare
benefits and social services, have a major influence on child health (Sidebotham
et al. 2014a).
21
2.4
Variations in childhood mortality
Comparisons of international childhood mortality rates are not unambiguous, as
countries publish data using different groupings for the causes of death, different
age bands and different time periods (Fraser et al. 2014). UNICEF and WHO
mostly report mortality statistics for infants and children less than five years of
age, but under-five mortality has less relevance in high-income countries, as
mortality in the age group 1−4 years is generally low. The death registration
systems in high-income countries can be considered reliable and well developed,
but discrepancies in the types of data and the forums used for their publication
may occur. Most mortality statistics are based on a single main cause of death as
defined in the International Classification of Diseases (ICD) (Fraser et al. 2014).
Under-five mortality decreased globally by 64% between 1970 and 2013,
from 17.6 million annual deaths to 6.3 million, the corresponding mortality rates
being 142.6/1000 and 44.0/1000 live births (Wang et al. 2014). In the
industrialized countries under-five mortality declined from 39/1000 to 6/1000 live
births and infant mortality from 32/1000 to 5/1000, respectively, in 1960−2008
(Stanton & Behrman 2011). The United Nations’ Millennium Development Goal
4 was aimed at reducing under-five childhood mortality by two thirds between
1990 and 2015 (The United Nations 2015), but the Millennium Development
Goal assessment showed that the global mortality rate had decreased by 53% and
therefore had not met the target (You et al. 2015). Only two regions, “East Asia
and the Pacific” and “Latin America and the Caribbean”, achieved the target,
while 62 out of 195 countries managed to reduce their under-five mortality by
two-thirds, 12 of these being low-income and another 12 lower/middle-income
countries. Sub-Saharan Africa and South Asia are the areas of highest mortality in
this age group, and urgent action will be needed there in the coming years to
prevent childhood deaths and further improve child survival. The proportional
decrease in under-five mortality in many low and middle-income countries during
the past 25 years has exceeded that in Western Europe and high-income countries
elsewhere, but this is because the major decline in the rate for the high-income
countries occurred a few decades earlier, and these accounted for only 1% of total
under-five deaths worldwide in 2015 (You et al. 2015).
Child mortality rates (0−4 years) in 2013 varied from 2.3/1000 live births in
Singapore to 152.5 in Guinea-Bissau (Wang et al. 2014). The average, lowest and
highest under-five child mortality rates per region in 2013 are presented in Table
1, highlighting the rates for low-mortality countries comparable to Finland.
22
Table 1. Average, lowest and highest under-five mortality rates per 1000 live births by
regions of the world in 2013 (Wang et al. 2014). Rates for low-mortality countries
comparable to Finland are highlighted in bold.
Region
Average
Lowest mortality rate
Highest mortality rate
2.3 Singapore
8.2 Brunei
mortality rate
(under five)
per 1000 live
births
High-income Asia
3.2
3.0 Japan
Central Asia
34.0
16.8 Armenia
52.3 Turkmenistan
East Asia
13.0
6.7 Taiwan
21.2 North Korea
South Asia
52.6
37.7 Nepal
90.2 Afghanistan
Southeast Asia
27.2
6.5 Malaysia
61.3 Laos
Australasia
4.6
4.4 Australia
5.6 New Zealand
Caribbean
35.5
5.7 Cuba
66.1 Haiti
Central Europe
6.7
3.0 Czech Republic
17.9 Albania
Eastern Europe
9.7
4.2 Estonia
12.6 Moldova
Western Europe
3.9
2.4 Iceland
7.0 Malta
2.6 Andorra
4.9 UK
2.7 Sweden
2.8 Luxembourg
3.0 Finland
3.0 Norway
3.0 Germany
Andean Latin America
28.2
22.0 Peru
41.9 Bolivia
Central Latin America
18.0
10.4 Costa Rica
28.1 Guatemala
Southern Latin America
12.3
7.4 Chile
14.2 Argentina
Tropical Latin America
18.1
18.0 Brazil
21.0 Paraguay
North Africa and Middle East
25.2
6.8 United Arab Emirates 50.4 Yemen
High-income North America
6.5
5.4 Canada
6.6 USA
Oceania
50.5
12.2 Samoa
57.0 Papua New Guinea
Central sub-Saharan Africa
110.7
60.4 Gabon
137.7 Central African Republic
Eastern sub-Saharan Africa
76.5
11.7 Seychelles
113.7 Somalia
Southern sub-Saharan Africa
46.9
30.9 Botswana
89.6 Lesotho
Western sub-Saharan Africa
114.3
24.1 Cape Verde
152.5 Guinea-Bissau
23
Despite the great decrease in childhood mortality in industrialised countries
during past decades, variations exist between and inside countries (Fraser et al.
2014). Comparison of all-cause childhood mortality per 100 000 children (aged
0−14 years) in the western European countries in 2006−2010 showed a variation
ranging from 26.5 in Luxembourg and 29.3 in Sweden to 47.8 in the UK and
Belgium (Wolfe et al. 2013). In Finland, mortality rate was the third lowest, 30.3.
Compared to Sweden, the best performing country in the analysis, on estimate
over 1900 child deaths (0−14 years old) might be prevented annually if the UK
health system would perform as well as the Swedish one (Wolfe et al. 2013).
2.4.1 Accidents and other unnatural causes
Approximately 950 000 children under 18 years of age throughout the world died
due to accidents in 2004 (World Health Organization & UNICEF 2008). Road
traffic accidents accounted for 22% of these deaths, drowning 17%, burns 9%,
falls 4% and poisoning 4%, whereas intentional deaths, i.e. homicides and
suicides accounted for 6% and 4%, respectively. The average unintentional death
rates per 100 000 children in high-income countries in 2004 were 28.0 for
children aged under one year, 8.5 for children of age 1−4 years, 5.6 for 5−9 years,
6.1 for 10−14 years old and 23.9 for 15−19 years old, respectively. The combined
mortality rates for all age groups per 100 000 children were 7.0 from road traffic
accidents, 1.2 from drowning, and 0.4 from both fires and poisoning (World
Health Organization & UNICEF 2008).
At the European level, about 24% of all deaths among children and
adolescents are due to injuries, i.e. over 9100 deaths annually (European Child
Safety Alliance 2012). Over two thirds of accidental deaths are unintentional.
There are significant variations between countries, however, as the mortality rates
for all injuries were five times higher in the poorer performing countries than in
the best performing ones, and six times higher when unintentional injuries were
analysed separately. Among the 27 European countries compared in 2010, Finland
was ranked 17th on the basis of deaths from injuries among children and
adolescents, with a mortality rate of 9.31/100 000 of population aged 0−19 years,
which was almost twice as high as in the Netherlands (4.99/100 000) and Sweden
(5.02/100 000), the countries sharing the lowest accidental mortality rates in
Europe. The highest accidental mortality rates among the European countries
were in Lithuania (23.91/100 000 population), Bulgaria (17.37/100 000) and
Romania (17.20/100 000) (European Child Safety Alliance 2012).
24
The incidence of fatal childhood accidents (0−14 years) in Finland decreased
dramatically between 1971 and 2010, from 20.1/100 000 to 2.3/100 000 in girls
and from 36.7/100 000 to 3.5/100 000 in boys (Parkkari et al. 2013). The most
notable decline occurred in deaths due to traffic accidents, drowning and
intentional deaths. Meanwhile, the proportion of total deaths attributable to
injuries decreased from 54% to 24%. Specific mortality rates for various
categories of accidental death in Finland, together with the lowest and highest
mortality rates in Europe, are presented in Table 2, based on data published by the
European Child Safety Alliance (2012).
Table 2. Cause-specific accidental mortality (per 100 000 children and adolescents
aged 0−19 years, by sex) in Finland, and the lowest and highest rates in Europe since
the turn of the century (European Child Safety Alliance 2012).
Category
Lowest mortality rate
Mortality rate in Finland Highest mortality rate
girls/boys
girls/boys
girls/boys
France 0.10/
0.22/0.62
Slovenia 1.26/
Portugal 0.03/0.14
1.89/4.72
Lithuania 4.34/8.02
Motorised two-wheelers
Several countries 0/
0.35/1.39
deaths
Portugal 0.11
Cycling deaths
Several countries 0/
Pedestrian deaths
Netherlands 0.19
Motor vehicle passenger or
Latvia 3.48
driver deaths
Belgium 0.40/
Croatia 2.15
0.15/0.20
Denmark 0.67/
Portugal 0.06
Latvia 0.88
Drowning
UK 0.09/0.48
0.41/0.81
Lithuania 2.09/
Falls
Finland 0/
0/0.47
Latvia 0.60
Latvia 7.53
Estonia 0
Bulgaria and Romania
1.18
Poisoning
Israel 0/0
0.30/1.14
Burns and fire
Slovenia 0/
0.15/0.34
Romania 1.25/
Lithuania 2.55
Czech Republic 0.07
Choking/strangulation
Sweden 0.07/0.14
Bulgaria 0.94/
Latvia 1.21
0.25/0.33
Estonia 1.86/2.93
25
2.4.2 Infectious diseases
Mortality due to infectious diseases has decreased dramatically since the 19th
century (Gale 1945) and the early 20th century (Martin 1945), and childhood
infectious disease mortality in both England and the United States decreased
almost 200-fold between 1861 and 1996, from nearly 400/100 000 to around
2/100 000 (DiLiberti & Jackson 1999). Most notable decreases during past
decades occurred in respiratory tract infections and central nervous system
infections. Mortality from all infectious diseases in children aged 0−4 years
decreased by 40% in Australia in 1979−1994 (Dore et al. 1998) and by 30% in the
United States in 1980−1992, from 30/100 000 to 21/100 000 (Pinner et al. 1996).
In the Netherlands the steepest decline in childhood infectious disease mortality
occurred in the 1970s and was most prominent in infants, from 40/100 000 to
10/100 000 (Veldhoen et al. 2009), whereas no decrease was observed in
mortality among children over five years of age during the same period.
4.9 million children globally died of infectious diseases before the age of five
years in 2010, accounting for 64% of total under-five mortality (Liu et al. 2012).
Pneumonia caused 18% of deaths worldwide, diarrhoea 11% and malaria 7%. In
Europe, pneumonia caused 12% of all under-five mortality and diarrhoea 4%.
Most common causes of fatal lower respiratory tract infections globally in
children from one month to one year of age were Respiratory Syncytial Virus
(RSV), Haemophilus influenzae type b (Hib) and pneumococci, whereas in the
age group 1−4 years they were pneumococci, Hib and influenza, respectively
(Lozano et al. 2012). Most common pathogens causing fatal gastroenteritis were
rotaviruses.
Mortality from pneumonia during childhood declined by 97% in the United
States from 1939 to 1996 (Dowell et al. 2000), with a particularly steep decline in
the late 1940s associated with the use of penicillin and a continuation of the
decline in 1966−1982 that was most probably attributable to improved access to
care. Diarrhoea-associated mortality in US children decreased by 75% between
1968 and 1985 (Kilgore et al. 1995).
Infections accounted for 20% of total childhood deaths in England and Wales
in 2003−2005, and a predisposing medical condition was detected in half of these
cases (Ladhani et al. 2010). Prematurity, neurological disorders and malignancies
were the most common underlying causes, with septicaemia accounting for 46%
of the fatal infections, respiratory tract infections for 30% and central nervous
system infections for 16%. The most common bacterial pathogens detected in
26
these fatal infections were meningococci (28%), pneumococci (18%) and other
streptococci (13%), of which meningococci were significantly more common in
previously healthy children. RSV caused 16% of the deaths due to viral
infections, adenovirus 13%, influenza 11% and cytomegalovirus almost 11%, the
proportion of RSV being as high as 25% in children with a medical condition
(Ladhani et al. 2010).
Infection-related deaths are more common in winter (Ladhani et al. 2010) and
influenza and RSV contribute substantially to the excess winter mortality
(Fleming et al. 2005). RSV causes excess mortality especially in infants (Fleming
et al. 2005, Thompson et al. 2003). Annual influenza attack rates in population
are highest in children and may exceed 20−30% (Heikkinen et al. 2003, Monto &
Sullivan 1993, Neuzil et al. 2002). The impact of these viruses varies greatly by
season, so that during the influenza season of 2003−2004, influenza-associated
mortality in children was the highest among vaccine-preventable diseases and
exceeded mortality from invasive pneumococcal disease in the United States
(Bhat et al. 2005). The influenza mortality rate per 100 000 children was 0.88 in
the age group under six months, approximately 0.25−0.3 in children aged 2−4
years, and around 0.1 from the age of five years onwards. Almost half of the
children who died of influenza were previously healthy (Bhat et al. 2005, Wong et
al. 2013). The pandemic influenza A H1N1 that was in season in 2009−2010
caused a significant increase in childhood influenza mortality (Sachedina &
Donaldson 2010, Sidebotham et al. 2014b, Wong et al. 2013), the rate in the UK
being 0.6/100 000 (Sidebotham et al. 2014b).
The ICD-9 classification of diseases understates the influence of infections on
morbidity and mortality, as the section ”Infectious and Parasitic Diseases” does
not include all infectious diseases, some of which are coded in the section relating
to the organ system (Wilson & Bhopal 1998). Lower respiratory tract infections
are the most common cause of death from infections in childhood, as also among
adults, and deaths from such causes are coded under ”Diseases of the Respiratory
Tract”. Consequently, caution has to be exercised when comparing and
interpreting data from different origins.
2.4.3 Congenital malformations
The total prevalence of major congenital anomalies in Europe in 2003−2007 was
23.9 per 1000 births (Dolk et al. 2010), 80% of which were live births. In 17.6%
of the cases the pregnancy was terminated following prenatal diagnosis of a foetal
27
anomaly. Stillbirths or foetal deaths from 20 weeks of gestation onwards were
recorded in 2.0% of cases, and 2.5% of the children born alive with congenital
malformations died during the first week of life. Chromosomal anomalies were
detected in 3.6/1000 births, and 28% of the stillbirths or foetal deaths attributed to
congenital anomalies and 48% of all terminations of pregnancy on account of a
foetal anomaly were due to chromosomal causes. Congenital heart defects were
detected in 6.5/1000 births, and anomalies of the nervous system in 2.3/1000
births (Dolk et al. 2010).
Perinatal mortality attributable to congenital anomalies occurred in 0.93/1000
births in Europe in 2004, and terminations of pregnancy on account of a foetal
anomaly were performed in 4.4/1000 births (Dolk et al. 2010). There were
considerable variations between the countries in both mortality rates and
terminations of pregnancy. Mortality was highest in Ireland (2.4/1000) and Malta
(2.6/1000), both of which are countries where the termination of pregnancy is
illegal. In Denmark, 11.1% of foetal deaths and 31.2% of infant deaths in
1995−2008 were associated with major congenital anomalies, with foetal and
infant mortality from congenital anomalies decreasing from 2.8/1000 births in
1995−1999 to 1.5/1000 in 2005−2008 and mortality from congenital
malformations during the first week of life from 1.14/1000 to 0.32/1000,
respectively (Garne et al. 2014).
Congenital heart defects accounted for 26% of the perinatal deaths due to
anomalies, chromosomal defects for 25% and nervous system anomalies for 21%.
The majority of deaths due to congenital anomalies (82.7%) occur during the first
year of life (Agha et al. 2006), and survival rates are greatly affected by the type
of anomaly (Wang et al. 2010), the highest risks being associated with
anencephaly, trisomies 13 and 18, and hypoplastic left heart.
2.4.4 Tumours and haematological diseases
Each year approximately 150 children are diagnosed with cancer in Finland
(Madanat-Harjuoja et al. 2014) and about 15 000 in Europe (Gatta et al. 2009).
During the period 1980−2010 leukaemia accounted for 35% of all childhood
cancers in Finland (Madanat-Harjuoja et al. 2014), tumours of the central nervous
system (CNS) for 26%, lymphomas 11%, neuroblastoma 7%, kidney tumours and
soft tissue sarcomas 6% and bone tumours 3%.
The overall age-standardized incidence rates of childhood cancers have
increased both in Europe, from 120 per million children in 1978−1982 to 141 per
28
million (aged 0−14 years) in 1993−1997 (Kaatsch et al. 2006), and in the USA,
from 140 per million (aged 0−19 years) in 1975 to 165 per million in 2006
(Smith et al. 2010). In Europe, incidence rates are highest in the north, averaging
160 per million, with Finland reaching an age-standardized incidence rate as high
as 173 per million (Kaatsch 2010). Incidence rates for leukaemia, lymphoma,
CNS tumours and soft tissue sarcomas increased equally throughout the Nordic
countries between 1978 and 1997 (Kaatsch et al. 2006).
On the other hand, the overall mortality rates associated with childhood
cancers declined by over 50% in the USA during the period 1975−2006 (Smith et
al. 2010). The rate of deaths from all cancers per 100 000 children (aged 0−19
years) decreased from 5.14 to 2.48 over that time span, those from leukaemia
from 2.03 to 0.75, those from CNS tumours from 0.93 to 0.64 and those from
neuroblastoma from 0.36 to 0.23, representing percentage decreases of 64% for
leukaemia, 75% for lymphomas and 30−40% for neuroblastoma and bone cancer,
respectively. Leukaemias accounted for 30% of fatal childhood cancers, CNS
tumours for 26%, neuroblastoma and bone cancers for around 9%, soft tissue
cancers for 7% and lymphomas for 6% in 2006 (Smith et al. 2010). Similarly,
age-standardized mortality rates in the UK declined by 59%, from 7.5/100 000 in
1965−1969 to 3.1/100 000 in 2000−2004 (Sidebotham et al. 2014b). Infections
play a major role in childhood cancer mortality, as they are said to have
contributed to 25% of the deaths due to haematological malignancies and 5% of
deaths from solid tumours (Bate et al. 2009).
The overall survival rate for childhood cancer has increased in Finland since
the 1950s, from approximately 25% to 82% (Madanat-Harjuoja et al. 2014), with
survival following all leukaemia increasing from almost zero to 83%, that for
acute lymphoblastic leukaemia (ALL) to 86%, that for Hodgkin lymphoma from
50% to 97% and that for non-Hodgkin lymphoma from around 20% to 89%.
Survival in CNS tumour cases has increased from 35% to 80%, neuroblastoma
from under 20% to 68%, kidney tumours from 25% to 86%, bone tumours from
35% to 71% and soft tissue sarcomas from 50% to 73%. The most prominent
increases in survival rates occurred during the 1970s and 1980s, and further
increases took place, but to a lesser extent, until the 1990s, after which a plateau
was reached.
29
2.4.5 Sudden infant death syndrome
Sudden infant death syndrome (SIDS) refers to the sudden, unexpected death of
an infant, the cause of which remains unexplained despite investigations into the
case history and place of death and the performing of a forensic autopsy
(Wennergren et al. 2015). The risk of SIDS is highest at the age of between two
and four months, and 90% of cases occur before the age of six months (Filiano &
Kinney 1994, Moon et al. 2007). The risk of SIDS is associated with sleeping in
the prone position (Fleming et al. 1990), bed sharing (Carpenter et al. 2004) and
maternal smoking during pregnancy and infancy, the last-mentioned effect being
dose-dependent (Mitchell et al. 1993). The risk may be reduced by breastfeeding
(Hauck et al. 2011) and the use of a pacifier (Hauck et al. 2005, Mitchell et al.
2006).
The mechanisms behind SIDS remain unknown despite extensive
epidemiological studies, but one commonly accepted model is the “triple risk
hypothesis” (Filiano & Kinney 1994), according to which SIDS may occur upon
the coincidence of three factors: a vulnerable infant, a critical homeostatic
developmental period and an exogenous stressor, such as sleeping in prone
position. Immature cardiorespiratory autonomic control and failure of the arousal
response while asleep are regarded as the final pathways leading to SIDS.
Although its incidence has declined dramatically since the 1980s thanks to
public campaigns promoting supine sleeping (Moon et al. 2007), SIDS remains a
major cause of death among infants aged one month to one year in developed
countries. In Sweden, for example, its incidence decreased from 1.2/1000 live
births in 1990 to around 0.2/1000 since the early-2000s (Wennergren et al. 2015),
while in Finland the decrease was from 0.65/1000 live births in the late 1980s to
0.25/1000 in the 2001 (Kirjavainen 2003). Japan and the Netherlands are
currently the countries with the lowest incidence of SIDS, 0.09 and 0.1/1000 live
births, respectively, whereas the highest SIDS mortality rates among developed
countries have been reported in New Zealand, 0.8/1000 live births (Moon et al.
2007).
2.4.6 Regional differences in childhood mortality and the impact of
socioeconomic differences
It is been possible to review regional differences in infant mortality in Finland,
along with Sweden, from the mid-18th century onwards (Pitkanen et al. 2000).
30
Figures were high in the 19th century, with as many as one child in five dying
during the first year of life, and regional differences were prominent. Lapland,
Ostrobothnia and Åland were the areas with the highest infant mortality, this
being associated with the brevity or avoidance of breastfeeding. Interestingly,
however, the regional differences in childhood mortality in the 19th century
differed from those in infant mortality, as childhood mortality was clearly of
minor significance in the areas with high infant mortality at that time, i.e. Lapland
and Åland, as compared with other regions. One possible explanation may be that
the areas concerned were remotely located and sparsely populated, and the spread
of infectious epidemics, which were a major cause of death in childhood, was not
so extensive there (Pitkanen et al. 2000).
By the 1950s Finland featured a notable distinction between the betterdeveloped southern part and more slowly developing eastern and northern parts,
where standard of living was substantially lower and health services poorer
(Pitkanen et al. 2000). Thus infant mortality at that time was significantly higher
in northern and eastern Finland than in the south and south-west. Also, by this
stage the regional differences in mortality among children aged one to fourteen
years showed similar trends to those in infant mortality (Pitkanen et al. 2000).
Alongside reports on the regional influence of socioeconomic differences on
infant mortality in the early 20th century (Martin 1945) mention is also made of an
association between social class and childhood mortality from infectious diseases
(Gale 1945) and close correlations between injury-associated childhood death
rates and both gross domestic product (GDP) and income inequality when
considering the European countries and certain regions within these (Avery et al.
1990, Sengoelge et al. 2013, Sengoelge et al. 2014). The higher the GDP, the
lower the mortality rates from all causes and from injuries, whereas increasing
income inequality is associated with higher child mortality rates.
Social equity in terms of health care is a major target in the public health
policies of the Nordic countries, which are in any case fairly homogeneous with
regard to standard of living and economic structures (Arntzen & Nybo Andersen
2004). Their child poverty rates, for example, are among the lowest in Europe,
around 10−13%, although they have increased lately, especially in Sweden and
Finland (Marmot et al. 2012), as would also seem to have been the case with
social inequality increased in these countries between the years 1980 and 2000
(Arntzen & Nybo Andersen 2004). Socioeconomic inequalities have nevertheless
been consistently less marked in Finland and Sweden than in Denmark and
Norway. The effect of family type on child mortality in Finland has been shown
31
to be greatest during early childhood (1–4 years), especially as far as accidental
and violent deaths are concerned (Remes et al. 2010, Remes et al. 2011). Excess
mortality tends to be concentrated in less educated families and single-parent
families, and may partly be explained by lower household incomes in the latter
case.
2.5
Validity of childhood mortality data
2.5.1 Comparability of the ICD revisions
Trends in cause-specific mortality are mainly attributed to changes in medical
treatment, environmental conditions and life-style, but long-term mortality trends
can also reflect changes in the classification of causes of death on death
certificates (Van der Stegen et al. 2014). The transition from ICD-9 to ICD-10, for
example, led to an enormous increase in the number of codes used, from about 6
000 in the former to around 10 000 in the latter. In addition, some diseases were
moved to different sections along with new insights into their aetiology and
pathogenesis.
Data on the effects of the transitions between ICD versions on cause-of-death
statistics are mainly available for the adult population or cover all age groups.
ICD coding changes between 1950 and 1999 (from ICD-6 to ICD-10) have been
analysed in six European countries, including Finland, and significant
discontinuities in cause-specific mortality have been pointed out for people aged
60 and older in the case of 10.8% of the revisions to cause-specific mortality
codes affecting 26 selected causes of death. These discontinuities were most
prominent, amounting to 16.0%, at the transitions from ICD-6 and ICD-7 to ICD8, whereas the proportion of discontinuities was 10.8% for the transition from
ICD-8 to ICD9 and 4.6% from ICD-9 to ICD-10 (Janssen & Kunst 2004). The
magnitude of ICD-related mortality discontinuities and the specific diagnoses in
which they appear seem to vary a little between countries (Anderson &
Rosenberg 2003, Janssen & Kunst 2004, Van der Stegen et al. 2014). In the USA,
for instance, substantial discontinuities in cause-of-death trends were noted in
deaths due to septicaemia, influenza and pneumonia, Alzheimer’s disease and
nephritis and nephrosis following the implementation of ICD-10 (Anderson &
Rosenberg 2003), while the same transition did not alter the overall trends in
deaths due to accidents, homicides or suicides in Italy and Norway, although
32
changes did occur in some injury subcategories (Gjertsen et al. 2013). So far only
limited data have been available on the comparability of ICD versions specifically
in children, although it has been noted that the classification system for the
paediatric complex chronic conditions showed a close comparability between the
ICD-9 and ICD-10 versions in the USA and did not lead to any substantial
discontinuity in the temporal trends observable in the death statistics (Feudtner et
al. 2014).
2.5.2 Validity of death certification
The reliability and validity of mortality statistics will depend on how accurate the
cause of death diagnoses on death certificates are and how correctly the
certificates are filled in (Lahti & Penttilä 2001). Despite the existence of
numerous epidemiological studies based on national mortality statistics, there
have been only a few studies focused on the validity of death certificates and
procedures for their validation (Lahti & Penttilä 2003). Routine validation of
death certificates in Finland showed them to possess good accuracy and validity
(Lahti & Penttilä 2001), however, so that this country’s death certification
practices and the procedure for validating causes of death form a relevant
reference background for epidemiological studies. Children’s death certificates
were included in the data, but not those of infants aged under one year (Lahti &
Penttilä 2001, Lahti & Penttilä 2003).
When the European Commission evaluated European cause-of-death statistics
in the project Quality and comparability improvement of European causes of
death statistics in 1999–2001 (European Commission 2001) certain Finnish
certification practices were placed at the forefront relative to those of other
European countries. Finland was the only country, for instance, where certifying a
death without considering the results of a postmortem examination that had been
performed was impossible, whereas in some countries postmortem results are not
included in death certificates because the Causes of Death Office is never
informed of them or the results are delayed. Finnish death certificates contain an
extensive amount of socio-demographic information, including many variables
extracted from the population register, such as family relationships, housing,
language and religion. Finland is one of only seven countries that use a specific
cause of death certificate for infant deaths, as recommended by the WHO. In
Finland this infant death certificate applies to the neonatal period and includes
stillbirths. Vocational training in matters of certification is less frequent in Europe,
33
as only 5/20 countries organize this. In Finland such training has been provided
by local forensic doctors in the context of transitions between ICD revisions. The
coverage of death certificates has been analysed by comparing the numbers of
deaths registered by the Mortality Statistics Offices with the corresponding data
in the General Population Register. The difference in Finland has been close to
zero (European Commission 2001).
2.6
Possibilities for preventing childhood deaths
Attempts to reduce the numbers of child deaths in the future need to be based on
an understanding of the modifiable risk factors and evidence on the efficacy,
acceptability and cost-effectiveness of preventive interventions (Petrou et al.
2014). Furthermore, because of the well-documented socioeconomic gradients
existing in childhood mortality, an understanding of the mechanisms by which
socioeconomic deprivation affects childhood mortality is of great importance. As
many as 26% of the child deaths subjected to a multidisciplinary panel enquiry in
the UK, in 2006 were identified with avoidable factors, and a further 43% of
cases with potentially avoidable factors (Pearson GE 2008). The most common
avoidable factors were failures to recognise a seriously ill child, mostly involving
the first contact with the health care services, and in most cases applying to
children who had previously been healthy, with no known life-limiting disease
(Pearson et al. 2011).
The potential areas in which child mortality in high-income countries could
be further reduced are mostly deaths from perinatal causes, acquired natural
causes such as acute respiratory problems or septicaemia, and external causes,
among which road traffic accidents play a major role (Petrou et al. 2014).
Multidisciplinary teams in England have investigated all unexpected deaths of
children under 18 years since 2008, and their findings have prompted local
preventative actions such as public campaigns, safety initiatives and further
education for professionals (Sidebotham et al. 2011).
2.6.1 Accidents
As accidents are the most common cause of death among children aged over one
year, prevention strategies aimed at reducing mortality from external causes are
among the main means adopted for reducing future child deaths. It has been
estimated that as many as 90% of all fatal injuries to children could be prevented
34
if the strategies that have proved effective were to be equally rigorously
implemented (European Child Safety Alliance 2012). Among the European
countries mortality from injuries is lowest in the Netherlands, and if the rates in
all 31 countries participating in the European Child Safety Report had matched
those reported in the Netherlands, over 3800 deaths of children and adolescents in
Europe would have been prevented in 2010.
The prevention of accidental deaths needs extensive collaboration between
the health authorities, education, police and legal services, industry and
consumers (Petrou et al. 2014). Legislation requiring the use of protective
equipment such as helmets, car seats and smoke alarms, and the promotion of
safety devices via media campaigns and professional counselling are effective
approaches for reducing injuries to children, as also are product modifications and
environmental modifications aimed at preventing road traffic accidents (Harvey et
al. 2009). The aim of the “Health in All Policies” approach is that policymakers in
all sectors (i.e. transport, education, employment, urban planning etc.) should
systematically take into account the health impact of their decisions, whether
positive or negative (National Institute for Health and Welfare 2012, World
Health Organization 2013). The approach emphasizes that health should be taken
as a basis for all policymaking, and that the promotion of health is the common
responsibility of all sectors of society and government. Education for children and
parents, alongside other injury prevention strategies and improvements in access
to pre-hospital and essential trauma care also play an important role (Harvey et al.
2009). Given the persistent socioeconomic gradient in childhood mortality,
especially in mortality from external causes, the prevention strategies should be
targeted by taking account of the population groups with the highest risks (Petrou
et al. 2014).
Effective interventions to prevent road traffic accidents include legislation
requiring seat belts, child restraints and bicycle helmets, speed limits around
schools and play areas, the separation of motorized from non-motorized traffic,
and the proper use of safety devices (European Child Safety Alliance 2006,
Harvey et al. 2009). Inappropriate use of child restraint devices, such as incorrect
installation, loose or improperly routed harness straps and seat belts and
premature graduation from child restraints to seat belts, is a significant risk factor
for severe and fatal road traffic accidents (Decker et al. 1984, Skjerven-Martinsen
et al. 2013, Still et al. 1992). Positioning children in the back seat can reduce the
risk of severe injury as well (Brown et al. 2006). The prevention of drowning
accidents requires close and constant supervision by adults especially in the case
35
of younger children around the lakes, rivers and pools and opportunities to learn
to swim at an early age (American Academy of Pediatrics Committee on Injury,
Violence, and Poison Prevention 2010, Safety Investigation Authority, Finland
2014).
Strategies for the prevention of suicide among young people have generally
been targeted at reducing known risk factors or early recognition of potential
cases with accompanying referral and treatment (Gould et al. 2003, Pelkonen &
Marttunen 2003). Data on the effectiveness of suicide prevention programmes has
so far been limited. The Saving and Empowering Young Lives in Europe
(SEYLE) study was the first European effort in this direction and one of the
largest randomized controlled trials, in fact a comparison between three widely
used, school-based suicide prevention programmes (Wasserman et al. 2015). The
Youth Aware of Mental Health (YAM) Programme, aimed at raising pupils’
awareness of mental health and enhancing their abilities to cope with adverse life
events, stress and mental health problems, had halved the rates of suicide attempts
and severe suicide ideation relative to the control group after only 12 months.
Interventions by school staff or health care professionals did not have any
significant effects (Wasserman et al. 2015). Involvement in bullying, as a victim,
perpetrator or both, has been identified as being associated with a risk of suicidal
ideation and behaviour (Holt et al. 2015).
2.6.2 Infectious diseases
The recognition of serious infections in children is a major challenge in health
care, as these have become rare in recent decades. The accuracy of diagnosis
greatly affects the survival of children. In a Finnish series of children diagnosed
with bacterial meningitis, 58% of the cases were detected at the first examination
and a clear diagnostic delay occurred in 11% (Valmari 1985), while in the UK
only 51% of children with meningococcal infection were sent to hospital after the
first contact with the health services (Thompson et al. 2006). This may be due to
the fact that the classic features of meningococcal disease, i.e. haemorrhagic rash,
meningism and impaired consciousness, develop late whereas death may occur
within 24 hours of the onset of symptoms, so that the time-window for diagnosis
is narrow.
Various warning scores and prediction rules have been established to
facilitate the task of recognising seriously ill children among the large group of
those with mild infections. In a systematic review to assess clinical features of
36
serious infections in children, no single rule-out feature was found, but cyanosis,
rapid breathing, slow capillary refill, meningeal irritation, decreased
consciousness and petechial rash were commonly identified as significant
warning signs (Van den Bruel et al. 2010). Parental concern and clinician instinct
were detailed as powerful warning signs in one primary care study. The Yale
Observation Scale, the most widely applied rule, was of no notable help in
confirming or excluding serious infections (Van den Bruel et al. 2010), but the
Bedside Paediatric Early Warning System score, based on heart rate, blood
pressure, capillary refill, respiratory rate and effort, oxygen saturation and oxygen
therapy, showed elevated and increasing scores 24 hours before clinical
deterioration and was capable of identifying children with a
risk of
cardiopulmonary arrest (Parshuram et al. 2011).
Many earlier common communicable diseases have nowadays become rare
thanks to national vaccination programmes. Measles was eradicated from Finland
in 1996, and mumps and rubella in 1997 (Peltola et al. 2008), while the incidence
of Hib meningitis in Scandinavia had decreased from 31/100 000/year in the
1970s, during the pre-vaccination era, to <1/100 000/year by 1995 (Peltola 2000).
Recent amendments to the Finnish national vaccination programme have
been the introduction of influenza vaccination for children aged 6 to 35 months in
autumn 2007, the availability of a rotavirus vaccine in autumn 2009 and a
pneumococcal conjugate vaccine in autumn 2010. The efficacy of the trivalent
inactivated influenza vaccine in children is reported as high as 60−80% as its best
(Heinonen et al. 2011, Hoberman et al. 2003, Treanor et al. 2012). Influenza may
expose people to bacterial complications such as pneumonia (Lahti et al. 2006),
and the widespread vaccination of children has also reduced the incidence of
influenza in older age groups (Hurwitz et al. 2000, Jordan et al. 2006). Invasive
pneumococcal diseases (IPD), pneumonia, bacteraemia and meningitis most
commonly affect children under two years of age (Bechini et al. 2009), and
pneumococcal conjugate vaccines have proved effective against these in
childhood while also protecting older age groups (Bechini et al. 2009,
Deceuninck et al. 2015, Waight et al. 2015). Rotavirus is the most common cause
of severe gastroenteritis requiring hospitalization, and the efficacy of the two
current vaccines against this is 85%, reaching 100% for the most severe forms
(Ruiz-Palacios et al. 2006, Vesikari et al. 2006).
RSV is a significant cause of acute respiratory tract infections in infancy and
is associated with marked morbidity, hospitalization and even mortality (Nair et
al. 2010). Children born prematurely or with existing clinical conditions such as
37
bronchopulmonary dysplasia or chronic lung disease of prematurity, congenital
heart disease, multiple congenital anomalies and immunodeficiency are in the
highest risk group for severe RSV infection (The IMpact-RSV Study Group
1998). Palivizumab, a humanized respiratory syncytial virus monoclonal
antibody, is effective in reducing hospitalizations due to RSV infections in highrisk children and is also given to highly prematurely born infants during RSV
epidemics or infants with chronic lung disease or haemodynamically significant
congenital heart disease during the first year of life (American Academy of
Pediatrics Committee on Infectious Diseases & American Academy of Pediatrics
Bronchiolitis Guidelines Committee 2014, Homaira et al. 2014).
2.6.3 Sudden infant death syndrome
Adoption of a supine sleeping position is a well-known practice for preventing
sudden infant death syndrome (SIDS) (Carpenter et al. 2004, Fleming et al. 1990,
Moon et al. 2007, Wennergren et al. 2015). Besides the prone position, sleeping
on one’s side is also associated with an increased risk of SIDS, as the position is
unstable and may allow the infant to accidentally roll into the prone position. Soft
bedding and soft surfaces in the bed are also considered risk factors for SIDS, as
are warm room temperatures and multiple layers of clothing (Fleming et al.
1990). Bed sharing has been shown in many studies to increase the risk of SIDS
(Carpenter et al. 2013, Carpenter et al. 2004), especially when the mother is a
smoker or has consumed alcohol or drugs. There have nevertheless been some
recent case-control studies in which co-sleeping without hazardous circumstances
such as smoking or alcohol consumption was not associated with any elevated
risk of SIDS (Blair et al. 2014). Regardless of these considerations, room sharing
without bed sharing has been said to reduce the risk of SIDS (Carpenter et al.
2004) and most recommendations nowadays emphasize this approach.
The use of a pacifier has been shown to reduce the risk of SIDS (Carpenter et
al. 2004, Hauck et al. 2005, Mitchell et al. 2006), possibly by allowing for a
lower arousal threshold (Franco et al. 2000) or by helping to keep the upper
airways open (Tonkin et al. 2007). A pacifier may also affect the sleeping
position, preventing the infant from adopting a prone position (Moon et al. 2007).
Recommendations for pacifier use in order to prevent SIDS have until recently
been made only in Germany and the Netherlands (Hauck et al. 2005), but the
updated Swedish recommendation also includes the option of providing a pacifier
when the infant is going to sleep (Wennergren et al. 2015). Besides the other
38
health benefits, breastfeeding, to any extent, is reported to reduce the risk of SIDS
(Hauck et al. 2011, Vennemann et al. 2009).
Exposure to smoking during pregnancy and infancy is a well-known, dosedependent risk factor for SIDS (Mitchell et al. 1993). Smoking during pregnancy
is associated with reduced birth weight, which is a known risk factor for SIDS,
and it may also contribute to foetal hypoxia. Infants exposed to smoking as
foetuses seem to show decreased arousability from sleep, both spontaneous and
evoked (Horne et al. 2004). Smoking during pregnancy also appears to induce
dysregulation of the autonomic nervous control of cardiovascular functions in the
newborn (Horne et al. 2004).
Public campaigns promoting safe sleeping have had a major influence on the
decline in SIDS mortality. Mortality from SIDS in the UK decreased by 75% after
the ”Back to Sleep” campaign of 1991 (Blair et al. 2006), and the popularity of
the prone position for sleeping infants has decreased by 50−90% as a
consequence of such campaigns in other countries, as has mortality from SIDS
(Hauck & Tanabe 2008, Moon et al. 2007). As sleeping in the prone position has
become more unusual these days, future prevention efforts should be targeted at
reducing the other risk factors connected with sleeping habits and at preventing
exposure to smoking. Like many other adverse outcomes in infancy and
childhood, the risk of SIDS is higher in the offspring of young mothers and in
socioeconomically deprived families (Fleming et al. 2015).
2.6.4 The role of primary care in promoting children’s health
The organization of services, training of professionals, co-operation between
health professionals and out-of-hours care are the main issues when seeking to
improve the quality of children’s first-contact care (Wolfe et al. 2013). Childhood
mortality rates are lowest in Sweden, and the functioning of the Swedish health
care system has been used as a baseline in European comparisons (Wolfe et al.
2011, Wolfe et al. 2013). If all 15 pre-2004 countries of the European Union had
had childhood mortality rates similar to Sweden, more than 6000 child deaths per
year could have been prevented. In 11 of these 15 countries paediatricians receive
at least five years of training (Wolfe et al. 2013), and the length of the training
period in Finland is six years. The training of GPs in child health varies greatly
between countries, however, so that while most GPs in Sweden have at least three
months’ training in paediatrics and work in health centres in close contact with
39
paediatricians and children’s nurses, the training of GPs in child health has
become infrequent nowadays in the UK, for example (Wolfe et al. 2011).
The European countries also differ with respect to their first access models
(Wolfe et al. 2011). The system in the UK and the Netherlands is based on GPs,
who work as gatekeepers to paediatricians operating at the secondary care level.
In Italy primary care paediatricians treat children directly, whereas in France and
Germany families may choose between a GP and a paediatrician in the first
instance. It has been estimated that integrated first access teams could fill the gap
between primary and secondary care that can so easily lead to a degrading of care.
The objective of integrated care is to provide high quality urgent and long-term
care and prevent unnecessary referrals and admissions, functioning in a manner
that is more convenient for the patient and provides rapid access to a specialist
opinion when needed (Wolfe et al. 2011).
40
3
Aims of the research
The aims of this research were:
1.
2.
3.
4.
to evaluate trends in childhood mortality in Finland over the period
1969−2004 (Paper I), especially whether the decline in mortality was
continuous and whether there were deaths that could have been prevented,
to analyse changes in childhood mortality due to infectious diseases in
Finland over the period 1969−2004 (Paper II) and evaluate whether the
figures could be further reduced,
to examine whether there were regional differences in postneonatal childhood
mortality in Finland in 1985−2004 (Paper III), especially in the case of causes
of death that were preventable, and
to evaluate the regional differences in childhood mortality due to accidents
and other unnatural causes in Finland in 1969−2013 (Paper IV), with the
intention of identifying the main preventable causes of death which might
need further measures in order to prevent injury.
41
42
4
Materials and methods
The materials and methods employed were to a great extent the same in all four
publications. The general methods presented here were used throughout, with
only minor differences between the papers. The specific features of each
publication will be discussed below in more detail.
The focus of the analysis shifted from trends in overall childhood mortality in
Finland between 1969 and 2004 (I) to trends in mortality from infectious diseases
over the same interval (II). This was followed by an evaluation of regional
differences in overall childhood mortality during the period from 1985 to 2004
(III) and in accidental childhood mortality from 1969 to 2013 (IV).
The annual mortality data for children who died before the age of 16 were
obtained from the official Finnish mortality statistics, the Cause of Death
Statistics, and were based on the death certificates of children younger than
sixteen years. We have not verified the validity of these data. In 1996 hospital
post-mortem examinations were performed in 54% of all cases of natural deaths
of children and adolescents (0–19 years) and forensic post-mortem examinations
in 17%, i.e. post-mortem examinations in 71% of cases altogether (Penttilä et al.
1999). Where unnatural deaths were concerned, forensic post-mortem
examinations were performed in 97% of cases. The annual birth rate at the
beginning of the period, in 1969, was approximately 67 000, but it had declined to
57 000 by 2004. As deaths during the first month of life are mainly due to
neonatal causes, we analysed these separately from the deaths of children aged
from 1 month to 16 years (I, II) and excluded them from the analysis in Papers III
and IV.
The causes of death were classified according to the International
Classification of Diseases (ICD) codes in the edition that was current at the time
of registration. ICD-8 was used in 1969−1986, ICD-9 in 1987−1995 and ICD-10
from 1996 onwards (Statistics Finland 2007). We then classified the diagnoses
into eight broad categories (accidents, congenital malformations, infectious
diseases, tumours and haematological diseases, metabolic diseases and endocrine
disorders, perinatal disorders, SIDS and other causes of death), as presented with
their corresponding ICD codes in Table 3. Infectious diseases were further
classified into seven categories, upper respiratory tract infections, lower
respiratory tract infections, septicaemia, central nervous system infections,
gastroenteritis, myocarditis and other infections (II), and accidents into 11
categories, traffic accidents, drowning, poisoning, therapeutic procedures, falls,
43
burns, exposure to natural forces, choking or strangulation, suicide, homicide and
others (IV). Annual mortality rates were calculated with reference to those at risk
of dying, i.e. all living children in the same age group, and rounded up to deaths
per 1 000 (II) or 100 000 children (I). 95% confidence intervals (95% CI) were
calculated on the assumption that mortality follows a Poisson distribution (I, II,
III) (Bailar 1964).
Table 3. Classification of causes of death and the corresponding ICD codes.
Category
ICD-8
ICD-9
ICD-10
Infectious diseases
000-136
001-139
A00-B99
Tumours and haematological diseases
140-239
140-239
C00-D89
Metabolic diseases and endocrine disorders
240-279
240-279
E00-E90
Perinatal disorders
760-779
760-779
P00-P96
Congenital malformations
740-759
740-759
Q00-Q99
Deaths from external causes of injuries or poisoning
800-959
800-999
S00-T98
795.99
7980A
R95
Sudden infant death syndrome (SIDS)
Other causes of death
4.1
Mortality due to infectious diseases (II)
In view of the changes in the registration of deaths implemented in 1987, about
half of the case descriptions after that time also included contributory causes of
death (40% of cases in the childhood group and 70% in the neonatal group).
Before that, only the main cause of death was reported. It was possible on the
basis of the contributory causes of death to analyse whether the children had
previously been healthy or had had a predisposing condition of some kind
(chronic disease). The predisposing chronic diseases were then classified into
seven categories: congenital malformations, cancers and haematological diseases,
neurological diseases, metabolic and endocrine disorders, prematurity, other
perinatal disorders and other causes. Age-specific mortality from infections was
calculated in two cohorts, 1969–1986 and 1987–2004, again defined by the
changes in the registration of deaths in 1987.
Respiratory syncytial virus (RSV) has traditionally caused epidemics every
second year in Finland (Waris 1991), with April, May, November and December
as its peak months in odd years and January and February in even years. We
analysed the distribution of deaths from all infections, lower respiratory tract
infections and SIDS in the years with and without RSV epidemics separately to
evaluate the possible excess mortality that RSV may cause, calculating the years
44
with RSV epidemics from April in each odd year to March in the following even
year and the years without such an epidemic from April in each even year to
March in the following odd year.
4.2
Regional differences in childhood mortality (III)
Regional post-neonatal childhood mortality in Finland between 1985 and 2004
was considered in two ten-year periods, 1985−1994 and 1995−2004, comparing
mortality rates between the five university hospital districts and the 15 central
hospital districts (Fig. 1). The mortality rates for the ten-year periods were
adjusted with reference to the population at risk of dying and rounded up as
percentages. Since the numbers of live births per hospital district were available
from 1987 onwards, having previously been reported per local government
district, the figures were combined where necessary in order to represent the
hospital districts as they were on 1 January 2005 (III, IV). Correspondingly, the
basic population figures used were the numbers of all children in the given age
group who were alive in 1990 for the first period (1985−1994) and in 2000 for the
latter period (1995−2004). The population data were obtained from the Statistical
Yearbook of Finland for 1969-1986 and from the Official Statistics of Finland
Perinatal Statistics for 1987 onwards (III, IV).
Since internal migration during childhood is rare in Finland, we estimated the
population on the basis of live births and child deaths before the age of 16,
defining the place of death as the place of domicile at the time of death (III, IV).
The causes of death were analysed in eight categories, but the results were
reported more specifically for accidents, congenital malformations, tumours and
haematological diseases and infectious diseases. The percentages of total deaths
for the specific categories and the corresponding ICD-10 codes are presented in
Table 4.
Differences between the time periods were identified with the binomial
Standardised Normal Deviate (SND) test and differences between hospital
districts with the chi-square test.
45
Fig. 1. Hospital districts in Finland, those with circles have university hospitals (Map
obtained from the Association of Finnish Local and Regional Authorities). Reprinted
with permission from John Wiley and Sons.
3 Varsinais-Suomi
13 Pohjois-Savo
4 Satakunta
14 Keski-Suomi
5 Kanta-Häme
15 Etelä-Pohjanmaa
6 Pirkanmaa
16 Vaasa
7 Päijät-Häme
17 Keski-Pohjanmaa
8 Kymenlaakso
18 Pohjois-Pohjanmaa
9 Etelä-Karjala
19 Kainuu
10 Etelä-Savo
20 Länsi-Pohja
11 Itä-Savo
21 Lappi
12 Pohjois-Karjala
25 Helsinki and Uusimaa
46
Table 4. Classification of causes of death, percentages of total deaths and
corresponding ICD-10 codes.
Category
Total deaths (%)
ICD-10 codes
1985-1994
1995-2004
Accidents
32
34
V02-Y86
Congenital malformations
19
17
Q00-Q99
Infectious diseases
8
9
A00-B99, G00-G09, I30,
J00-J22, J69, N39, P23,
P35-P39
Tumours and haematological
12
14
C14-D47, D56-D82
3
5
E10-E88
Perinatal disorders
4
3
P02-P91
Sudden infant death syndrome
10
7
R95
12
12
Not classified above
diseases
Metabolic diseases and endocrine
disorders
(SIDS)
Other causes of death
4.3
Regional differences in childhood mortality due to accidents (IV)
Childhood mortality from accidents was assessed regionally for 20 hospital
districts of Finland in 1969–2013 (Fig. 1), calculating average annual mortality
rates for each of four periods (1969–1984, 1985–1994, 1995–2004 and 2005–
2013) as deaths per 100 000 children, adjusted to the population at risk of dying.
The population (number of all children in the age group who were alive) during
the middle year of each period served as the basic population (1976 for the period
1969–1984, 1990 for the period 1985–1994, 2000 for the period 1995–2004 and
2010 for the period 2005–2013). Fatal accidents and other unnatural deaths were
divided into 11 categories and more specific results were reported for the most
common causes: traffic accidents, drowning, suicides and homicides. The
percentages of total deaths and numbers of deaths in each category, together with
their corresponding ICD-10 codes, are presented in the Results section. Because
of the smaller number of cases, suicides and homicides were considered in three
time periods: 1969–1984, 1985–2004 and 2005–2013. It is significant that the
ICD-10 classification does not categorize alcohol intoxication as a form of
poisoning.
To determine the stability of the regional differences in accidental childhood
mortality, the 20 hospital districts were ranked in order from the lowest to the
highest mortality rate for each time period, and the ranking scores of all three
47
(suicides and homicides) or four (all accidents, traffic accidents and drowning)
periods were summed for each hospital district. As some hospital districts had no
drowning deaths, suicides or homicides during certain periods, these were all
ranked as 1. This combining of the ranking scores enabled us to aggregate the
time periods and construct an equal system for rating the hospital districts. It also
made the differences in regional mortality comparable, thus enabling us to
analyse the consistency of accidental mortality in each region.
Total post-neonatal child mortality showed a notable peak in December 2004,
when 44 Finnish children died in the tsunami in Southeast Asia. This event
accounted for 6% of all accidental deaths (750) in 1995−2004, and its effect on
accidental mortality in 1995−2004 was concentrated in certain hospital districts,
with 16% in Helsinki and Uusimaa, 8% in Pirkanmaa, Päijät-Häme and EteläSavo, and 6% in Kanta-Häme, whereas it had little or no effect on the others.
These tsunami deaths were excluded from the data, as the intention was to analyse
regional differences in accidental childhood deaths that might be preventable.
48
5
Results
5.1
Trends in childhood mortality in Finland, 1969 – 2004 (I)
5.1.1 Neonatal mortality
Annual neonatal mortality in Finland declined by 78%, from 1113/100 000 (95%
CI 1036/100 000 to 1195/100 000) to 246/100 000 (95% CI 208/100 000 to
289/100 000), between 1969 and 2004 (Fig. 2), the most marked change being in
the 1970s. Perinatal disorders were the leading cause of death throughout the
period, but it was a rapid decline in mortality from antenatal and perinatal
disorders, from 830/100 000 (95% CI 764/100 000 to 901/100 000) in 1969 to
183/100 000 (95% CI 151/100 000 to 217/100 000) in 1982, that accounted for
the decline in the 1970s, while to the proportion of congenital malformations,
another major cause of death, remained stable until the mid-1980s and declined
from 174/100 000 (95% CI 143/100 000 to 209/100 000) to 59/100 000 (95% CI
41/100 000 to 82/100 000) between 1985 and 2004. Mortality from infectious
diseases also declined markedly throughout the period, from 50/100 000 (95% CI
35/100 000 to 70/100 000) in 1969 to 16/100 000 (95% CI 7/100 000 to 29/100
000) in 2004. Altogether, decreases of 82% in mortality from perinatal disorders,
70% in that from congenital malformations and 69% in that from infectious
diseases took place over the whole period. It was not possible to evaluate the
proportion of premature infants because only a fraction of main causes of death
were classified according to birth weight or gestational age in the earlier version
of the ICD.
5.1.2 Childhood mortality
Mortality among children aged from one month to 16 years declined by 65%
during the period concerned, from 67/100 000 (95% CI 62/100 000 to 71/100
000) in 1969 to 23/100 000 (95% CI 20/100 000 to 26/100 000) in 2004, the
actual numbers of deaths per year declining from 855 to 224 (Fig. 3, Table 5).
Accidents and violent deaths were the leading causes, followed by congenital
malformations, tumours and haematological diseases, and infectious diseases in
that order (Table 5).
49
All
Perinatal disorders
Congenital malformations
Infections
12
Mortality (‰)
10
8
6
4
2
0
1970
1975
1980
1985
1990
1995
2000
2005
Year
Fig. 2. Neonatal mortality in Finland in 1969−2004. Reprinted with permission from
John Wiley and Sons.
0,7
All
Accidents
Congenital malformations
Tumours and haematology
Infections
0,6
Mortality (‰)
0,5
0,4
0,3
0,2
*
0,1
*
0,0
1970
1975
1980
1985
1990
1995
2000
2005
Year
Fig. 3. Mortality among children aged one month to 16 years from all causes, accidents,
congenital malformations, tumours and haematological diseases, and infectious diseases
in Finland in 1969–2004. Mortality rates for 2004 from all causes and from accidents are
also presented without deaths due to the South Asian tsunami catastrophe. Reprinted with
permission from John Wiley and Sons.
50
Table 5. Main causes of death in childhood. The number of live births during the 36 years
examined was 2 187 180.
Category
Proportio Total absolute Incidence
Incidence
Decline (%)
95% CI of
n (%) of
number of
(‰) 2004
1969-2004
decline
all deaths
deaths
(‰) 1969
Accidents
37
5259
0.28
0.10
65
50.1-82.9
Congenital
18
2531
0.098
0.032
67
51.9-85.1
14
1925
0.087
0.033
62
47.5-79.5
malformations
Tumours and
haematological diseases
Infectious diseases
11
1621
0.12
0.013
89
71.5-109.5
Total
100
14213
0.67
0.23
65
50.1-82.9
A notable peak in total mortality occurred in 2004 on account of the Asian
tsunami in December of that year, in which 44 Finnish children perished,
accounting for 20% of all deaths and 45% of deaths due to accidents in that year.
If the tsunami deaths are excluded, the decline in mortality is seen to have
continued in 2004, since mortality caused by other accidents reached the lowest
level ever.
Traffic accidents and drowning were most common fatal injuries, but
mortality from both causes decreased markedly over the years, from 189 cases in
traffic accidents and 96 cases of drowning in 1969 to 16 and 11, respectively, in
2004. By contrast, the numbers of suicides and homicides remained quite stable
and no clear decline was seen.
Heart defects were the most common fatal congenital malformation,
accounting for 45% of all fatal malformations (N=1145 deaths, 95% CI 1080 to
1213). Malformations of the central nervous system accounted for 15% of deaths
(N=385, 95% CI 348 to 425) and chromosomal defects for 10% (N=247, 95% CI
218 to 279).
Leukaemia was the most common cancer of childhood, causing 37% of all
deaths from tumours and haematological diseases (N=715, 95% CI 664 to 769),
while brain tumours accounted for 24% of all malignancies, lymphomas for 6.9%
and sarcomas for 6.7%, the numbers of deaths being 463 (95% CI 422 to 507),
133 (95% CI 111 to 158) and 130 (95% CI 109 to 154), respectively.
Lower respiratory tract infections (pneumonia, bronchitis and bronchiolitis)
caused 580 deaths (95% CI 534 to 629), central nervous system infections 397
(95% CI 359 to 438) and septicaemia 186 (95% CI 160 to 215). Myocarditis
caused 99 deaths (95% CI 80 to 121), gastroenteritis 96 (95% CI 78 to 117) and
51
upper respiratory tract infections, including diagnoses such as acute laryngitis, 83
(95% CI 66 to 103).
Sudden infant death syndrome (SIDS) is a diagnosis of exclusion given to
unexpected and unexplained deaths occurring during the first year of life. As only
this age group is at risk of receiving such a diagnosis, mortality rates for SIDS
were calculated by comparing the numbers of deaths attributed to SIDS among
children aged 0 to 12 months with those of all live births during the same years.
Since SIDS was recognised as a specific cause of death in Finland from 1979
onwards, only a few deaths were given this diagnosis before that. Mortality from
SIDS was 32/100 000 (95% CI 19/100 000 to 49/100 000) in 1979 and doubled to
63/100 000 (95% CI 45/100 000 to 86/100 000) the next year (Fig. 4). It then
remained high throughout the 1980s but declined rapidly in the 1990s. Mortality
from SIDS in 2004 was 19/100 000 (95% CI 10/100 000 to 34/100 000).
0,7
0,6
Mortality (‰)
0,5
0,4
0,3
0,2
0,1
0,0
1970
1975
1980
1985
1990
1995
2000
2005
Year
Fig. 4. Mortality attributed to SIDS in Finland in 1969–2004. SIDS was accepted as a
specific cause of death in this country in the late 1970s. Reprinted with permission from
John Wiley and Sons.
52
5.2
Changes in mortality due to infectious diseases (II)
5.2.1 Neonatal mortality from infections
Infection was detected as the main cause of death in 661 of the 11 263 cases, i.e.
6% of children who died before the age of one month, the rate being highest
during the first week of life. Neonatal mortality from infections varied markedly
during the period studied here, but it declined significantly, by 69% in
1969−2004, from 0.50‰ (95% CI 0.35‰ to 0.70‰) to 0.16‰ (95% CI 0.07‰ to
0.30‰) (Fig. 5).
Septicaemia was the most common fatal infection in the neonatal period, with
no clear decline over time, although fluctuations were seen from year to year (Fig.
5). Only a few fatal CNS infections were reported after the 1980s. Streptococci
and Escherichia coli caused most of the fatal septicaemia cases, and streptococci
were the most common bacterial pathogen in CNS infections. Only the 10th
edition of ICD included specifications of streptococcal subspecies. Even though
group B streptococcus is the typical pathogen causing invasive bacterial
infections at this age, only 17% of streptococcaemia cases were attributed to this
group. None of the reports of CNS infections due to streptococci contained a
definition of the subspecies involved. Three deaths annually could have been
avoided if group B streptococcal infections had been preventable by vaccination.
Out of the total of 3461 children who died during the neonatal period from
1987 onwards, infection was detected as the main cause in 165 cases (5%), with
138 of these having a predisposing condition. Other perinatal disorders (52% of
all causes), prematurity (27%) and congenital malformations (19%) were the most
common of such conditions. Infection was reported as a contributory cause of
death in 110 cases.
53
All
Sepsis
CNS
Mortality /1000
0,8
0,6
0,4
0,2
0,0
1970
1975
1980
1985
1990
1995
2000
2005
Year
Fig. 5. Neonatal mortality from all infections, septicaemia and central nervous system
(CNS) infections in Finland, 1969–2004. Reprinted with permission from Wolters
Kluwer Health, Lippincott Williams & Wilkins.
5.2.2 Childhood mortality due to infections
Out of the 14 214 deaths of children aged one month to 16 years recorded during
the period examined here, 11% (i.e. 1620) were attributable to an infection.
Mortality from infections declined notably by 89%, from 0.12‰ (95% CI 0.10‰
to 0.15‰) in 1969 to 0.013‰ (95% CI 0.007‰ to 0.023‰) in 2004, the greatest
change occurring during the 1970s (Fig. 6). Mortality from infections was highest
before the age of three years (Fig. 7).
Pneumonia, CNS infections and septicaemia were the most common fatal
infections, and mortality in all these categories decreased with time (Fig. 6).
Gastroenteritis, myocarditis and upper respiratory tract infections were minor
causes, accounting for only a few deaths annually. Mortality from gastroenteritis
declined during the 1970s, whereas no decline was seen in mortality from
myocarditis.
54
All
Pneumonia
Sepsis
CNS
0,14
0,12
Mortality /1000
0,10
0,08
0,06
0,04
0,02
0,00
1970
1975
1980
1985
1990
1995
2000
2005
Year
Fig. 6. Childhood mortality from all infections, pneumonia and other lower respiratory
tract infections, septicaemia and central nervous system infections in Finland, 1969–
2004. Reprinted with permission from Wolters Kluwer Health, Lippincott Williams &
Wilkins.
0,5
1969-1986
1987-2004
Mortality /1000
0,4
0,3
0,2
0,1
0,0
0
2
4
6
8
10
12
14
Age (years)
Fig. 7. Age-specific mortality from infections in two cohorts (1969–1986 and 1987–
2004), excluding those who died during the first month of life. Reprinted with
permission from Wolters Kluwer Health, Lippincott Williams & Wilkins.
55
Only a minor proportion of the lower respiratory tract infections were attributable
to a specified pathogen. Influenza viruses were detected in 5.2% of cases, and
pneumococci in 4.9% of the lower respiratory tract infections.
Respiratory Syncytial Virus (RSV) has typically caused epidemics in Finland
every second year, unlike the situation in most European countries, where such
epidemics occur each winter (Waris 1991). There were slightly more deaths from
all infections and from lower respiratory tract infections during the years of the
RSV epidemics, but the number of deaths attributed to the sudden infant death
syndrome (SIDS) was not elevated following these epidemics (Fig. 8).
Hib and meningococci were the most common bacteria detected in fatal CNS
infections, the incidence of which has declined markedly in Finland since
vaccinations against Hib were launched (Fig. 9). There has been only one case of
fatal Hib meningitis since the 1980s, in 1994. Meningococci were clearly the
most common cause of fatal septicaemia.
From 1987 onwards the mortality data also included contributory causes of
death. Infection was detected as the main cause of death in 386 cases in
1987−2004, including 233 cases (60%) in which the children had previously been
healthy and 153 cases (40%) where they had had a predisposing condition. Lower
respiratory tract infections made up 28% of the fatal infections in the children
with no predisposing condition, CNS infections 20%, septicaemia 17%,
myocarditis 12%, gastroenteritis 8% and upper respiratory tract infections 6%. Of
the children with chronic conditions, 48% died of lower respiratory tract
infections, 14% of CNS infections, 9% of septicaemia, 6% of myocarditis, 5% of
gastroenteritis and 1% of upper respiratory tract infections.
Infection was detected as a contributory cause of death in 810 cases in
1987−2004, involving 40 previously healthy children and 770 with a predisposing
condition. The main cause of death in the previously healthy children was most
commonly an accident. Among the children who died of infections as main cause,
congenital malformations were detected as predisposing conditions in 35% of
cases, neurological diseases in 30%, cancers in 14%, metabolic and endocrine
disorders in 7% and perinatal disorders in 3%.
56
RSV epidemic
no epidemic
Number of deaths
800
600
400
200
0
All
LRTI
SIDS
Fig. 8. Distribution of deaths from all infections, lower respiratory tract infections
(LRTI), and sudden infant death syndrome (SIDS) in years of RSV epidemics and years
without epidemics. RSV epidemics typically occur in Finland every second year, with
peaks in April, May, November and December in odd years and January and February
in even years. The years for the RSV epidemics are calculated from April in each odd
year to March in the following even year and those without an RSV epidemic from
April in each even year to March in the following odd year. Reprinted with permission
from Wolters Kluwer Health, Lippincott Williams & Wilkins.
57
A
60 (17.7%)
28 (8.26%)
23 (6.78%)
7 (2.06%)
7 (2.06%)
130 (38.35%)
84 (24.78%)
Meningococci
Haemophilus influenzae
Pneumococci
Streptococci
Staphylococci
Escheria coli
Other or non-specified
Total 339
B
4 (6.06%)
19 (28.79%)
33 (50%)
10 (15.15%)
Total 66
Fig. 9. The most common bacteria causing fatal septicaemia and CNS infections in the
childhood group in 1969–86 (A) and 1987–2004 (B). Reprinted with permission from
Wolters Kluwer Health, Lippincott Williams & Wilkins.
58
Vaccines against pneumococci, influenza, rotavirus and varicella were not
included in the Finnish national vaccination programme during the period for
which the data were gathered, and it may be estimated that pneumococcal
conjugate vaccination could have prevented one death from a lower respiratory
tract infection and one from septicaemia or a CNS infection each year and
influenza vaccination at least one death annually. Pneumococci and influenza
viruses were detected in only 10% of all cases of fatal lower respiratory tract
infections, which may suggest that the effect of vaccines on mortality could have
been even greater than estimated. Gastroenteritis caused approximately two
deaths annually, and since rotaviruses are the most common cause of fatal
gastroenteritis, it may be estimated that rotavirus vaccines would most probably
have prevented between one and two deaths per year. In total 24 children died of
varicella during the period concerned, of which 10 were CNS infection cases. The
inclusion of varicella in the vaccination programme would have prevented
approximately 0.7 deaths annually.
5.3
Regional differences in childhood mortality (III)
5.3.1 University hospital districts
Post-neonatal childhood mortality in the five university hospital districts varied
from 0.28% to 0.32% in 1985−1994 and from 0.21% to 0.24% in 1995−2004
(Fig. 10), but the individual districts did not differ statistically significantly (Table
6). Mortality rates in the hospital districts declined by between 18% and 30%
during the two periods 1985−1994 and 1995−2004, the changes being statistically
significant in four districts.
Accidents were the most common cause of death in all the university hospital
districts, followed by congenital malformations, tumours and haematological
diseases, and infectious diseases in that order (Fig. 11). There were considerable
differences in mortality due to accidents between the hospital districts in
1985−1994, but these were reduced in the latter period. Mortality from infectious
diseases showed minor differences between the hospital districts in 1985−1994,
and mortality from tumours and haematological diseases did not vary regionally,
nor did it decrease significantly between the two periods. Congenital
malformations were the cause of death that showed the most notable decrease in
mortality in all the university hospital districts.
59
UNIVERSITY HOSPITAL DISTRICT
1985-1994
1995-2004
*
3
*
6
*
18
*
25
13
0,00
0,05
0,10
0,15
0,20
0,25
0,30
MORTALITY / 10 YEARS
Fig. 10. Childhood mortality (% and 95% CI) in the Finnish university hospitals,
1985−2004.
* A statistically significant decline in mortality between the two periods
(p< 0.05). Reprinted with permission from John Wiley and Sons.
60
Table 6. Mortality rates in the university and central hospital districts, 1985–1994 and
1995–2004.
Hospital
districts
Difference
95% CI of
Number of deaths /
Mortality rate
in mortality
the
population
% (95% CI)
between
difference
periods (%)
1985–1994
1995–2004
1985–1994
1995–2004
University
3
261 / 82715
186 / 81264
0.32 (0.28–0.36) 0.23 (0.20–0.26)
0.09
6
244 / 80357
172 / 80446
0.30 (0.27–0.34) 0.21 (0.18–0.25)
0.09
0.04–0.14
0.04–0.14
13
150 / 52988
109 / 48112
0.28 (0.24–0.33) 0.23 (0.19–0.27)
0.06
-0.01–0.12
18
258 / 87565
203 / 83757
0.29 (0.26–0.33) 0.24 (0.21–0.28)
0.05
0.00–0.10
25
731 / 250666
578/271380
0.29 (0.27–0.31) 0.21 (0.20–0.23)
0.08
0.05–0.11
Combined
1644/554291
1248/564959
0.30 (0.28–0.31) 0.22 (0.21–0.23)
0.08
0.06–0.09
4
154 / 48839
103 / 41933
0.32 (0.27–0.37) 0.25 (0.20–0.30)
0.07
0.00–0.14
5
116 / 29850
79 / 30162
0.39 (0.32–0.47) 0.26 (0.21–0.33)
0.13
0.04–0.22
7
118 / 39807
68 / 37375
0.30 (0.25–0.36) 0.18 (0.14–0.23)
0.12
0.05–0.19
8
109 / 35090
80 / 31544
0.31 (0.26–0.38)
0.06
-0.02–0.14
Central
0.25 (0.20-0.32)
9
77 / 25277
51 / 22265
0.31 (0.24–0.38) 0.23 (0.17–0.30)
0.08
-0.02–0.17
10
76 / 21486
29 / 18564
0.35 (0.28–0.44) 0.16 (0.11–0.22)
0.20
0.10–0.30
11
51 / 11087
25 / 10854
0.46 (0.34–0.61) 0.23 (0.15–0.34)
0.23
0.08–0.39
12
125 / 36619
79 / 32945
0.34 (0.28–0.41) 0.24 (0.19–0.30)
0.10
0.02–0.18
14
157 / 51846
106 / 49630
0.30 (0.26–0.35) 0.21 (0.18–0.26)
0.09
0.03–0.15
15
157 / 42623
94 / 38503
0.37 (0.31–0.43) 0.24 (0.20–0.30)
0.12
0.05–0.20
16
107 / 35230
54 / 32504
0.30 (0.25–0.37) 0.17 (0.13–0.22)
0.14
0.07–0.21
17
43 / 18897
27 / 16697
0.23 (0.17–0.31) 0.17 (0.11–0.24)
0.07
-0.03–0.16
19
73 / 21098
54 / 16805
0.35 (0.27–0.44) 0.32 (0.24–0.42)
0.03
-0.10–0.14
20
43 / 16192
54 / 13954
0.27 (0.19–0.36) 0.39 (0.29–0.51)
-0.12
-0.26–0.01
21
115 / 28379
61 / 25656
0.41 (0.34–0.49) 0.24 (0.18–0.31)
0.17
0.07–0.27
Combined
1521/ 462320
964/ 419391
0.33 (0.31–0.35) 0.23 (0.22–0.24)
0.10
0.08–0.12
61
1985-1994
1995-2004
ACCIDENTS
CONGENITAL MALFORMATIONS
18
UNIVERSITY HOSPITAL DISTRICT
UNIVERSITY HOSPITAL DISTRICT
13
18
3
6
25
13
3
6
25
0,00
0,02
0,04
0,06
0,08
0,10
0,12
0,14
0,00
TUMOURS AND HAEMATOLOGICAL DISEASES
25
6
13
18
0,00
0,02
0,03
0,04
0,05
0,06
0,07
INFECTIOUS DISEASES
6
UNIVERSITY HOSPITAL DISTRICT
UNIVERSITY HOSPITAL DISTRICT
3
0,01
25
3
13
18
0,01
0,02
0,03
0,04
MORTALITY / 10 YEARS
0,05
0,00
0,01
0,02
0,03
MORTALITY / 10 YEARS
Fig. 11. Mortality (% and 95% CI) due to accidents, congenital malformations, tumours
and haematological diseases, and infectious diseases in the Finnish university
hospital districts, 1985−2004. Reprinted with permission from John Wiley and Sons.
62
5.3.2 Central hospital districts
Post-neonatal childhood mortality in the central hospital districts varied from
0.23% to 0.46% in 1985−1994 and from 0.16% to 0.39% in 1995−2004 (Fig. 12).
The regional differences in mortality were more notable during the first period
and were statistically significant between districts with the lowest and highest
mortality rates (Table 6). Eight hospital districts during the first period and seven
during the latter period differed statistically significantly in their mortality rates
from the lowest figure recorded. Mortality declined during both periods, the
greatest changes being seen in the districts with highest mortality in the earlier
period. The changes in mortality between the two periods were not statistically
significant in six hospital districts (hospital districts 8, 9, 14, 17, 19 and 20). The
only hospital district in which mortality did not decline was one of the smallest,
and here it increased in all four categories.
The most common causes of death were the same as in the university hospital
districts, accidents, congenital malformations, tumours and haematological
diseases, and infectious diseases (Fig. 13), but there were notable regional
differences in mortality in all these categories. In 1985−1994 the differences
between the highest and lowest rates of mortality among the hospital districts
were four-fold in the case of accidents, almost three-fold for congenital
malformations, over three-fold for tumours and haematological diseases and fourfold for infectious diseases, and although the gaps were slightly reduced in
1995−2004, they had not totally disappeared.
63
1985-1994
1995-2004
*
CENTRAL HOSPITAL DISTRICT
11
*
21
*
5
*
*
15
10
19
*
12
*
4
8
9
*
16
14
*
7
20
17
0,00
0,05
0,10
0,15
0,20
0,25
0,30
0,35
0,40
0,45
0,50
0,55
MORTALITY / 10 YEARS
Fig. 12. Childhood mortality (% and 95% CI) in the Finnish central hospital districts,
1985−2004. * A statistically significant decline in mortality between the two periods (p<
0.05). Reprinted with permission from John Wiley and Sons.
64
1985-1994
1995-2004
CONGENITAL MALFORMATIONS
21
11
11
19
15
10
CENTRAL HOSPITAL DISTRICT
CENTRAL HOSPITAL DISTRICT
ACCIDENTS
12
20
5
9
8
16
10
4
19
5
21
7
14
12
17
9
4
8
7
15
14
20
17
16
0,00 0,02 0,04 0,06 0,08 0,10 0,12 0,14 0,16 0,18 0,20
0,00
TUMOURS AND HAEMATOLOGICAL DISEASES
5
4
19
0,06
0,08
0,10
0,12
0,14
8
CENTRAL HOSPITAL DISTRICT
CENTRAL HOSPITAL DISTRICT
0,04
INFECTIOUS DISEASES
11
15
0,02
21
19
16
4
10
20
14
8
7
17
16
14
15
21
9
12
5
10
11
17
9
7
12
20
0,00 0,01 0,02 0,03 0,04 0,05 0,06 0,07 0,08 0,09
MORTALITY / 10 YEARS
0,00
0,01
0,02
0,03
0,04
0,05
MORTALITY / 10 YEARS
Fig. 13. Mortality (% and 95% CI) from accidents, congenital malformations, tumours
and haematological diseases, and infections in the Finnish central hospital districts,
1985−2004. Reprinted with permission from John Wiley and Sons.
65
5.4
Regional differences in childhood mortality due to accidents
(IV)
Annual mortality from accidents and other unnatural causes ranged between
16.2/100 000 (N=232 for the whole period) and 25.1/100 000 (N=178) in
1969−1984, between 4.8/100 000 (N=9) and 16.9/100 000 (N=48) in 1985–1994,
between 4.2/100 000 (N=7) and 15.8/100 000 (N=22) in 1995–2004, and between
3.4/100 000 (N=2) and 11.4/100 000 (N=24) in 2005–2013 (Fig. 14). Thus
mortality has declined noticeably from the first period (1969−1984), but markedly
more slowly since the end of the 1980s, with no significant decline in the last two
periods (1995–2004 and 2005–2013). The classification of accidents with
corresponding ICD-10 codes, numbers of deaths and percentages of total deaths
are presented in Table 7. The regional differences were considerable, as mortality
varied more than three-fold between the hospital districts with the lowest and
highest mortality rates in 1985–2013. The summed ranking scores showed that
mortality rates were consistently highest in Etelä-Pohjanmaa, Pohjois-Pohjanmaa
and Lappi, whereas they remained lowest in Keski-Pohjanmaa, Helsinki and
Uusimaa and Etelä-Savo.
Traffic incidents were the most common fatal accidents, accounting for 50%
of total accidental mortality during the first two periods, but these decreased
significantly in 1995–2013 so that their proportion of total accidental mortality
diminished from 50% to 40%. Annual mortality from traffic accidents varied from
7.8/100 000 (N=299 for the whole period) to 13.7/100 000 (N=97) in 1969−1984,
from 2.7/100 000 (N=5) to 8.2/100 000 (N=35) in 1985–1994, from 1.9/100 000
(N=51) to 8.6/100 000 (N=12) in 1995–2004 and from 0.84/100 000 (N=1) to
6.1/100 000 (N= 12) in 2005–2013 (Fig. 15). Pedestrian-related deaths accounted
for 23% of total traffic accidents in both periods, deaths due to cycling for 22% in
1987–2004 and 15% in 2005–2013, and deaths associated with mopeds and
motorcycles for 14% in 1987–2004 and 25% in 2005–2013, respectively. EteläPohjanmaa and Länsi-Pohja had the highest mortality from traffic accidents
throughout the entire time span, whereas Helsinki and Uusimaa, KeskiPohjanmaa and Keski-Suomi were the areas with the lowest mortality. The
variation in mortality between the lowest and highest rates was more than six-fold
in 2005–2013.
66
2005-2013
(24)
4
Lappi 21
HOSPITAL DISTRICT NUMBER
(13)
(13)
Vaasa 16
Pohjois-Karjala 12
(12)
Kanta-Häme
5
(12)
Etelä-Karjala
9
(8)
(7)
Länsi-Pohja 20
Varsinais-Suomi
3
(30)
(26)
(14)
Keski-Suomi 14
Päijät-Häme
15
(21)
8
6
21
(11)
Pohjois-Savo 13
Pirkanmaa
18
(18)
Etelä-Pohjanmaa 15
Kymenlaakso
4
(45)
Pohjois-Pohjanmaa 18
7
13
HOSPITAL DISTRICT NUMBER
Satakunta
1969-2013
(11)
8
16
12
5
9
20
6
3
14
7
(86)
HUS 25
Kainuu 19
Keski-Pohjanmaa 17
25
(6)
19
(6)
17
(6)
Etelä-Savo 10
10
(2)
Itä-Savo 11
0
2
4
11
6
8
10
0
12
10
20
30
40
50
60
70
SUMMED RANKING SCORES OF ALL PERIODS
ANNUAL MORTALITY / 100 000
Fig. 14. Annual mortality and number of deaths (in parentheses) from all accidents and
other unnatural causes in the hospital districts of Finland in 2005–2013, and summed
ranking scores for the total interval 1969–2013.
Table 7. Classification of fatal accidents, their corresponding ICD-10 codes, percentages
of total deaths and numbers of deaths per period (in parentheses). *Including tsunami
deaths in 2004.
Category
ICD-10 codes
Percentage of total deaths
1969–1984
1985–1994
1995–2004
2005–2013
(N=3481)
(N=1028)
(N=750)
(N=377)
% (N)
% (N)
% (N)
% (N)
50.6 (1759)
50 (514)
39.4 (296)
40.8 (154)
14.3 (54)
Traffic accidents
V03–V93, Y85
Drowning
W66–W74
20.7 (719)
14.4 (148)
17.6 (132)
Poisoning
X40–X47
1.9 (66)
1.3 (13)
1.5 (11)
1.1 (4)
Therapeutic procedure
Y74
0.2 (6)
0.6 (6)
0.1 (1)
0.3 (1)
Falling
W01–W23
4.5 (158)
3.7 (38)
4.4 (33)
4.8 (18)
Burn
X00–X01
3.3 (115)
4.0 (41)
3.6 (27)
2.4 (9)
Exposure to natural forces X31–X39
0.8 (28)
1.3 (13)
6.5 (49*)
0.5 (2)
Choking/strangulation
W75–W83
7.3 (253)
5.3 (54)
5.2 (39)
9.5 (36)
Suicide
X61–X83
4.1 (144)
7.8 (80)
9.3 (70)
11.7 (44)
Homicide
X85–X99, Y00–Y08
3.6 (125)
6.7 (69)
8.7 (65)
9.8 (37)
Others
Not categorised
3.1 (108)
5.1 (52)
3.6 (27)
4.8 (18)
above
67
2005-2013
(12)
Etelä-Pohjanmaa 15
15
(6)
Länsi-Pohja 20
20
(8)
Kymenlaakso 8
Satakunta 4
8
4
(10)
13
(11)
Pohjois-Savo 13
HOSPITAL DISTRICT NUMBER
HOSPITAL DISTRICT NUMBER
1969-2013
(19)
Pohjois-Pohjanmaa 18
(6)
Pohjois-Karjala 12
Etelä-Savo 13
(5)
Lappi 21
(4)
Itä-Savo 11
(2)
(5)
Vaasa 16
(12)
Varsinais-Suomi 3
Päijät-Häme 7
(5)
Kainuu 19
(3)
(10)
Pirkanmaa 6
18
12
10
21
11
16
3
7
19
6
Kanta-Häme 5
(3)
5
HUS 25
(27)
25
Etelä-Karjala 9
(1)
9
Keski-Suomi 14
(2)
14
Keski-Pohjanmaa 17
(1)
0
17
1
2
3
4
5
0
6
10
20
30
40
50
60
70
80
SUMMED RANKING SCORES OF ALL PERIODS
ANNUAL MORTALITY / 100 000
Fig. 15. Annual mortality and numbers of deaths (in parentheses) from traffic accidents in
the hospital districts of Finland in 2005–2013, and summed ranking scores for the total
interval 1969–2013.
1969-2013
2005-2013
(7)
Vaasa 16
(2)
21
Keski-Suomi 14
(4)
14
Keski-Pohjanmaa 17
(2)
17
Päijät-Häme 7
7
(3)
HOSPITAL DISTRICT NUMBER
HOSPITAL DISTRICT NUMBER
16
Lappi 21
(3)
Satakunta 4
(6)
Pohjois-Pohjanmaa 18
(2)
Kymenlaakso 8
(15)
HUS 25
Etelä-Karjala 9
(1)
Pohjois-Savo 13
(2)
Etelä-Savo 10
Kanta-Häme 5
(1)
(1)
Etelä-Pohjanmaa 15
(1)
Varsinais-Suomi 3
(2)
Pirkanmaa 6
(2)
4
18
8
25
9
13
10
5
15
3
6
Länsi-Pohja 20
20
Itä-Savo 11
11
Kainuu 19
19
12
Pohjois-Karjala 12
0
1
2
3
4
ANNUAL MORTALITY / 100 000
0
10
20
30
40
50
60
SUMMED RANKING SCORE OF ALL PERIODS
Fig. 16. Annual mortality and numbers of deaths (in parentheses) from drowning in the
hospital districts of Finland in 2005–2013, and summed ranking scores for the total
interval 1969–2013.
68
Drowning accounted for 15−20% of all accidental deaths throughout the
period examined here, with annual mortality ranging between 2.6/100 000 (N=14
for the whole period) and 6.0/100 000 (N=15) in 1969−1984, between 0.5/100
000 (N=2) and 3.6/100 000 (N=4) in 1985–1994, between 0 and 3.0/100 000
(N=5) in 1995–2004, and between 0 and 4.3/100 000 (N=7) in 2005–2013 (Fig.
16). Mortality from
drowning decreased considerably, but the regional differences were smaller than
for other fatal accidents and showed no consistency with time.
Annual mortality from suicides varied from 0 to 1.9/100 000 (N=12) in
1969−1984, from 0 to 2.0/100 000 (N=6) in 1985–2004, and from 0 to 3.5/100
000 (N=4) in 2005–2013 (Fig. 17), while mortality from homicides ranged
between 0 and 1.2/100 000 (N=3) in 1969−1984, between 0 and 1.5/100 000
(N=11) in 1985–2004, and between 0 and 1.9/100 000 (N=4) in 2005–2013 (Fig.
18). The summed ranking scores for suicides were highest in Lappi, Etelä-Karjala
and Pohjois-Pohjanmaa and lowest in Itä-Savo, Vaasa and Keski-Pohjanmaa.
Helsinki and Uusimaa and Pohjois-Pohjanmaa had the highest summed ranking
scores for homicides, with those in Vaasa, Lappi and Etelä-Karjala consistently
the lowest. Since the numbers of deaths in hospital districts other than Helsinki
and Uusimaa were small, the differences may be explained largely by variations
due to chance alone. Deaths associated with medical procedures were rare in
Finland throughout the period examined here.
69
2005-2013
SUICIDE
Etelä-Karjala 9
(4)
9
(3)
Pohjois-Karjala 12
12
(3)
Kanta-Häme 5
Lappi 21
5
(2)
Pohjois-Pohjanmaa 18
(6)
Keski-Suomi 14
(3)
Pohjois-Savo 13
(3)
21
18
HOSPITAL DISTRICT NUMBER
HOSPITAL DISTRICT NUMBER
1969-2013
(2)
Päijät-Häme 7
(1)
Kainuu 19
Pirkanmaa 6
(4)
HUS 25
(10)
Kymenlaakso 8
(1)
(1)
Etelä-Pohjanmaa 15
Varsinais-Suomi 3
(1)
Etelä-Savo 10
Länsi-Pohja 20
14
13
7
19
6
25
8
15
3
10
20
Satakunta 4
4
Keski-Pohjanmaa 17
17
Vaasa 16
16
Itä-Savo 11
0,0
11
0,5
1,0
1,5
2,0
2,5
3,0
3,5
0
ANNUAL MORTALITY / 100 000
10
20
30
40
50
60
SUMMED RANKING SCORES OF ALL PERIODS
Fig. 17. Annual mortality and numbers of deaths (in parenthesis) due to suicide in the
hospital districts of Finland in 2005–2013, and summed ranking scores for the total
interval 1969–2013.
2005-2013
Satakunta
4
(4)
HUS 25
19
(1)
12
HOSPITAL DISTRICT NUMBER
HOSPITAL DISTRICT NUMBER
25
(1)
Pohjois-Karjala 12
(1)
Etelä-Pohjanmaa 15
Varsinais-Suomi
3
(2)
Pirkanmaa
6
(2)
Keski-Suomi 14
(1)
Pohjois-Savo 13
(1)
Länsi-Pohja 20
8
Itä-Savo 11
5
Päijät-Häme
7
18
(14)
Kainuu 19
Kanta-Häme
4
(7)
Pohjois-Pohjanmaa 18
Kymenlaakso
1969-2013
15
3
6
14
13
20
8
11
5
7
Etelä-Savo 10
10
Keski-Pohjanmaa 17
17
9
9
Lappi 21
21
Etelä-Karjala
Vaasa 16
16
0,0
0,5
1,0
1,5
ANNUAL MORTALITY / 100 000
2,0
0
10
20
30
40
50
SUMMED RANKING SCORES OF ALL PERIODS
Fig. 18. Annual mortality and numbers of deaths (in parentheses) due to homicide in
the hospital districts of Finland in 2005–2013, and summed ranking scores for the
total interval 1969–2013.
70
6
Discussion
6.1
Trends in childhood mortality
Childhood mortality in Finland has decreased notably during past decades,
reaching one of the lowest levels to be recorded globally. Even though it is
currently very low, further reductions can still be achieved. The nature or
incidence of the diseases contributing to childhood mortality may change
unpredictably over the years, and individual health care professionals and even
units meet with uncommon diseases so infrequently that it is difficult or
impossible to notice even significant changes of this kind. Continuous monitoring
of the national mortality data can enable us to analyse the major causes of death
and contributing factors and to plan preventive actions in a timely manner.
Accidents
Accidents are the leading cause of death from early childhood to adolescence, but
mortality due to them has declined by 65% during recent decades. Mortality from
traffic accidents and drowning has declined most noticeably, probably by virtue of
improved traffic safety through the promotion of safety devices and advances in
the management of trauma cases, and perhaps also through public campaigns to
prevent drowning, poisonings and burns (Parkkari et al. 2000). As 75% of fatal
accidents are attributed to predisposing factors such as a dangerous environment
or inadequate adult supervision (Itkonen et al. 1996), it is obvious that mortality
could be reduced further by improving safety measures.
Finland was the third highest among the western European countries in terms
of childhood and adolescent mortality due to accidents in 2009−2010, just below
Belgium and Luxembourg, but had only about half the level of fatal accidents
recorded in the Baltic states (Safety Investigation Authority, Finland 2014).
Accidental mortality rates among children under 15 years of age in Finland
remain at the average western European level, whereas the 15−19 year age group
contributes greatly to the excess mortality. Pedestrian-related mortality among
children and adolescents in Finland was clearly below the European average in
the 2000s (European Child Safety Alliance 2012), whereas motor vehicle
passenger or driver deaths in Finland exceeded the average for Europe. Deaths
associated with motorized two-wheelers (mopeds and motor scooters) in Finland
71
were among the highest in Europe, although interestingly, the country’s passenger
safety and moped/motor scooter safety policies were rated as among the best in
Europe by European Child Safety Alliance (2012). Deaths in Finland associated
with cycling were close to the European average (European Child Safety Alliance
2012).
Suicides are the most common cause of death in the 15−19 year age group
(Safety Investigation Authority, Finland 2014) and the associated mortality rates
in Finland are among the highest in Europe, immediately below Estonia and
Lithuania (European Child Safety Alliance 2012). The mortality rate due to
suicide in this age group in Finland was 11.7/100 000 in 2009−2010, the range
across Europe being from 1.3/100 000 in Spain to 13.4/100 000 in Lithuania. In
fact, considering all the countries with data available from the 1960s onwards,
young people’s suicide rates in Finland persisted among the highest in the world
throughout the decades studied (Wasserman et al. 2005). Mortality due to
violence, on the other hand, was at the average level for Europe (European Child
Safety Alliance 2012). Fatal maltreatment of children may manifest itself as
infanticides, covert homicides, severe physical assaults, extreme neglect or
deprivational abuse, or deliberate or overt homicides (Sidebotham et al. 2014b).
Considering the European Child Safety Score, which evaluates overall safety
performance and 12 specific issues such as traffic safety, water safety and the
prevention of falls and poisonings in childhood (European Child Safety Alliance
2012), Finland gained the top score in Europe (45/60) in 2012, and it was also
among the countries with greatest improvements in injury prevention in 2009–
2012. Nevertheless, since its figures for accidental childhood mortality remain
higher than in many other European countries, the Finnish National Institute for
Health and Welfare published an extensive, detailed national programme entitled
‘Providing a Safe Environment for Our Children and Young People’ in 2009 that
was aimed at reducing childhood mortality from accidents at the national,
regional and local levels (Markkula & Öörni 2010).
Infectious diseases
Childhood mortality from infectious diseases has declined noticeably during
recent decades, by 89% in childhood and by 69% during the first month of life.
This decline has occurred equally in all infection categories and evenly over all
age groups. Mortality from infections declined most rapidly in the 1970s, and
figures have remained quite stable at a low level since 1982, which conforms to
72
the changes in childhood infectious disease mortality described in the USA
(DiLiberti & Jackson 1999), Australia (Dore et al. 1998) and the Netherlands
(Veldhoen et al. 2009). As the numbers of cases are currently low, the annual
changes are mostly random ones. One typical feature in Finland is the low
prevalence of HIV infection in the population, so that childhood mortality due to
HIV is practically non-existent.
Influenza and pneumococcus were the most common pathogens detected in
fatal respiratory tract infections in the present survey. Influenza vaccination
targeted at children aged six to 35 months was started as a part of the national
vaccination programme in Finland in autumn 2007. The health benefits acquired
through this programme are substantial and the immunization of children has
found to be cost-effective in this country (Salo et al. 2006). Pneumococcal
vaccines were previously used only occasionally in Finland and were not included
in the national vaccination programme until autumn 2010. The serotypes included
in the 10-valent conjugate vaccine account for 85% of the invasive pneumococcal
infections identified in Finnish children (Klemets et al. 2008), and the
vaccinations have reduced the overall incidence of IPD by 80%, reaching 92% in
the case of vaccine-type IPD (Jokinen et al. 2015). A decrease of almost 50% was
also detected in children aged 2−5 years, who were not eligible to receive
vaccine.
Mortality from central nervous system infections has decreased notably in
this country since the late 1980s, coinciding with the launching of vaccinations
against Haemophilus influenzae type b, the cause of approximately two thirds of
all our cases of meningococcal disease (Jaakola et al. 2014), which have not
previously been preventable by vaccination. A new vaccine against group B
meningococcus (4CMenB) has recently been developed (Vesikari et al. 2013) and
licensed in Europe, USA, Australia and Canada (Drysdale & Pollard 2015),
enabling the prevention of meningococcal B infections.
Deaths from gastroenteritis declined markedly in the 1970s, with the numbers
of annual cases varying from none to four between the years 1977 and 2004, the
trend being similar to that in the USA (Kilgore et al. 1995). Novel rotavirus
vaccines were launched in the Finnish vaccination programme in September
2009, and these have led to a significant decline in hospitalizations (Anderson et
al. 2011, Hartwig et al. 2014) and deaths in over 47 countries where they now
form part of routine vaccination programmes (Glass et al. 2014). Varicella is often
considered a benign disease of childhood, but it can carry with it severe
complications such as septicaemia, pneumonia, encephalitis and invasive skin
73
infections that require admission to a paediatric intensive care unit. It has also
been noted that most complications apart from death affect previously healthy
children (Cameron et al. 2007). Varicella vaccinations were launched as part of
the national immunization programme in the United States in 1995 and varicella
mortality during childhood and adolescence subsequently decreased by 97%
(Marin et al. 2011). Varicella is not currently included in the Finnish nationwide
vaccination programme, even though experts have recommended this.
Neonatal mortality from early-onset group B streptococcal infection was
approximately 0.8 per 10 000 live births in Britain, 1.0 in Finland, 1.1 in Sweden,
1.6 in Australia, 2.6 in New Zealand and 2.8 in the United States in the 1980s and
1990s (Embleton et al. 1999). The average annual incidence of early-onset
disease varied between health districts in Finland from 0.1/1000 live births to
1.3/1000, being on average 0.6/1000 in 1995−2000 (Lyytikäinen et al. 2003). One
third of the cases involved at least one risk factor for infection, i.e. prolonged
rupture of the membranes, preterm delivery or intrapartum fever, and most
mothers of affected infants had not received intrapartum antibiotics. The
incidence of neonatal GBS infection in the USA declined by 65% in 1993−1998,
from 1.7 to 0.6/1000 live births, following the launching of guidelines for its
perinatal prevention (Schrag et al. 2000).
Infectious diseases currently cause fewer deaths in childhood than do cancers,
and the associated mortality rates have reached a low level. They could have been
further reduced, however, by means of existing vaccines. Vaccinations against
pneumococci, influenza, rotaviruses and varicella could have saved the lives of a
few children each year. Even though the numbers of deaths prevented might have
been small, the numbers of years of life saved would have been great, because the
life expectancy of children is long.
Other causes of death
Mortality from congenital malformations declined by 67% between 1969 and
2004. Enhanced prenatal diagnostics together with increased numbers of
terminations of pregnancy on account of foetal anomalies have reduced the
numbers of children born with chromosomal defects or major anomalies, at same
time as advanced surgical techniques have contributed to a better prognosis for
affected children. The rate of terminations of pregnancy for foetal anomalies in
Finland has increased from approximately 30/10 000 births in the 1990s to around
55/10 000 in the 2010s (Ritvanen & Sirkiä 2014). An average of 64% of all neural
74
tube defect pregnancies (anencephaly, spina bifida) and half of all Down
pregnancies detected were terminated each year in 1993−2011. The results are
similar to those reported for Denmark, where the numbers of terminations of
pregnancy for foetal anomalies have doubled, coinciding with decreases in foetal
and infant mortality from congenital anomalies (Garne et al. 2014). Prenatal
detection of chromosomal defects is reported to have increased from 27% to 71%
in Denmark between 1986−1989 and 2000−2007 (Froslev-Friis et al. 2011).
Better surgical treatment will contribute to the better survival of children with
major anomalies as well. The long-term survival of paediatric patients undergoing
operations for cardiac defects in Finland has improved markedly during the past
six decades, and patients are being treated at an increasingly younger age, as the
mean age for all operations has decreased from 8.9 years in the 1950s to 2.2 in the
2000s (Raissadati et al. 2015). In conjunction with this, early mortality following
the operation has diminished from 7% in the 1970s to 3% in the 2000s, and the
22-year survival rate following transposition of the great arteries has increased
from 71% to 93%, for example, when comparing those operated on in 1953−1989
and in 1990−2009. In Norway, the median age at the first heart operation
decreased from 1.6 years in 1971−1979 to 0.19 years in 2000−2011 (Erikssen et
al. 2015), and simultaneously the cumulative survival rate in cases of complex
congenital heart defects up to the age of 16 years has increased from 62.4%
(operated on in 1971−1989) to 86.9% (1990−2011). The results have been greatly
enhanced in the 2000s, as 1-year survival has increased from 90.7% to 96.5%,
and 5-year cumulative survival from 88.8% to 95.0% when comparing those
operated on in 2000−2004 and 2005−2011.
Screening policies during pregnancy vary greatly between European
countries. Boyd et al. (2008) reported that 10 out of 18 European countries
considered had a national policy of screening for Down’s syndrome and 14 out of
18 for structural anomalies. The overall prenatal rate of detection of severe
structural congenital malformations was 64% in 17 selected European regions,
ranging from 25% to 88% (Garne et al. 2005). The highest prenatal detection rate
was 94%, for anencephaly, and the lowest 27%, for transposition of the great
arteries.
The prognosis for cancers in childhood has improved markedly during recent
decades as diagnostics and risk classifications, chemotherapy, radiation treatment
and supportive care have all improved (Davies 2007). The survival rates for
childhood cancers in the Northern Europe have been better than the European
average from the late 1970s onwards (Magnani et al. 2006). In one large
75
European survey of survival among children with cancer in 1995−2002, Finnish
survival rates were among the highest in Europe (Gatta et al. 2009). The overall
good survival rates reported in Finland and the other Nordic countries stem from
the achievements of the Nordic Society of Paediatric Haematology and Oncology
(NOPHO), which has created uniform diagnosis, treatment and clinical follow-up
protocols in all the Nordic countries, and a system of collaboration that has led to
a substantial improvement in the prognosis for childhood cancers in all these
countries in recent decades (Gustafsson et al. 2000, Hjalgrim et al. 2003, Lie et
al. 2005).
The marked decline of almost 80% in neonatal mortality during the period
examined here stems mainly from improvements in neonatal intensive care,
including the introduction of surfactant replacement therapy, high-frequency
ventilation and antenatal steroid therapy (Johansson et al. 2004, Richardson et al.
1998). We suggest that the policy of centralizing care and deliveries for high-risk
pregnancies will greatly contribute to persistent low perinatal mortality in Finland
(Rautava et al. 2007).
6.2
Regional differences in childhood mortality
Where marked regional differences have previously been characteristic of
childhood mortality in Finland (Pitkanen et al. 2000), the present survey suggests
that the differences in post-neonatal mortality between the university hospital
districts have mostly disappeared and that the quality of care, as measured by
childhood mortality, is essentially the same at all the university hospitals.
Mortality from tumours and haematological diseases, for example, was of
practically the same magnitude in every university hospital district. These results
are similar to the trends in childhood cancer mortality reported in Ireland, where
no regional variation in overall survival was detected (Walsh et al. 2011). The
absence of regional differences in childhood cancer survival most probably stems
from the uniformity of the treatment at the national level and the usage of
standard treatment protocols.
By contrast, post-neonatal childhood mortality fluctuated greatly between the
central hospital districts, partly reflecting historical differences in such mortality
(Pitkanen et al. 2000). In the 1950s a clear division was seen between Finland’s
more developed southern region and its less developed eastern and northern
regions, with their substantially lower standard of living and poorer health
services. Thus the Swedish-speaking region of Ostrobothnia had the lowest
76
mortality rates during the first period, 1985−1994, but several other central
hospital districts had achieved the same level in post-neonatal childhood mortality
by the latter period, 1995−2004. In addition to these regional differences in
childhood mortality, there are also significant regional variations in the utilization
of health services in childhood, e.g. in the rate of hospitalization and the use made
of regular medication (Gissler et al. 2000). There is a clear association between
social class and childhood mortality in Finland, in that mortality rates are higher
in lower social classes, especially where younger children and accidental and
violent deaths are concerned (Remes et al. 2010). The northern and eastern parts
of the country were the areas with the highest mortality rates at the level of the
central hospital districts in this survey, possibly reflecting historical differences in
socioeconomic development. There may also be regional differences in risk
exposure, e.g. to traffic accidents and drowning, in the characteristics of the
population and in the availability of health services.
We also found noticeable regional differences in accidental childhood
mortality, especially in traffic accidents, suicides and homicides. Considerable
regional variation in fatal childhood accidents has also been reported in other
countries. In Norway, mortality from injuries were reported to be lowest in the
county of Oslo in 1971−1989 and highest in northern Norway, where the
incidence of fatal injuries was three times that recorded in Oslo (Samuelsen et al.
1993). The variation in overall death rates was from 9.4/100 000 person years to
21.7/100 000, and regional differences were most prominent in the case of
drowning. In the USA, mortality from childhood injuries in the early 1980s were
highest in the mountain states and in the southern part of the country and lowest
in New England, the Mid-Atlantic States and the Mid-West, the rates varying
from 11.2/100 000/year to 35.0/100 000/year (Waller et al. 1989). Mortality rates
in the UK varied from 7.5/100 000 to 12.1/100 000 in 1980−1984 and were
higher in urban than in rural areas (Avery et al. 1990). Taking into account
different periods of time and age bands involved, mortality rates in Finland were
of the same magnitude as those in Norway, somewhat higher than in the United
Kingdom, and lower than the contemporary figures in the USA. In Finland
mortality from causes other than homicide was the highest in the rural areas.
Traffic accidents are the most common cause of accidental deaths in
childhood, and regional differences in mortality due to these are marked.
According to the ranking scores, Etelä-Pohjanmaa and Länsi-Pohja had the
highest mortality rates throughout the period concerned, whereas mortality
consistently remained lowest in Helsinki and Uusimaa, Keski-Pohjanmaa and
77
Keski-Suomi. Similarly, the density of cars per head of population in Finland is
the highest in Etelä-Pohjanmaa and the lowest in Uusimaa (Finnish Transport
Agency 2007) and the density of mopeds is the second highest in EteläPohjanmaa and the lowest in Helsinki and Uusimaa (Finnish Transport Safety
Agency Trafi 2013), correlating with the highest and lowest ranking scores for
traffic accidents. Regional differences in deaths due to drowning were smaller
than for other causes of fatal accidents. Falling into water rather than swimming
itself causes half of the drowning accidents (Safety Investigation Authority,
Finland 2014).
Suicides are the most common cause of death among 15 to 19-year-olds in
Finland (Safety Investigation Authority, Finland 2014), and the figures in this
survey were highest in Northern Finland (Lappi and Pohjois-Pohjanmaa)
throughout the period concerned, although they were also high in Etelä-Karjala
and Kymenlaakso. Itä-Savo, Vaasa and Keski-Pohjanmaa had persistently the
lowest mortality from suicides. Mental health problems, experiences of bullying
and general unsociability have been associated with suicides in previous studies
(Safety Investigation Authority, Finland 2014), and suicide attempts and severe
suicidal ideation have been reported to decrease by almost 50% upon pupiltargeted intervention as compared with a control group, whereas intervention by
school personnel or health care professionals had no significant effects
(Wasserman et al. 2015). Unlike other fatal accidents, homicides were most
common in the Helsinki and Uusimaa area throughout the period, although
mortality rates were also high in Pohjois-Pohjanmaa, Pohjois-Savo and PohjoisKarjala. Parents’ mental health and substance abuse problems and problems in
personal relationships form the background to homicides in most cases (Ministry
of the Interior 2012).
6.3
What can be done to reduce childhood mortality in future?
Organizing paediatric care
The notable changes in childhood mortality that have taken place during the past
decades may be attributed to the achievements of the well-functioning health care
system in Finland and to progress in injury prevention, especially in traffic safety.
The Finnish health care system as a whole was rated as the 4th best in Europe in
the Euro Health Consumer Index of 2014 (Health Consumer Powerhouse 2014),
78
and its high-ranking outcomes have been achieved at fairly low cost, since it is
the leading country in terms of value-for-money in health care. On the other hand,
the Finnish system was estimated to be somewhat antiquated compared with those
of the other Nordic countries where user-friendliness was concerned. Infant
deaths were assessed as being the best single indicator when estimating the
overall quality of a healthcare system, and Finland had the second lowest rate of
infant mortality in Europe in 2014 (Health Consumer Powerhouse 2014).
Comparing childhood mortality rates in relation to the structure of national
health care systems can provide insights into beneficial models for organizing
paediatric care. Childhood mortality rates in the UK are high compared with those
in other western European countries, and death rates are particularly high in
diseases which rely heavily on first access services such as meningococcal
disease, pneumonia and asthma (Wolfe et al. 2011). Sweden was the country with
the lowest childhood mortality rates when the various models for organizing
paediatric care were compared in selected European countries, but the rates in
Finland were equal or almost equal to those achieved in Sweden. The better
performance of the Swedes was thought to be due to the fact that the first contact
professional is usually a general practitioner (GP) or else a paediatrician working
in a children’s health centre, and that nearly all GPs have postgraduate training in
paediatrics. In the UK the first contact professional is mostly a GP or a nurse, and
training in paediatrics has become more infrequent nowadays, as currently only
40% of GPs have such training, and then for less than six months. Primary care
and specialized health care are separately managed and funded organizations in
the UK. The Swedish model of locating both GPs and paediatricians in health
centres may provide the benefits in terms of family medicine, but additionally it
can improve first access care and provide coordinated multidisciplinary health
services for children with chronic conditions (Wolfe et al. 2011). The
fragmentation of care and costs in the health care sector has been reduced in
Sweden by merging small hospitals (Åhgren & Axelsson 2011) and establishing
“chains of care” to ensure the integration of primary and specialist care (Åhgren
2003).
The Finnish social and health care system will undergo major reform in the
near future, and the organizing of health care for children in the optimal way is a
major task that needs to be resolved in the reform, and one in which the good
situation regarding children’s survival that has already been achieved must not be
jeopardized. The effect of the structure of the health care system on childhood
mortality was not studied here as such, but it may be suggested on the basis of the
79
regional differences in childhood mortality that paediatric care may need further
centralization, especially in smaller units, in order to ensure equal care for all
Finnish children, provided that distances from paediatric care units do not become
substantially longer. First access care should still be provided by doctors in order
to achieve the most beneficial outcomes for the children. A summary of the
procedures suggested here for reducing childhood mortality in future is presented
in Table 8.
Prevention of deaths in future
The effect of prevention measures on childhood mortality was likewise not
studied specifically here, but on the basis of the trends in childhood mortality and
the most important causes of death at present it is possible to highlight the most
important targets for the prevention of childhood deaths in Finland in future. One
of the most demanding challenges in primary care is that of distinguishing
potentially severe diseases from minor problems. Potentially avoidable primary
care factors were identified in 20% of child deaths in the UK, and these included
failures to recognize and cope with serious infections, incomplete vaccination and
inadequate management of asthma and epilepsy (Harnden et al. 2009). The clear
variations among European countries in childhood mortality from acute illnesses
such as meningococcal disease (ranging from 0.09 per 100 000 children aged
0−14 years in Sweden to 0.47 in the UK), pneumonia (from 0 per 100 000
children aged 0−14 years in Luxembourg to 1.76 in Greece) and asthma (from
0.01 per 100 000 children aged 0−14 years in Sweden and Italy to 0.27 in the UK)
may suggest that access to acute care is not sufficiently quick in some countries
(Wolfe et al. 2011, Wolfe et al. 2013). Prompt diagnosis may be difficult where
rare diseases such as childhood cancer are concerned, since it has been estimated
that a GP in the UK will see a child with a new cancer once in 20 years
(Feltbower et al. 2004). Measures suggested for improving the recognition of the
severity of illnesses include the use of clinical decision rules such as the
paediatric early warning system score (Parshuram et al. 2011) or red flags for
serious infections, listening to parental concerns and trusting in the clinician’s
instinct (Van den Bruel et al. 2010). Also of importance is the provision of proper
care instructions and information on red flag signs for parents, including advice
on when to seek a timely re-consultation if the child’s condition worsens (Petrou
et al. 2014). As the recognition of severe illness in children is difficult, training in
80
paediatrics at some stage in their careers is essential for professionals to improve
their skills.
Vaccination coverage has traditionally been high in Finland, although it has
shown a slightly diminishing trend since 2005 (National Institute for Health and
Welfare 2015). The coverage achieved by the DTaP-IPV-Hib vaccine against
diphtheria, tetanus, pertussis, polio and Haemophilus influenzae type b, for
example, declined from 99.0% in 2005 to 97.2% in 2012, and that of the MMR
(measles, mumps, rubella) vaccine from 98.5% to 95.4%, respectively.
Simultaneously, the proportion of totally unvaccinated children increased from
0.5% in 2005 to 1.4% in 2012. National real-time surveillance of vaccination
coverage is vital, and each child’s personal vaccination data should be exploited
when assessing the risk of severe infections. It is the duty of health professionals
to maintain true, objective public debate concerning vaccines. Meanwhile, the
adoption of novel vaccines into the national vaccination programme in order to
reduce morbidity and prevent deaths should be seriously considered on the basis
of recommendations from health care professionals.
Accidental mortality is almost twice as high in Finland than in Sweden. In
fact, Sweden has made a considerable effort to tackle the burden of injury
fatalities in childhood and has achieved one of the lowest levels in the world
(Bergman & Rivara 1991). This progress has been based on a broad corpus of
injury surveillance data, a firm commitment to injury research, constant efforts to
produce a safer environment for children via legislation and regulations and
extensive safety education campaigns through the media, schools, child-care
centres and health-care professionals. Sweden is also one of the few countries
which have followed the WHO recommendations for organizing national
multisectoral safety promotion programmes and allowing academic institutes to
contribute to public-health policy-making (Ramsay 2001). The “Health in All
Policies” approach (National Institute for Health and Welfare 2012, World Health
Organization 2013) could be exploited more extensively in contexts where the
prevention of injuries has to be taken into account.
Accidental childhood deaths have also declined markedly throughout Finland
in the past decades, following investments in better traffic safety and safer
environments for children. There are nevertheless notable regional differences in
childhood mortality due to accidents and other unnatural causes, and local
investments in injury prevention and resources for family services are of great
importance in this respect, especially in areas where mortality rates exceed the
national average. The prevention of traffic accidents is not an unambiguous
81
matter, as the traffic environments, traffic volumes, and also the population and
its traffic behaviour can all affect road safety. As environmental modifications
such as speed limits around schools and play areas and the separation of
motorized from non-motorized traffic, educational campaigns and promotion of
the proper use of safety devices are effective tools for injury prevention (Harvey
et al. 2009), special local actions for the improvement of traffic safety are needed
in areas with a high density of cars and mopeds.
In the case of drowning accidents the most effective prevention can be
achieved through constant close parental supervision (American Academy of
Pediatrics 2000, Asher et al. 1995, Schyllander et al. 2013), although participation
in swimming lessons, even at a very young age, may reduce the risk of drowning
in children aged one to four years (Brenner et al. 2009, Yang et al. 2007).
Drowning incidents in connection with boating could almost entirely be prevented
by the use of life vests or other personal floatation devices (European Child
Safety Alliance 2006).
The prevention of suicides should include adequate resources and easy access
to mental health services through the schools (Safety Investigation Authority,
Finland 2014). Given the clear regional variation in mortality due to suicide,
prevention programmes and psychiatric services should be organized specifically
in areas with high mortality, to meet the local demand. The early recognition of
family problems is crucial for preventing homicides in which children are victims
(Safety Investigation Authority, Finland 2014). Investments in preventive child
protection and family work should be considered locally, especially in areas
where problems accumulate. The prevention of parents’ suicides is also one
measure for reducing filicides (Putkonen et al. 2009).
82
Table 8. What can be done to reduce childhood mortality in future?
Challenge
Solution
Organizing paediatric care
Further centralization of paediatric care if applicable
Doctor as the preferable first-contact professional
Recommended training in paediatrics for GP’s (optional)
Recognition of severely ill
Training in paediatrics
children
Use of clinical decision rules and red flags
Proper information for parents on care instructions and re-consultation
Vaccinations
Assessment of child’s personal vaccination status
National real-time surveillance of vaccine coverage data
Inclusion of novel vaccines in national vaccination programmes
Prevention of accidents
Local investments in injury prevention, especially for traffic accidents
Resources for family services (preventive child protection, family work)
Easy access to mental health services in schools
Parental supervision to prevent drowning
6.4
Strengths and limitations of the research
The Finnish mortality data are based on death certificates classified according to
the ICD revision current at the time of death. The frequency of post-mortem
examinations in cases of natural death in Finland is higher in children and
adolescents (0–19 years) than for any other age group, i.e. 71%, where the
average for all age groups is 26% (Penttilä et al. 1999). The quality of the data in
Finnish administrative registers has been shown to be good, with high coverage
internal validity and conformity with patient records (Gissler & Haukka 2004).
The determinations of cause of death and the certification and coding practices
are well regulated, and all death certificates that are filled in inconsistently
undergo a routine validation procedure at Statistics Finland, including requests for
further information where necessary (Lahti & Penttilä 2001, Lahti & Penttilä
2003). As a consequence of this routine validation procedure, statistically
significant changes (decreases) in causes of death were detected only in the
categories of symptoms, signs and ill-defined conditions and pulmonary
circulation diseases, i.e. the procedure thus serves essentially to improve the
specificity of the Finnish cause of death statistics (Lahti & Penttilä 2001). No
research has been conducted specifically into the validity of Finnish cause of
death statistics with regard to children, but death certificates for children (other
83
than those aged under one year) were included in the data considered by Lahti &
Penttilä (2001, 2003). In fact, due to the smaller number of deaths in childhood
and the high frequency of post-mortem examinations in children, the accuracy of
death certification in children may still be more accurate when compared to
adults. Death certificates in the oldest age groups (over 65 years old) were the
most prone to be queried in the data of Lahti & Penttilä (2003), most probably
due to the presence of several diseases and the diminished use of postmortem
examinations. The proportion of all deaths subjected to post-mortem
examinations in Finland was among the highest in Europe in 1996, and
medicolegal post-mortem examinations were considerably more common in
Finland in 1991–1992 than in the other Nordic countries (Penttilä et al. 1999).
The detailed recommendation issued by the European Commission that the
quality and intercomparability of European cause of death statistics should be
improved has already to a great extent been implemented in Finland (European
Commission 2001). Register data will always be susceptible to errors, however,
and although Finnish registers have shown to be accurate (Gissler & Haukka
2004), it is only reasonable to assess their validity from time to time.
International comparisons of mortality data are not straightforward to
perform on account of national variations in coding practises, death certification
procedures and the completeness of register data, although register data from
high-income countries may typically be regarded as reliable, with complete or
near-complete registration of child deaths (Fraser et al. 2014). Countries also
publish data applying to different time periods, age bands and groupings of the
cause of death codes, and delays and discrepancies may occur in the publication
of data, especially when deaths are examined by the police. Additionally, the
accuracy of national mortality statistics has raised concerns in some countries. A
review panel in the UK, for example, detected inaccuracies in 35% of the death
certificates of children that it examined, mostly ones involving deaths related to
congenital or chronic medical conditions (Pearson 2008). It was mainly for these
reasons that we were unable to compare our mortality rates directly with those of
other countries, although the timing and magnitude of the decrease in childhood
mortality could partly be assessed in proportion to the figures for other countries.
Our data was based on the Official Statistics of Finland with regard to annual
births and deaths among children younger than 16 years old. As the information
was gathered from only one source, we were unable to identify the predisposing
conditions for death or whether the death could potentially have been avoidable.
The combining of information from different sources would have been more
84
difficult during the first decade of the period studied here due to the higher
number of deaths per year and the lack of adequate data from other registers, but
nowadays, due to the smaller annual number of deaths, the Medical Birth Register
(established in 1987), with its additional information on maternal socioeconomic
background, and the Hospital Discharge Register, together with hospitals’ patient
records, could be exploited more extensively alongside the mortality statistics. In
fact, studies combining data from different sources would be important in order to
identify the modifiable factors contributing child deaths in order to further reduce
childhood mortality in Finland. The effect of prevention in reducing mortality
would also be an important topic for study in the future in order to be able to
target preventive measures in an appropriate manner.
85
86
7
Conclusions
Childhood mortality in Finland has decreased noticeably during the past decades,
and the changes are mainly due to the achievements of the well-functioning health
care system in Finland and improvements in injury prevention. Finnish childhood
mortality rates have been equal to or almost equal to those achieved in Sweden,
where the absolute rates have been the lowest in the world (Wolfe et al. 2013).
Taking into account the clearly higher mortality due to injuries in Finland
(European Child Safety Alliance 2012), it may in fact be that the Finnish health
care system performs even better in some respects than the Swedish one does.
Childhood mortality due to infectious diseases has declined markedly in all
the major categories and all age groups. Existing vaccines not included in the
national vaccination programme during the period concerned would probably
have prevented a few deaths annually. Mortality due to infectious diseases has
now reached a very low level in Finland.
The clear regional differences in childhood mortality between the central
hospital districts may reflect historical differences in socioeconomic development
in Finland, but it was noticeable that childhood mortality did not differ between
the university hospital districts. We suggest that paediatric hospital care may need
further centralization in future in order to ensure equally high-quality care for all
Finnish children.
There were also significant regional differences in childhood mortality
attributable to accidents and intentional causes, which are the most important
preventable causes of death in childhood. Prevention as such was not studied
here, but it may be suggested on the basis of the regional differences in mortality
that local investments in injury prevention and resources for family services are
needed, especially in areas with high mortality.
Even though Finland has achieved one of the lowest childhood mortality rates
in the world, there still are noticeable regional differences within the country in
this respect, and therefore a potential for further reductions in mortality. The
organizing of paediatric care in an optimal manner will be one major task for the
forthcoming structural reform of the Finnish social and health care system. The
favourable situation with regard to the survival of children survival cannot be
jeopardized in the reform. On the other hand, the recognition of severely ill
children is a demanding process that requires training in paediatrics at some stage
in a GP’s career. Continuous monitoring of changes in childhood mortality, and
87
especially regional variations, could provide a sound basis for decision-making in
health care matters.
88
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104
Original papers
I
Lantto M, Renko M & Uhari M (2008) Trends in childhood mortality from 1969 to
2004 in Finland. Acta Paediatr 97(8): 1024–9.
II Lantto M, Renko M & Uhari M (2013) Changes in infectious disease mortality in
children during the past three decades. Pediatr Infect Dis J 32(9): e355–9.
III Lantto M, Renko M & Uhari M (2014) Regional differences in postneonatal
childhood mortality in Finland, 1985−2004. Acta Paediatr 104(5):466–72.
IV Lantto M, Serlo W, Uhari M & Renko M (2015) Regional differences in childhood
mortality due to accidents in Finland, 1969−2013. Manuscript.
Reprinted with permission from John Wiley and Sons (I, III) and Wolters Kluwer
Health, Lippincott Williams & Wilkins (II).
These original publications are not included in the electronic version of the
dissertation.
105
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ACTA UNIVERSITATIS OULUENSIS
SERIES D MEDICA
1315. Pentikäinen, Ilkka (2015) Distal chevron osteotomy for hallux valgus surgery :
role of fixation and postoperative regimens in the long-term outcomes of distal
chevron osteotomy – a randomised, controlled, two-by-two factorial trial of 100
patients
1316. Mikkonen, Paula (2015) Low back pain and associated factors in adolescence : a
cohort study
1317. Hakalahti, Antti (2015) Efficacy and safety of radiofrequency catheter ablation in
the treatment of atrial fibrillation
1318. Hannula, Virva (2015) The prevalence of diabetic retinopathy and its effect on
social well-being and health related quality of life in children and young adults
with type 1 diabetes
1319. Leppänen, Virpi (2015) Epävakaan persoonallisuuden hoitomallitutkimus Oulun
mielenterveyspalveluissa
1320. Piira, Olli-Pekka (2015) Effects of emotional excitement on cardiovascular
regulation
1321. Sonkajärvi, Eila (2015) The brain's electrical activity in deep anaesthesia : with
special reference to EEG burst-suppression
1322. Tirkkonen, Tiina (2015) Early attachment, mental well-being and development of
Finnish children at preschool age : twinship – risk or opportunity?
1323. Pylväs-Eerola, Marjo (2015) Oxidative stress in the pathogenesis and prognosis of
ovarian cancer
1324. Tokola, Heikki (2015) Mechanical stretch and peptide growth factors in the
regulation of the hypertrophic response of cardiomyocytes : ANP and BNP as
model genes
1325. Kinnunen, Eeva-Maija (2015) Perioperative bleeding and use of blood products in
coronary artery bypass grafting
1326. Emelyanova, Anastasia (2015) Cross-regional analysis of population aging in the
Arctic
1327. Hirvasniemi, Jukka (2015) Novel X-ray-based methods for diagnostics of
osteoarthritis
1328. Uusitalo, Jouko (2015) The role of drug metabolism in drug discovery and
development – Case Ospemifene
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Marjo Lantto
University Lecturer Santeri Palviainen
Marjo Lantto
Professor Esa Hohtola
CHILDHOOD MORTALITY IN
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Postdoctoral research fellow Sanna Taskila
Professor Olli Vuolteenaho
University Lecturer Veli-Matti Ulvinen
Director Sinikka Eskelinen
Professor Jari Juga
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Publications Editor Kirsti Nurkkala
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