Adult All-cause Mortality Research Articles

Blood transfusion is correlated with elevated adult all-cause mortality and cardiovascular mortality in the United States: NHANES 1999 to 2018 population-based matched propensity score study

The association of blood transfusion with an increase in medium- and short-term mortality in specific populations has been confirmed. However, the correlation between blood transfusion and long-term mortality in the general population remains unclear. This cohort study evaluated the correlation between blood transfusion and overall and cause-specific mortality in the general American adult population. The authors utilized 10 sets of 2-year cycle data (1999-2018) from the National Health and Nutrition Examination Survey on the outcomes of adults who did and did not receive blood transfusions. Propensity score-matching (1:1) was performed based on age, sex, race, education level, marital status, poverty-income ratio, arteriosclerotic cardiovascular disease, cancer, anemia, hypertension, and diabetes status. After controlling for demographic characteristics and clinical risk factors, Cox regression analysis was performed to evaluate the correlation between blood transfusion and all-cause and cause-specific mortality. The study included 48,004 adult participants. The risk of all-cause mortality increased by 101 % with blood transfusion, and the risk of cardiovascular mortality increased by 165 %. After propensity score-matching, 6,116 pairs of cases were retained, and the risk of all-cause mortality increased by 84 % with blood transfusion, and the risk of cardiovascular mortality increased by 137 %. The sensitivity analysis results were robust. In the general American population, blood transfusion significantly impacts long-term all-cause and cardiovascular mortality and may be an unacknowledged risk factor for death. Thus, the effective management of blood transfusion in the general population may be beneficial.

Area-based social inequalities in adult mortality: construction of French deprivation-specific life tables for the period 2016-2018.

In order to tackle social inequalities in mortality, it is crucial to quantify them. We produced French deprivation-specific life tables for the period 2016-2018 to measure the social gradient in adult all-cause mortality. Data from the Permanent Demographic Sample (EDP) were used to provide population and death counts by age, sex and deprivation quintile. The European Deprivation Index (EDI), applied at a sub-municipal geographical level, was used as an ecological measure of deprivation. Smoothed mortality rates were calculated using a one-dimensional Poisson counts smoothing method with P-Splines. We calculated life expectancies by age, sex and deprivation quintile as well as interquartile mortality rate ratios (MRR). At the age of 30, the difference in life expectancy between the most and least deprived groups amounted to 3.9 years in males and 2.2 years in females. In terms of relative mortality inequalities, the largest gaps between extreme deprivation groups were around age 55 for males (MRR = 2.22 [2.0; 2.46] at age 55), around age 50 in females (MRR = 1.77 [1.48; 2.1] at age 47), and there was a decrease or disappearance of the gaps in the very older adults. There is a strong social gradient in all-cause mortality in France for males and females. The methodology for building these deprivation-specific life tables is reproducible and could be used to monitor its development. The tables produced should contribute to improving studies on net survival inequalities for specific diseases by taking into account the pre-existing social gradient in all-cause mortality.

Educational inequalities in adult mortality: a systematic review and meta-analysis of the Asia Pacific region

ObjectivesIn this study, we aim to analyse the relationship between educational attainment and all-cause mortality of adults in the high-income Asia Pacific region.DesignThis study is a comprehensive systematic review and...

Methods Matter: A Comparative Review of Health Risk Assessments for Ambient Air Pollution in Switzerland.

Objectives: Air pollution health risk assessments (AP-HRAs) provide a method to quantify health effects for entire populations. In Switzerland, AP-HRAs are included in Swiss assessments for Transport Externalities (STEs), ordered by public authorities since the 1990s. This study aimed to describe the differences among national and international AP-HRAs for Switzerland. Methods: We compared input data, approaches and results across AP-HRAs over time. Results and input data for each AP-HRA were expressed as a ratio compared to the most recent STE (in most cases STE-2010). Results: Substantial variation across AP-HRAs was found. For all-cause adult mortality attributed to particulate matter (the most frequent outcome-pollutant pair), the ratio in HRAs oscillated from 0.40 to 2.09 (times the STE-2010 value). Regarding input data, the ratio ranged from 0.69 to 1.26 for population exposure, from 0 to 1.81 for counterfactual scenario, from 0.96 to 1.13 for concentration-response function and from 1.03 to 1.13 for baseline health data. Conclusion: This study demonstrates that methods matter for AP-HRAs. Transparent and possibly standardized reporting of key input data and assumptions should be promoted to facilitate comparison of AP-HRAs.

Alcohol control policy measures and all-cause mortality in Lithuania: an interrupted time-series analysis.

Alcohol use has been identified as a major risk factor for burden of mortality and disease, particularly for countries in eastern Europe. During the past two decades, several countries in this region have implemented effective alcohol policy measures to combat this burden. The aim of the current study was to measure the association between Lithuania's alcohol control policies and adult all-cause mortality. Interrupted time-series methodology by means of general additive models. Lithuania. Adult population of Lithuania, aged 20years and older. Alcohol control policies were ascertained via a document review of relevant legislation materials. Policy effects were evaluated as follows: (1) slope changes in periods of legislative (non-)activity with regard to alcohol control policy (analysis 1); (2) level changes of three interventions following recommendations of the World Health Organization (analysis 2); and (3) level changes of seven interventions judged a priori by an international panel of experts (analysis 3). Mortality was measured by sex-stratified and total monthly age-standardized rates of all-cause mortality for the adult population. During the period 2001-18, effective alcohol control policy measures were implemented on several occasions, and in those years the all-cause mortality rate declined by approximately 3.2% more than in years without such policies. In particular, the implementation of increased taxation in 2017 was associated with reduced mortality over and above the general trend for men and in total for all analyses, which amounted to 1452 deaths avoided (95% confidence interval=-166 to -2739) in the year following the implementation of the policy. Alcohol control policies in Lithuania appear to have reduced the overall adult all-cause mortality over and above secular trends.

Impact of a 22q11.2 Microdeletion on Adult All-Cause Mortality in Tetralogy of Fallot Patients

BackgroundBecause of the importance of identifying factors that affect late outcomes in the increasing population of those with tetralogy of Fallot (TOF), we aimed to determine the effect of a 22q11.2 microdeletion on adult mortality, while accounting for pulmonary atresia, known to be enriched in 22q11.2 deletion syndrome (22q11.2DS). MethodsWe studied 612 individuals with TOF recruited as adults at a single centre, 80 (13.1%) with molecularly confirmed 22q11.2 deletions and 532 without 22q11.2DS, followed for a total of 5961.3 person-years. Using a case-control design, Cox proportional hazard regression and Kaplan-Meier curves, we evaluated the effect of a 22q11.2 deletion on mortality and survival. ResultsAll-cause mortality was 1.87% per person-year in the 22q11.2DS-TOF group and 0.80% in the other-TOF group. The presence of a 22q11.2 microdeletion was a significant predictor of adult mortality in TOF (hazard ratio, 5.00; P < 0.0001), after accounting for pulmonary atresia (hazard ratio, 2.71; P = 0.0106) and other factors. Overall, individuals with 22q11.2DS died on average 17.7 years earlier (P = 0.0055) than others with TOF, predominantly of cardiovascular causes, with proportionately more sudden cardiac deaths in those with 22q11.2DS-TOF (n = 5 [38.5%] vs n = 5 [11.9%], other-TOF; P = 0.0447). Kaplan-Meier curves showed reduced survival for those with 22q11.2DS (P < 0.0001); probability of survival to age 45 years, without pulmonary atresia, was 72% (22q11.2DS-TOF) and 98% (other-TOF). ConclusionsThe results suggest that the 22q11.2 deletion significantly contributes to premature mortality in adults with TOF, mediated only in part by greater anatomic complexity. The interpretation of late outcome data in TOF will likely benefit from further genetic subtyping.

Education inequalities in adult all-cause mortality: first national data for Australia using linked census and mortality data.

BackgroundNational linked mortality and census data have not previously been available for Australia. We estimated education-based mortality inequalities from linked census and mortality data that are suitable for international comparisons.MethodsWe used the Australian Bureau of Statistics Death Registrations to Census file, with data on deaths (2011–2012) linked probabilistically to census data (linkage rate 81%). To assess validity, we compared mortality rates by age group (25–44, 45–64, 65–84 years), sex and area-inequality measures to those based on complete death registration data. We used negative binomial regression to quantify inequalities in all-cause mortality in relation to five levels of education [‘Bachelor degree or higher’ (highest) to ‘no Year 12 and no post-secondary qualification’ (lowest)], separately by sex and age group, adjusting for single year of age and correcting for linkage bias and missing education data.ResultsMortality rates and area-based inequality estimates were comparable to published national estimates. Men aged 25–84 years with the lowest education had age-adjusted mortality rates 2.20 [95% confidence interval (CI): 2.08‒2.33] times those of men with the highest education. Among women, the rate ratio was 1.64 (1.55‒1.74). Rate ratios were 3.87 (3.38‒4.44) in men and 2.57 (2.15‒3.07) in women aged 25–44 years, decreasing to 1.68 (1.60‒1.76) in men and 1.44 (1.36‒1.53) in women aged 65–84 years. Absolute education inequalities increased with age. One in three to four deaths (31%) was associated with less than Bachelor level education.ConclusionsThese linked national data enabled valid estimates of education inequality in mortality suitable for international comparisons. The magnitude of relative inequality is substantial and similar to that reported for other high-income countries.

A Low-Cost, Community Knowledge Approach to Estimate Maternal and Jaundice-Associated Mortality in Rural Bangladesh.

In the absence of a civil registration system, a house-to-house survey is often used to estimate cause-specific mortality in low- and middle-income countries. However, house-to-house surveys are resource and time intensive. We applied a low-cost community knowledge approach to identify maternal deaths from any cause and jaundice-associated deaths among persons aged ≥ 14 years, and stillbirths and neonatal deaths in mothers with jaundice during pregnancy in five rural communities in Bangladesh. We estimated the method's sensitivity and cost savings compared with a house-to-house survey. In the five communities with a total of 125,570 population, we identified 13 maternal deaths, 60 deaths among persons aged ≥ 14 years associated with jaundice, five neonatal deaths, and four stillbirths born to a mother with jaundice during pregnancy over the 3-year period before the survey using the community knowledge approach. The sensitivity of community knowledge method in identifying target deaths ranged from 80% for neonatal deaths to 100% for stillbirths and maternal deaths. The community knowledge approach required 36% of the staff time to undertake compared with the house-to-house survey. The community knowledge approach was less expensive but highly sensitive in identifying maternal and jaundice-associated mortality, as well as all-cause adult mortality in rural settings in Bangladesh. This method can be applied in rural settings of other low- and middle-income countries and, in conjunction with hospital-based hepatitis diagnoses, used to monitor the impact of programs to reduce the burden of cause-specific hepatitis mortality, a current World Health Organization priority.

The Long Harm of Childhood: Childhood Exposure to Mortality and Subsequent Risk of Adult Mortality in Utah and The Netherlands

How do early-life conditions affect adult mortality? Research has yielded mixed evidence about the influence of infant and child mortality in birth cohorts on adult health and mortality. Studies rarely consider the specific role of mortality within the family. We estimated how individuals’ exposure to mortality as a child is related to their adult mortality risk between ages 18 and 85 in two historical populations, Utah (USA) 1874–2015 and Zeeland (The Netherlands) 1812–1957. We examined these associations for early community-level exposure to infant and early (before sixth birthday) and late (before eighteenth birthday) childhood mortality as well as exposure during these ages to sibling deaths. We find that that exposure in childhood to community mortality and sibling deaths increases adult mortality rates. Effects of sibling mortality on adult all-cause mortality risk were stronger in Utah, where sibling deaths were less common in relation to Zeeland. Exposure to sibling death due to infection was related to the surviving siblings’ risk of adult mortality due to cardiovascular disease (relative risk: 1.06) and metabolic disease (relative risk: 1.42), primarily diabetes mellitus, a result consistent with an inflammatory immune response mechanism. We conclude that early-life conditions and exposure to mortality in early life, especially within families of origin, contribute to adult mortality.

Comparing indigenous mortality across urban, rural and very remote areas: a systematic review and meta-analysis.

It remains unclear how indigenous mortality varies between residential areas. We conducted a systematic review and meta-analysis on mortality patterns in urban, rural and very remote areas for the adult and infant indigenous populations of Australia, Canada, New Zealand and the USA. A literature search was performed using major online electronic publication repositories. Studies presenting indigenous mortality or disease incidence/prevalence in urban, rural or very remote areas were included. Indigenous mortality and disease incidence/prevalence in both urban and very remote areas were compared with those in rural areas. Studies that reported number of deaths or disease incidences along with population were included in the meta-analysis. Thirty-one studies were included with data from Australia (n=19), Canada (n=3), New Zealand (n=1) and the USA (n=8). Indigenous adult all-cause mortality, cervical cancer mortality, trauma mortality and incidence of myocardial infarction were all significantly lower in urban areas compared with rural areas. Likewise, indigenous adult cardiovascular mortality and renal disease mortality were significantly lower in very remote areas compared with rural areas, while indigenous infant all-cause mortality showed no significant difference in urban, rural or very remote areas. Urban areas consistently experienced lower adult indigenous mortality compared with rural areas, as did some very remote areas. Indigenous infants, however, experience similar mortality rates across all residential areas.

Empirical validation of the UNAIDS Spectrum model for subnational HIV estimates: case-study of children and adults in Manicaland, Zimbabwe.

More cost-effective HIV control may be achieved by targeting geographical areas with high infection rates. The AIDS Impact model of Spectrum - used routinely to produce national HIV estimates - could provide the required subnational estimates but is rarely validated with empirical data, even at a national level. The validity of the Spectrum model estimates were compared with empirical estimates. Antenatal surveillance and population survey data from a population HIV cohort study in Manicaland, East Zimbabwe, were input into Spectrum 5.441 to create a simulation representative of the cohort population. Model and empirical estimates were compared for key demographic and epidemiological outcomes. Alternative scenarios for data availability were examined and sensitivity analyses were conducted for model assumptions considered important for subnational estimates. Spectrum estimates generally agreed with observed data but HIV incidence estimates were higher than empirical estimates, whereas estimates of early age all-cause adult mortality were lower. Child HIV prevalence estimates matched well with the survey prevalence among children. Estimated paternal orphanhood was lower than empirical estimates. Including observations from earlier in the epidemic did not improve the HIV incidence model fit. Migration had little effect on observed discrepancies - possibly because the model ignores differences in HIV prevalence between migrants and residents. The Spectrum model, using subnational surveillance and population data, provided reasonable subnational estimates although some discrepancies were noted. Differences in HIV prevalence between migrants and residents may need to be captured in the model if applied to subnational epidemics.

Exposure to out-of-home care in childhood and adult all-cause mortality: a cohort study.

Background: Children placed in out-of-home care (OHC) have exceedingly high rates of health problems. Their poor health tends to persist across adolescence and into young adulthood, resulting in increased risks of mortality. Yet, very little is known about this group’s mortality risks later in life. The aim of this study was to investigate whether OHC was associated with the risk of all-cause mortality across adulthood, and whether these risks varied across different placement characteristics. Moreover, the study addressed potential confounding by including two comparison groups with children who grew up under similarly adverse living conditions but did not experience placement. Methods: Data were derived from a 60-year follow-up of a Stockholm cohort born in 1953 (n = 15 048), of whom around 9% have had experiences of OHC. The associations between OHC and subsequent all-cause mortality were analysed by means of Cox’s proportional hazards regression models. Results: Individuals who were placed in OHC at any point during their formative years had increased mortality risks across ages 20 to 56 years. Elevated risk of mortality was particularly pronounced among those who were placed in adolescence and/or because of their own behaviours. Children who were exposed to OHC had increased risks of mortality also when compared with those who grew up under similar living conditions but did not experience placement. Conclusions: Children in OHC constitute a high-risk group for subsequent mortality. In order to narrow the mortality gap, interventions may need to monitor not only health aspects but also to target the cognitive and social development of these children.

Delayed Effects of Obese and Overweight Population Conditions on All-Cause Adult Mortality Rate in the USA.

Currently, there are few studies separating the linkage of pathological obese and overweight body mass indices (BMIs) to the all-cause mortality rate in adults. Consequently, this paper, using annual Behavioral Risk Factor Surveillance System data of the 50 US states and the District of Columbia, estimates empirical regression models linking the US adult overweight (25 ≤ BMI < 30) and obesity (BMI ≥ 30) rates to the all-cause deaths rate. The biochemistry of multi-period cumulative adiposity (saturated fatty acid) from unexpended caloric intakes (net energy storage) provides the natural theoretical foundation for tracing unhealthy BMI to all-cause mortality. Cross-sectional and panel data regression models are separately estimated for the delayed effects of obese and overweight BMIs on the all-cause mortality rate. Controlling for the independent effects of economic, socio-demographic, and other factors on the all-cause mortality rate, our findings confirm that the estimated panel data models are more appropriate. The panel data regression results reveal that the obesity-mortality link strengthens significantly after multiple years in the condition. The faster mortality response to obesity detected here is conjectured to arise from the significantly more obese. Compared with past studies postulating a static (rather than delayed) effects, the statistically significant lagged effects of adult population BMI pathology in this study are novel and insightful. And, as expected, these lagged effects are more severe in the obese than overweight population segment. Public health policy implications of this social science study findings agree with those of the clinical sciences literature advocating timely lifestyle modification interventions (e.g., smoking cessation) to slow premature mortality linked with unhealthy BMIs.

How old are you, really? Communicating chronic risk through 'effective age' of your body and organs.

In communicating chronic risks, there is increasing use of a metaphor that can be termed ‘effective-age’: the age of a ‘healthy’ person who has the same risk profile as the individual in question. Popular measures include ‘real-age’, ‘heart-age’, ‘lung-age’ and so on.Here we formally define this concept, and illustrate its use in a variety of areas. We explore conditions under which the years lost or gained that are associated with exposure to risk factors depends neither on current chronological age, nor the period over which the risk is defined. These conditions generally hold for all-cause adult mortality, which enables a simple and vivid translation from hazard-ratios to years lost or gained off chronological age. Finally we consider the attractiveness and impact of this concept.Under reasonable assumptions, the risks associated with specific behaviours can be expressed in terms of years gained or lost off your effective age. The idea of effective age appears a useful and attractive metaphor to vividly communicate risks to individuals.Electronic supplementary materialThe online version of this article (doi:10.1186/s12911-016-0342-z) contains supplementary material, which is available to authorized users.

Can a criminal justice alcohol abstention programme with swift, certain, and modest sanctions (24/7 Sobriety) reduce population mortality? A retrospective observational study

In the UK and USA, various jurisdictions have launched new approaches for managing alcohol-involved offenders that might have public health implications. These programmes require participants to abstain from alcohol and submit to frequent alcohol testing with swift, certain, and modest sanctions for violations, with the aim to reduce crime and keep alcohol-involved offenders in the community. In this study we examine whether the 24/7 Sobriety programme in South Dakota, USA-the largest such programme to date-is associated with reductions in mortality. With a differences-in-differences design, we used variation in the timing of 24/7 Sobriety implementation across South Dakota counties between 2005 and 2011 to estimate the association between programme introduction and county-level mortality. We used monthly, county-level, aggregate counts for mortality from January, 2000, to June, 2011. We assessed total deaths, and deaths due to external injuries, circulatory disorders, digestive disorders, and cancer (as a potential placebo). Between January, 2005, and June, 2011, 16 932 people (about 3% of the adult population) participated in the 24/7 Sobriety programme. The analysis was based on a sample size of 9 108 county-month observations (ie, 66 counties × 12 months × 11·5 years). Implementation of 24/7 Sobriety was associated with a 4·2% (95% CI 1·5-6·9) reduction in all-cause adult mortality, with the largest associations among women (8·0%, 95% CI 3·9-11·8) and individuals older than 40 years (4·3%, 95% CI 1·4-7·0). Associations were most evident among circulatory disorders. 24/7 Sobriety might have public health benefits, which could extend beyond individuals directly enrolled in the programme. However, further research, including randomised controlled trials and analyses of individual-level data, is needed to corroborate the finding, reassess the size of these associations, and gain insight into causal mechanisms. Should a negative association be replicated, it might represent a substantial advance in our understanding of how criminal justice interventions could help shape public health. National Institute on Alcohol Abuse and Alcoholism, US National Institutes of Health.

Mortality changes after grants from the Global Fund to Fight AIDS, tuberculosis and malaria: an econometric analysis from 1995 to 2010.

BackgroundSince its founding in 2002, the Global Fund to Fight AIDS, Tuberculosis, and Malaria (Global Fund) has become the dominant multilateral health financier in low- and middle-income countries. The health impact of the Global Fund remains unknown because existing evaluations measure intermediate outcomes or do not account for preexisting and counterfactual trends.MethodsWe conducted an econometric analysis of data from all countries eligible to receive Global Fund grants from 1995 to 2010, prior to and during the Global Fund’s activities. We analyzed three outcomes: all-cause adult (15–59 years), all-cause under-five, and malaria-specific under-five mortality. Our main exposure was a continuous longitudinal measure of Global Fund disbursements per capita. We used panel fixed effect regressions, and analyzed mortality trends controlling for health spending, health worker density (a measure of health system capacity), gross domestic product, urbanization, and country fixed-effects.Results and discussionWe find that following Global Fund disbursements, adult mortality rate declined by 1.4 % per year faster with every $10 per capita increase in disbursements (p = 0.005). Similarly, malaria-specific under-five mortality declined by 6.9 % per year faster (p = 0.033) with every $10 high per capita Global Fund disbursements. However, we find no association between Global Fund support and all-cause under-five mortality. These findings were consistent after subanalyses by baseline HIV prevalence, adjusting for effects of concurrent health aid from other donors, and varying time lags between funding and mortality changes.ConclusionsGrants from the Global Fund are closely related to accelerated reductions in all-cause adult mortality and malaria-specific under-five mortality. However, up to 2010 the Global Fund has not measurably contributed to reducing all-cause under-five mortality.Electronic supplementary materialThe online version of this article (doi:10.1186/s12889-015-2305-1) contains supplementary material, which is available to authorized users.

Maximizing benefits of new strategies to prevent mother-to-child HIV transmission without harming existing services.

Maximizing benefits of new strategies to prevent mother-to-child HIV transmission without harming existing services.

The impact of antiretroviral treatment on mortality trends of HIV‐positive adults in rural Uganda: a longitudinal population‐based study, 1999–2009

ObjectiveTo investigate trends in all-cause adult mortality after the roll-out of an antiretroviral therapy (ART) programme in rural Uganda.MethodsLongitudinal population-based cohort study of approximately 20 000 residents in rural Uganda. Mortality in adults aged 15–59 years was determined for the 5-year period (1999–2003) before introduction of ART in January 2004 and for the 5-year period afterwards. Poisson regression was used to estimate mortality rate ratios (RRs) for the period before ART, 1 year after ART introduction (from January 2004 to January 2005) and more than 1 year after ART introduction. Trends in mortality were analysed by HIV status, age and sex.ResultsBefore ART became available, the mortality rate (deaths per 1000 person-years) was 4.0 (95% CI = 3.3–4.8) among HIV-negative individuals and 116.4 (95% CI = 101.9–133.0) among HIV-positive individuals. During the period January 2004–end November 2009, 279 individuals accessed ART. In the year after ART was introduced, the mortality rate (deaths per 1000 person-years) among HIV-negative individuals did not change significantly (adjusted RR = 0.95, 95% CI = 0.61–1.47), but among HIV-positive individuals dropped by 25% to 87.4 (adjusted RR = 0.75, 95% CI = 0.53–1.06). In the period 2005–2009, the mortality rate (deaths per 1000 person-years) among HIV-positive individuals fell further to 39.9 (adjusted RR = 0.33, 95% CI = 0.26–0.43). The effect was greatest among individuals aged 30–44 years, and trends were similar in men and women.ConclusionThe substantially reduced mortality rate among HIV-positive individuals after ART roll-out lends further support to the intensification of efforts to ensure universal access to ART.

Uncrossing the U.S black-white mortality crossover: the role of cohort forces in life course mortality risk.

In this article, I examine the black-white crossover in U.S. adult all-cause mortality, emphasizing how cohort effects condition age-specific estimates of mortality risk. I employ hierarchical age-period-cohort methods on the National Health Interview Survey-Linked Mortality Files between 1986 and 2006 to show that the black-white mortality crossover can be uncrossed by factoring out period and cohort effects of mortality risk. That is, when controlling for variations in cohort and period patterns of U.S. adult mortality, the estimated age effects of non-Hispanic black and non-Hispanic white U.S. adult mortality risk do not cross at any age. This is the case for both men and women. Further, results show that nearly all the recent temporal change in U.S. adult mortality risk was cohort driven. The findings support the contention that the non-Hispanic black and non-Hispanic white U.S. adult populations experienced disparate cohort patterns of mortality risk and that these different experiences are driving the convergence and crossover of mortality risk at older ages.

HIV Development Assistance and Adult Mortality in Africa

The effect of global health initiatives on population health is uncertain. Between 2003 and 2008, the US President's Emergency Plan for AIDS Relief (PEPFAR), the largest initiative ever devoted to a single disease, operated intensively in 12 African focus countries. The initiative's effect on all-cause adult mortality is unknown. To determine whether PEPFAR was associated with relative changes in adult mortality in the countries and districts where it operated most intensively. Using person-level data from the Demographic and Health Surveys, we conducted cross-country and within-country analyses of adult mortality (annual probability of death per 1000 adults between 15 and 59 years old) and PEPFAR's activities. Across countries, we compared adult mortality in 9 African focus countries (Ethiopia, Kenya, Mozambique, Namibia, Nigeria, Rwanda, Tanzania, Uganda, and Zambia) with 18 African nonfocus countries from 1998 to 2008. We performed subnational analyses using information on PEPFAR's programmatic intensity in Tanzania and Rwanda. We employed difference-in-difference analyses with fixed effects for countries and years as well as personal and time-varying area characteristics. Adult all-cause mortality. We analyzed information on 1 538 612 adults, including 60 303 deaths, from 41 surveys in 27 countries, 9 of them focus countries. In 2003, age-adjusted adult mortality was 8.3 per 1000 adults in the focus countries (95% CI, 8.0-8.6) and 8.5 per 1000 adults (95% CI, 8.3-8.7) in the nonfocus countries. In 2008, mortality was 4.1 per 1000 (95% CI, 3.6-4.6) in the focus countries and 6.9 per 1000 (95% CI, 6.3-7.5) in the nonfocus countries. The adjusted odds ratio of mortality among adults living in focus countries compared with nonfocus countries between 2004 and 2008 was 0.84 (95% CI, 0.72-0.99; P = .03). Within Tanzania and Rwanda, the adjusted odds ratio of mortality for adults living in districts where PEPFAR operated more intensively was 0.83 (95% CI, 0.72-0.97; P = .02) and 0.75 (95% CI, 0.56-0.99; P = .04), respectively, compared with districts where it operated less intensively. Between 2004 and 2008, all-cause adult mortality declined more in PEPFAR focus countries relative to nonfocus countries. It was not possible to determine whether PEPFAR was associated with mortality effects separate from reductions in HIV-specific deaths.