The effects and contribution of childhood diseases on the geographical distribution of all-cause under-five mortality in Uganda

INTRODUCTION: Information on the causes of death among under-five children is key in designing and implementation of appropriate interventions. In Uganda, civil death registration is incomplete which limits the estimation of disease-related mortality burden especially at a local scale. In the absence of routine cause-specific data, we used household surveys to quantify the effects and contribution of main childhood diseases such as malaria, severe or moderate anaemia, severe or moderate malnutrition, diarrhoea and acute respiratory infections (ARIs) on all-cause under-five mortality (U5M) at national and sub-national levels. We related all-cause U5M with risks of childhood diseases after adjusting for geographical disparities in coverages of health interventions, socio-economic, environmental factors and disease co-endemicities. METHODS: Data on U5M, disease prevalence, socio-economic and intervention coverage indicators were obtained from the 2011 Demographic and Health Survey, while data on malaria prevalence were extracted from the 2009 Malaria Indicator Survey. Bayesian geostatistical Weibull proportional hazards models with spatially varying disease effects at sub-national scales were fitted to quantify the associations between childhood diseases and the U5M. Spatial correlation between clusters was incorporated via locational random effects while region-specific random effects with conditional autoregressive prior distributions modeled the geographical variation in the effects of childhood diseases. The models addressed geographical misalignment in the locations of the two surveys. The contribution of childhood diseases to under-five mortality was estimated using population attributable fractions. RESULTS: The overall U5M rate was 90 deaths per 1000 live births. Large regional variations in U5M rates were observed, lowest in Kampala at 56 and highest in the North-East at 152 per 1000 live births. National malaria parasitemia prevalence was 42%, with Kampala experiencing the lowest of 5% and the Mid-North the highest of 62%. About 27% of Ugandan children aged 6–59 months were severely or moderately anaemic; lowest in South-West (8%) and highest in East-Central (46%). Overall, 17% of children were either severely or moderately malnourished. The percentage of moderately/severely malnourished children varied by region with Kampala having the lowest (8%) and North-East the highest (45%). Nearly a quarter of the children under-five years were reported to have diarrhoea at national level, and this proportion was highest in East-Central (32%) and Mid-Eastern (33%) and lowest in South-West (14%). Overall, ARIs in the two weeks before the survey was 15%; highest in Mid-North (22%) and lowest in Central 1 (9%). At national level, the U5M was associated with prevalence of malaria (hazard ratio (HR) = 1.74; 95% BCI: 1.42, 2.16), severe or moderate anaemia (HR =1.37; 95% BCI: 1.20, 1.75), severe or moderate malnutrition (HR = 1.49; 95% BCI: 1.25, 1.66) and diarrhoea (HR = 1.61; 95% BCI: 1.31, 2.05). The relationship between malaria and U5M was important in the regions of Central 2, East-Central, Mid-North, North-East and West-Nile. Diarrhoea was associated with under-five deaths in Central 2, East-central, Mid-Eastern and Mid-Western. Moderate/severe malnutrition was associated with U5M in East-Central, Mid-Eastern and North-East. Moderate/severe anaemia was associated with deaths in Central 1, Kampala, Mid-North, Mid-Western, North-East, South-West and West-Nile. At the national level, 97% (PAF = 96.9; 95%BCI: 94.4, 98.0), 91% (PAF = 90.9; 95%BCI: 84.4, 95.3), 89% (PAF = 89.3; 95%BCI: 76.0,93.8) and 93% (PAF = 93.3 95%BCI: 87.7,96.0) of the deaths among children less than five years in Uganda were attributable to malaria, severe/moderate anaemia, severe/moderate malnutrition and diarrhoea respectively. The attribution of malaria was comparable in Central 2, East-Central, Mid-North, North-East and West-Nile while severe/moderate anaemia was more common in all regions except Central 2, East-Central and Mid-Eastern. The attribution of diarrhoea in Central 2, East-Central, Mid-Eastern and Mid-Western was similar. The attribution of severe/moderate malnutrition was common in East-Central, Mid-Eastern and North-East. CONCLUSION: In Uganda, the contribution and effects of childhood diseases on U5M vary by region. Majority of the under-five deaths are due to malaria, followed by diarrhoea, severe/moderate anaemia and severe/moderate malnutrition. Thus, strengthening disease-specific interventions especially in the affected regions may be an important strategy to accelerate progress towards the reduction of the U5M as per the SDG target by 2030. In particular, Indoor Residual Spraying, iron supplementation, deworming, exclusive breastfeeding, investment in nutrition and education in nutrition practices, oral rehydration therapy or recommended home fluid, improved sanitation facilities should be improved.