Original Article

Mortality from Pneumonia in Children in the United States, 1939 through 1996

List of authors.
  • Scott F. Dowell, M.D., Thou.P.H.,
  • Benjamin A. Kupronis, Yard.P.H.,
  • Elizabeth R. Zell, M.Stat.,
  • and David Grand. Shay, Chiliad.D., M.P.H.

Abstruse

Background and Methods

Pneumonia remains an important cause of babyhood deaths throughout the world, only in developed countries, the mortality rate is decreasing. We reviewed expiry records for children in the United States from 1939 through 1996. A plot of the almanac rates of change in the number of deaths from pneumonia was used to generate hypotheses about the influence of various events and interventions. We used data from the National Hospital Discharge Survey, the Medicaid program, and published reports to test these hypotheses.

Results

During the 58-twelvemonth report menstruation, the number of children who died from pneumonia declined past 97 percent, from 24,637 in 1939 to 800 in 1996. During the same flow, the rate of bloodshed from other causes declined past 82 pct. There were steep declines in the mortality rates for pneumonia from 1944 to 1950, although the charge per unit increased among older children in 1957, and at that place were sustained declines in all age groups from 1966 to 1982. From 1966 to 1982, the mortality declined by an boilerplate of 13.0 percent annually, and these decreases coincided with increases in the proportion of poor children covered by Medicaid, increases in rates of hospitalization for pneumonia, a narrowing of the gap between the bloodshed rate for blackness children and the rate for white children, and a convergence between the mortality rate in the South and the rates in the other 3 census regions.

Conclusions

Since 1939, the charge per unit of mortality from pneumonia in children in the United States has declined markedly. We hypothesize that the steep declines in the late 1940s are attributable to the use of penicillin, that the top in 1957 was due to the flu A pandemic, and that the sustained pass up from 1966 through 1982 may be attributable in office to improved access to medical care for poor children.

Introduction

Pneumonia remains a leading crusade of death among children throughout the earth. Each year, an estimated iv million children, primarily in developing countries, die from pneumonia.1 Efforts to reduce the rate of mortality from childhood pneumonia in developing countries have focused on vaccination against measles and pertussis and on the utilise of elementary algorithms and empirical treatment for presumed pneumonia by hamlet health workers.one,2 In the United states of america, pneumonia remains a common and occasionally severe childhood infection, only new vaccines against Streptococcus pneumoniae and influenzavirus offer promise for reducing its incidence.three-5 Recently legislated expansion of medical insurance coverage for children may also atomic number 82 to reductions in the charge per unit of bloodshed from pneumonia if at that place is before or improved care.half dozen,vii

We reviewed the decline in the rate of mortality from pneumonia among U.S. children since 1939 to place factors that may have contributed to the decline and to speculate on the potential furnishings of new vaccines, expanded access to intendance, and other hereafter developments.

Methods

Sources of Data on Deaths

Nosotros used expiry-certificate data reported to the U.Southward. Vital Statistics System from 1939 through 1996 to identify underlying causes of deaths attributed to pneumonia or influenza in children (defined as persons under the age of 15 years for the purpose of this study). We excluded years before 1939 because the cause-of-expiry portion of the death certificate was substantially unlike in earlier years.8 Data on the crusade of death were available for more than 99 per centum of all deaths in the United States, except for 1972, when a fifty percent sample was used to estimate the number of deaths.8 Except for the add-on in 1989 of a fuller description of the chain of events leading to death, no major changes were fabricated to death certificates after 1949. To calculate mortality rates, we used birth data as the population denominators for infants (children less than one year old), and demography data every bit the population denominators for preschool children (one to 4 years old) and school-age children (5 to xiv years quondam).

Deaths were classified as due to pneumonia on the basis of the International Classification of Diseases (ICD) codes for pneumonia and flu in the editions of the ICD that were current during the study catamenia. In add-on, we used a lawmaking for pneumonia in newborns (children less than four weeks old) that was introduced in the sixth edition of the ICD. The eighth edition deleted the lawmaking for pneumonia in newborns and introduced a code for sudden death from an unspecified cause. In the ninth edition, a lawmaking was introduced for pneumonitis due to aspiration of solids and liquids, and a specific code for the sudden infant death syndrome was added. Beginning with the sixth edition of the ICD, comparability studies were performed in which deaths in a particular twelvemonth were classified according to the codes in the new edition and according to the codes in the preceding edition.9-12 The comparability ratio was 0.86 for the fifth and sixth editions, 0.94 for the sixth and seventh, 0.96 for the seventh and 8th, and 0.93 for the eighth and ninth.

Changes in the Mortality Rate

To reduce the influence of random fluctuations in the number of pneumonia-associated deaths, we calculated the annual per centum modify in the mortality rate by using a iii-year moving average, so that the percentage for each year was an average of the change in the rate for that year and for the previous and subsequent years.

To make up one's mind whether reductions in the bloodshed charge per unit during certain periods were more pronounced for bacterial pneumonia than for viral pneumonia, we classified two codes in the 9th revision of the ICD as representing possible bacterial pneumonia (codes 481 and 482) and two as representing possible viral pneumonia (codes 480 and 487). Similarly, for the period from 1944 to 1950, nosotros compared the code for lobar pneumonia (more than likely to have a bacterial cause than a nonbacterial cause; code 108 in the 5th edition of the ICD) with the codes for bronchopneumonia and flu (more likely to have a nonbacterial cause; codes 107 and 33).

Hospitalizations

Data from the National Hospital Discharge Survey, which were available for the flow from 1970 through 1996, were analyzed according to previously reported methods.13 For children under the age of 15 years, we compared the estimated number of infirmary discharges after a diagnosis of pneumonia per ten,000 children with the number subsequently all other diagnoses during the menstruum when at that place were steep declines in the rate of mortality from pneumonia (1970 through 1982).

Medicaid Data

Using data from the Health Care Financing Administration, we calculated the ratio of the number of children covered by Medicaid to the number of persons under the historic period of eighteen years who were living in poverty, for the period from the inception of the program, in 1965, through 1985. Estimates of the total number of Medicaid recipients were not available for 1966 or 1967, and estimates of the number of children covered past Medicaid were unavailable for the period from 1968 through 1974. To gauge the number of children covered by Medicare in these years, we used the boilerplate ratio of the number of children covered to the total number of covered persons for the period from 1975 through 1984 (0.43; range, 0.42 to 0.49) and applied it to the total number of recipients each year from 1968 through 1974. Information on persons nether the age of eighteen years who were living in poverty were obtained from census estimates (http://www.census.gov/hhes/poverty/histpov/hstpov03.txt).

Results

Figure 1. Figure ane. Deaths from Pneumonia and from Other Causes in Childhood, from 1939 through 1996.

Gaps in the curves point changes in the International Classification of Diseases codes.

Rates of bloodshed from childhood pneumonia in the United States declined by 97 percent in the 58-year menstruum from 1939 through 1996. This decline paralleled but exceeded the 82 percent turn down in overall childhood mortality (Effigy ane). The number of deaths ascribed to pneumonia dropped from 24,637 in 1939 to 800 in 1996, an absolute difference of 23,837 deaths, despite the substantial increase in the population during this period. Bloodshed rates declined by 98 percent for infants (children under the historic period of i year), by 99 percent for preschool children (1 to four years former), and by 97 percent for school-age children (five to 14 years sometime).

Figure 2. Figure 2. Annual Pct Change in Rates of Mortality from Pneumonia and from Other Causes in Infants and Older Children, from 1939 through 1996.

The curves were smoothed past using a three-year moving average (i.east., the percent change for each year is an average of the changes for that year and for the previous and subsequent years).

The reduction in the numbers of deaths from pneumonia over the 58-twelvemonth menses represented an boilerplate almanac decline of 6.8 percent, as compared with 3.0 percent for deaths from other causes. Nonetheless, variations in the rate of decline were apparent when the smoothed annual rates of change were examined (Figure ii). The curves for the charge per unit of mortality from pneumonia were singled-out from that for the rate of bloodshed from other causes at 3 times during the study period: from 1944 to 1950, when the rate of mortality from pneumonia declined steeply; in 1957, when there was a sharp increase; and from 1966 to 1982, when at that place was a sustained decline.

The boilerplate annual decline in the rate of mortality from pneumonia for the vii years from 1944 to 1950 was 9 percent for infants, 14 pct for preschool children, and 13 percent for school-historic period children. The almanac declines were similar for lobar pneumonia (14 percentage), bronchopneumonia (ten percent), and influenza (10 pct).

The elevation in the rate of bloodshed from pneumonia in 1957 was principally the event of an increased number of deaths amidst schoolhouse-age children. Amid these children, deaths from pneumonia increased by 69 percent, from 736 in 1956 to 1241 in 1957, as compared with a 22 percent increase for preschool children and an 11 percent increase for infants. The increase in the mortality charge per unit among schoolhouse-age children in 1957 was similar to the increases in the rates among persons who were 15 to 25 years former and those who were over the age of 65 years (data not shown).

From 1966 through 1982, the almanac rate of bloodshed from pneumonia declined by an average of 15 percent for infants and past an boilerplate of eleven percent for children 1 to 14 years old. The decline in infant deaths coded equally pneumonia (from 226 per 100,000 births in 1968 to 21 per 100,000 in 1982) coincided with a steep increment in deaths coded every bit due to the sudden infant expiry syndrome (from 20 per 100,000 births in 1968 to 141 per 100,000 in 1982). By definition, no deaths among preschool or school-historic period children were coded as the sudden infant decease syndrome.

An etiologic agent was not specified for almost deaths from pneumonia during the catamenia from 1966 through 1982. In 1980, for example, 75 percentage of deaths from pneumonia were coded as either pneumonia, type unspecified, or bronchopneumonia. For deaths from pneumonia that were attributed to viruses, the annual rate of decline was thirteen percent, which was similar to the rate of turn down for deaths attributed to bacterial pneumonia (xi per centum).

Nosotros evaluated other causes of death to determine whether coding practices might have influenced changes in the rate of mortality from pneumonia during this period. For example, amid school-age children, the number of deaths attributed to asthma increased from 139 in 1970 to 191 in 1995, an increment that was less than 5 percent of the number of deaths attributed to pneumonia and flu in the same menses. Similarly, changes in mortality rates for respiratory failure (codes 518.4 and 518.eight in the 9th edition of the ICD) and sepsis (lawmaking 038) were not associated with the observed declines in bloodshed rates for pneumonia. Amid deaths for which pneumonia was listed anywhere on the expiry certificate, the proportion coded every bit due to pneumonia was highest for infants (74 percent in 1968) and lowest for school-age children (39 percent), and the proportion declined by an boilerplate of ii percent annually from 1968 through 1982.

Effigy 3. Figure 3. Medicaid Coverage and Rates of Hospitalization for Pneumonia, from 1965 through 1985.

Panel A shows the ratio of the number of children covered past Medicaid to the number of persons under the age of 18 years and living in poverty. The Medicaid program started in 1965. No national information on numbers of enrollees were available for 1966 or 1967 (indicated past the broken lines). We estimated the proportions of children covered from 1968 to 1974, since specific data on the coverage of children were non available for these years. Panel B shows rates of hospitalization for pneumonia and for all other disorders, on the basis of information from the National Infirmary Discharge Survey, which began in 1970. The gaps in the curves indicate changes in the International Nomenclature of Diseases codes.

Nosotros estimated that the ratio of children covered past Medicaid to all children living in poverty increased from 0 in 1965, when the plan started, to 0.97 in 1976 then declined to 0.70 in 1982 (Figure 3A).

A review of National Hospital Discharge Survey data for the period from 1970 through 1985 showed that rates of hospitalization due to pneumonia amongst children did not refuse in parallel with mortality rates for pneumonia (Figure 3B). In fact, rates of hospitalization for pneumonia increased, whereas rates of hospitalization for all other disorders remained stable. The introduction of new codes in the 9th ICD revision in 1979 led to an increase in the rate of hospitalization for pneumonia (indicated by the gaps in the curves). Even so, between 1970 and the implementation of the new codes in 1979, the rate of hospitalization for pneumonia increased by 19 percent, whereas the rate of hospitalization for other disorders decreased past ane pct. Nosotros could not directly examine the rate of hospitalization for pneumonia among poor children because data on insurance coverage were missing in upward to 25 percent of records.

Figure 4. Effigy 4. Rates of Mortality from Childhood Pneumonia According to Region and Race, from 1965 through 1985.

Console A shows mortality rates for the iv census regions of the United States. Data on deaths amidst children under the age of fifteen years were non available according to census region before 1970. Panel B shows mortality rates for black children and for white children.

Equally Medicaid coverage increased and the charge per unit of hospitalization for pneumonia rose, the departure between the rate of mortality from pneumonia in the South and the rates in other regions narrowed (Effigy 4A), equally did the difference between the rates for black children and for white children (Figure 4B). Census information on children were non bachelor according to region for the period from 1965 through 1969, and we were therefore unable to summate mortality rates according to region for this period.

Discussion

The 97 percentage decline in rates of mortality from pneumonia among U.S. children over the past one-half century is a notable achievement in medicine and public health. With the adult countries currently preparing to introduce a battery of new pneumonia vaccines and with an opportunity to expand Medicaid coverage of uninsured children, information technology is appropriate to examine the rates of bloodshed from childhood pneumonia in earlier eras. We examined three periods when changes in the rate of mortality from pneumonia were distinct from changes in the rate of bloodshed from other causes, and we speculated on possible explanations for these changes. These periods were the 1940s, immediately after the introduction of penicillin; the year 1957, when the influenza pandemic occurred; and the 1960s and 1970s, when the War on Poverty expanded access to medical care for millions of people.

New Antimicrobial Agents

Penicillin became available for widespread use in the mid-1940s. Its predecessors, sulfanilamide and sulfapyridine, were less constructive in treating pneumonia.xiv,15 Analysis of information available in the 1950s led some government to conclude at the time that the newer antimicrobial agents had greatly influenced rates of mortality from pneumonia.16,17 The greatest reduction in the rate of mortality from pneumococcal pneumonia was among patients who were 12 to 29 years old, with progressively smaller reductions among older patients.15 Nosotros found steep declines in the rates of mortality from pneumonia during the period from 1944 through 1950, which may exist attributable to the increased availability of antimicrobial agents; withal, we did not find that the new agents led to substantially larger reductions in the number of deaths from lobar pneumonia than in the number from bronchopneumonia.

A series of new antimicrobial agents have been introduced since the 1940s for the treatment of pneumonia in children, only we found no association between reductions in mortality rates and the introduction of these agents. For example, there were steep declines in mortality rates during the 1970s, a time when several new cephalosporins with β-lactamase stability became available.18,19 Even so, we found no articulate testify that mortality rates for bacterial pneumonia declined more than steeply than those for viral pneumonia.

The 1957 Influenza Pandemic

The 1957 flu pandemic had a dramatic influence on rates of bloodshed from babyhood pneumonia. The pandemic, associated with the appearance of the so-called Asian influenza acquired past influenza A (H2N2) virus, caused an estimated 69,800 excess deaths from pneumonia and flu in the United States.20 Our finding that the number of deaths from pneumonia increased disproportionately amid children who were 5 to 14 years quondam is consequent with the observations of others. In an analysis of deaths from pneumonia and influenza during the menses from October through Dec 1957, the rate of backlog bloodshed (the observed mortality charge per unit in relation to the expected historic period-specific charge per unit) amid persons 5 to 20 years old peaked at 400 percent, a rate that was two to iii times as high equally that in whatever other age group.21

Increased Admission to Medical Intendance

I of the most striking changes in the rates of mortality from childhood pneumonia was the annual decrease in the rates between 1966 and 1982. We considered several potential explanations for this sustained refuse.

The reduction in the rates of mortality from pneumonia among infants is attributable in part to the introduction of a new code for sudden decease in infants. A series of exploratory analyses, however, showed no disarming bear witness that the declines among infants that were not due to the new codes or the substantial declines among preschool and older children were owing to improved handling of bacterial infections, changes in the use of antimicrobial agents, changes in the distribution of pathogens, regional differences in medical care, earlier or improved intendance of critically sick children, or coding artifacts. The mortality rate for bacterial pneumonia did not decline more steeply than the rate for viral pneumonia, every bit might have been expected if before or improved antimicrobial treatment had been responsible for the declines. The introduction of the Women, Infants, and Children program in 1972 may have led to improvements in nutritional status, simply it is not clear that malnutrition of the severity associated with fatal pneumonia was widespread in the United states of america in the 1970s.22 The declines in mortality rates too could not be attributed to the introduction of ICD codes for deaths from asthma, respiratory failure, sepsis, or other disorders apart from pneumonia.

Amid preschool children, the rate of mortality from pneumonia declined steeply during the period from 1963 through 1968 (data non shown). This reject, which immediately preceded and overlapped the overall reduction in mortality from pneumonia, coincided with the availability of the measles vaccine. Measles may exist the leading preventable cause of expiry from childhood pneumonia throughout the world.23,24 Currently, measles accounts for approximately 1 1000000 deaths per year, mostly amongst children in developing countries who are 9 to 24 months old.24,25 Measles vaccine was introduced in the United States in 1963, and vaccination programs resulted in a 95 percent reduction in reported cases of measles, from 481,530 in 1962 to 22,231 in 1968.26 Thus, the decline in the rate of mortality from pneumonia amidst preschool children occurred at the fourth dimension and in the age group in which measles vaccination was likely to have had the greatest effect. Yet, except for a more prominent pass up in this age group, it is difficult to divide the decline betwixt 1963 and 1968 from the sustained turn down during the period from 1966 through 1982.

Table 1. Table 1. U.South. Health Intendance Programs for Children in the 20th Century.

The relative decline in rates of mortality from pneumonia among children of all ages from 1966 through 1982 may be attributable to improved admission to medical intendance amongst poor children, primarily as a outcome of the Medicaid program. Testify from several sources supports this hypothesis. Title Nineteen of the Social Security Human activity (the Medicaid program) was enacted in 1965 and ushered in a 15-year era of expanded federal health intendance programs for poor children that was unique in the 20th century (Table i).27-29 These programs were scaled back with the passage of the Jitney Budget Reconciliation Deed in 1981, although access to intendance has again improved since 1990.30 From 1965 through 1976, the proportion of poor children who were covered past Medicaid increased dramatically. Others accept besides plant that Medicaid benefits were introduced incrementally during this period.29,31 The sustained decline in the rate of bloodshed from childhood pneumonia betwixt 1966 and 1982 thus coincides with the introduction and expansion of federally mandated coverage of medical care for poor children.

If expanded admission to medical care contributed to the decline in bloodshed rates during the 1970s, the steepest refuse would be expected among poor children. However, expiry certificates do not include information well-nigh family income and insurance coverage. The narrowing of the gap between the mortality rates for black children and for white children and between the rates in the S and in other regions in the 1970s constitutes evidence of the role of expanded admission to care. Blackness race has been used as a crude surrogate for poverty, as has residence in the S.29 During the 1970s, the South had the largest population of poor children (6 meg in 1969, as compared with 6.6 million in all other regions combined) and the lowest expenditures for children's wellness care (a hateful expenditure of $24 per poor child, as compared with $36 or $37 per poor child for each of the other regions).29

The greatly expanded access to acute medical care amidst poor children during this period is well documented. Between 1964 and 1975, for example, the annual number of visits to a physician among children in the quartile with the lowest income increased by 70 pct (from 2.7 to 4.6 visits per child), whereas the number of visits for children in the quartile with the highest income decreased by 10 percent (from 5.0 to four.five visits per child).29 Our analysis further demonstrated that rates of hospitalization for pneumonia among children increased in proportion to rates of hospitalization for other disorders during this menses. Thus, the steep decline in the rates of mortality from pneumonia cannot be attributed to a decrease in the incidence of pneumonia merely may correspond instead to increased access to care.

The Medicaid plan was criticized in the 1970s for its excessive costs and for its focus on acute care at public clinics and hospitals rather than on preventive care.31,32 In fact, this focus may accept reduced mortality from babyhood pneumonia and other acute weather that do good from prompt access to physicians and hospitals. The number of deaths from diarrhea among children, for example, declined by 75 pct between 1968 and 1985, a change that was likewise out of proportion to changes in the numbers of deaths from other causes during this menstruum.33

Further support for the possibility that increased access to care reduced the rate of mortality from pneumonia comes from a series of placebo-controlled studies showing that improved access to intendance and early antimicrobial treatment can subtract the rate of mortality from childhood pneumonia by approximately 50 percent.1,two,34-36 Most of these studies have been conducted in developing countries, where the base-line rates of bloodshed from pneumonia are at least as high equally the rates in the United States in the 1940s.

Limitations of the Written report

Our analysis is discipline to important limitations inherent in evaluations based on death records. The information independent in such records is quite limited and the documented cause of death may exist inaccurate.37 Our findings provided a useful framework for speculating on the factors that influence rates of bloodshed from pneumonia, but the events and interventions nosotros proposed every bit influential factors may accept been associated simply indirectly with changes in these rates. Coding artifacts probably did not influence mortality rates, except for the effect of the new code for the sudden infant decease syndrome on infant mortality rates. Some of the findings in our study are robust and not attributable to antiquity, such as the 97 percent turn down in the rate of bloodshed from pneumonia over a flow of 58 years and the sustained steep decline among older children between 1966 and 1982.

Conclusions

We believe that some of the largest reductions in rates of mortality from babyhood pneumonia during the past fifty years may have resulted from expanded access to medical treat poor children. New vaccines offer opportunities to reduce the incidence and severity of childhood pneumonia, and an additional expansion of wellness intendance coverage for poor children who might otherwise not receive prompt clinical attention may further reduce mortality rates.

Funding and Disclosures

Presented in part at the 37th coming together of the Infectious Diseases Society of America, Philadelphia, November xviii–21, 1999.

Nosotros are indebted to Onnalee Hennebury for aid with literature searches and to Anne Schuchat, Larry Anderson, Robert Holman, Joseph Bresee, Umesh Parashar, and Orin Levine at the National Eye for Infectious Diseases for reviewing the manuscript.

Writer Affiliations

From the Respiratory Diseases Branch (Southward.F.D.) and the Biostatistics and Data Management Co-operative (B.A.K., Eastward.R.Z.), Sectionalisation of Bacterial and Mycotic Diseases, and the Respiratory and Enteric Viruses Branch, Division of Viral and Rickettsial Diseases (D.K.S.), National Center for Infectious Diseases, Atlanta.

Accost reprint requests to Dr. Dowell at Mailstop C-23, Centers for Disease Control and Prevention, 1600 Clifton Rd., NE, Atlanta, GA 30333, or at [electronic mail protected].

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