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Impact

of the Human

Immunodeficiency

Virus

Epidemic

on Mortality

in Children,

United

States

Susan

Y. Chu,

PhD; James

W. Buehler,

MD; Margaret

J. Oxtoby,

MD;

and Barbara

W. Kilbourne,

RN, MPH

From the Division of HIV/AIDS, Center for Infectious Diseases, Centers for Disease Control, Public Health Service, US Department of Health and Human Services,

Atlanta, Georgia

ABSTRACT.

To assess the effect of the human

immuno-deficiency virus (HIV) epidemic on mortality in US chil-then younger than 15 years of age and to identify asso-ciated causes of death, the authors examined final na-tional mortality statistics for 1988, the most recent year for which such data are available. In 1988, there were 249

deaths attributed to HIV/acquired immunodeficiency

syndrome (AIDS) in children younger than 15 years of

age. Associated causes of death listed most frequently on

270 death certificates with any mention of HIV/AIDS included conditions within the AIDS surveillance case definition (30%), pneumonia (excluding Pneumocystis carinii pneumonia) (17%), septicemia (10%), and

nonin-fectious respiratory diseases (8%). The impact of HIV/

AIDS as a cause of death was most striking in the

1-through 4-year-old age group and in black and Hispanic children, particularly in the Northeast. By 1988 in New

York State, HIV/AIDS was the first and second leading cause of death in Hispanic and black children 1 through

4 years of age, accounting for 15% and 16%, respectively,

of all deaths in these age-race groups. With an estimated

1500 to 2000 HIV-infected children born in 1989, the impact of HIV on mortality in children will become more severe. Pediatrics 1991;87:806-810; human immunodefi-ciency virus, mortality, acquired immunodeficiency syn-drome.

ABBREVIATIONS. AIDS, acquired immunodeficiency syndrome; HIV, human immunodeficiency virus.

Received for publication Jun 12, 1990; accepted Jan 8, 1991. These data were presented, in part, at the Sixth Annual National

Pediatric AIDS Conference, Washington, DC, February 9-12, 1991.

Reprint requests to (S.Y.C.) Surveillance Branch, Division of

HIV/AIDS, Center for Infectious Diseases, Centers for Disease Control, Mailstop E-47, 1600 Clifton Rd NE, Atlanta, GA 30333. PEDIATRICS (ISSN 0031 4005). Copyright © 1991 by the

American Academy of Pediatrics.

Although children younger than 15 years of age account for fewer than 2% of all reported cases of acquired immunodeficiency syndrome (AIDS) in the United States,1 the problem of AIDS in children threatens to grow disproportionately in the coming years. In 1988, human immunodeficiency virus (HIV)/AIDS was already the ninth leading cause of death among children 1 to 4 years of age and the sixth leading cause of death among black children 1 to 4 years of age. If current trends continue, HIV/ AIDS may become one of the top five leading causes of death in this age group in the next few years.2’3

In this analysis, we used national mortality sta-tistics for 1988 to determine the effect of the HIV epidemic on the mortality of children. We also describe causes of death that were associated with HIV-related deaths in children.

METHODS

Methods used in this analysis were similar to those described in detail in previous reports on HIV-related mortality in adults.4’5 We limited our analyses to children younger than 15 years of age at the time of death who were residents of the United States (excluding territories). We used final mortality data on public-use computer tapes pre-pared by the National Center for Health Statistics of the Centers for Disease Control for 1988,6 the most recent year for which such data are available. We used mid-year (July 1) age-, gender-, and

race-specific population estimates for 1988 from

public-use computer tapes prepared from Bureau of the Census data7 to calculate annual death rates (deaths/100 000 population per year).

(2)

Dis-trict of Columbia.8 Therefore, death rates for

chil-dren of Hispanic ethnicity were calculated for those reporting areas only, and not for the entire United States. State-specific 1988 population estimates for Hispanic children were extrapolated from US Bur-eua of the Census reports.9”#{176} Because death records list Hispanic ethnicity separately from race (white, black, etc), mortality tabulations include white per-sons of Hispanic ethnicity in the white race group and black persons of Hispanic origin in the black race group, etc.

For multiple cause-of-death analyses and

rank-ings, we used 1988 final National Center for Health

Statistics mortality statistics. Deaths attributable to HIV infection were classified to category num-bers 042 through 044, codes introduced in 1987 for

classifying and coding HIV infection.’1 To identify

causes of death that may be associated with

HIV-related deaths, we reviewed multiple cause-of-death listings for deaths that included any mention of HIV/AIDS. Using the International Classification

of Diseases, Ninth Edition,12 we grouped causes of death into categories similar to those used in

pre-vious analyses,4’5 with additional categories for

causes specific to infants and children (eg, perinatal conditions). For cause-of-death rankings, we used categories that conform with National Center for Health Statistics mortality tabulations.8 All cause-of-death analyses were done separately for the fol-lowing age groups: younger than 1 year of age (infants), 1 through 4 years of age, and 5 through 14 years of age.

Lastly, we compared the number of HIV/AIDS

deaths from vital statistics with the number of deaths reported from national surveillance of AIDS

cases.

RESULTS

In 1988, 249 deaths in children younger than 15 years of age (rate = 0.5 per 100 000 population) had

HIV/AIDS listed as the underlying cause. These deaths represented 0.4% of all deaths in this age group.

The demographic characteristics of children who died of HIV/AIDS in 1988 are presented in Table 1. Most infants who died of HIV/AIDS were black, while most children 5 through 14 years of age who died of HIV/AIDS were white. Data on Hispanic ethnicity were available for 153 children who died of HIV/AIDS; 39 (25%) of these children were Hispanic. All 39 children of Hispanic origin were white.

Most children who died of HIV/AIDS resided in the Northeast or South (Table 1). The regional distribution for children who died of HIV/AIDS

has shifted somewhat from the previous year. From 1987 to 1988, the percentage of deaths that occurred in the South increased from 24% to 33%, while the percentage of deaths that occurred in the West decreased from 20% to 8%.

Nearly all (99%) of the infant deaths occurred during the postneonatal period (>28 days).

Race-

and Region-Specific

Rates

The death rate for HIV/AIDS among black chil-dren younger than 15 years of age was approxi-mately six times higher than the rate among white children (Table 2). The racial disparity was greater among infants and children 1 through 4 years of age than among children 5 through 14 years of age.

Death rates for HIV/AIDS in children younger than 15 years of age varied substantially by region of the United States and by state. In the Northeast, the death rate for HIV/AIDS was 1.3 per 100 000 population, about seven times the rate in the Mid-west and the West (0.2 per 100 000). The South had an intermediate rate of 0.4 per 100 000 popu-lation. Among the 50 states and the District of Columbia, the highest death rates for HIV/AIDS among children younger than 15 years of age oc-curred in New York, Florida, and New Jersey, with death rates of 2.1, 1.9, and 1.7 per 100 000 popula-tion, respectively.

The higher death rates for black and Hispanic children in the United States overall were consist-ent across states. For example, in 1988, death rates in New York for black, Hispanic, and white children

younger than 15 years of age were 6.0, 3.2, and 1.2

per 100 000 population, respectively. In New Jersey, death rates for HIV/AIDS for black, Hispanic, and white children younger than 15 years of age were

5.7, 2.6, and 0.8 per 100 000 population, respec-tively. In New York, HIV/AIDS was the leading cause of death among Hispanic children 1 through 4 years of age (surpassing unintentional injuries) and was the second leading cause of death among black children 1 through 4 years of age; these deaths accounted for 15% and 16% of all deaths in His-panic and black children, respectively, 1 through 4

years of age. In New Jersey, HIV/AIDS was the

second leading cause of death among Hispanic chil-dren 1 through 4 years of age and was the third leading cause of death among black children 1 through 4 years of age; these deaths accounted for 14% and 11% of all deaths in Hispanic and black children, respectively, 1 through 4 years of age.

Associated

Causes

of Death

(3)

TABLE 1. Characteristics of

Human Immunodeficiency Vi

States, 1988, by Age Group*

Children Younger Than

rus/Acquired Immunodefici

15

enc

Years of

y Syndrom

Age

e (n

Who Died = 249), Unit

of ed

Characteristic <1 y 1-4 y 5-14 y Total

Sex

Male 49 (60) 62 (54) 34 (63) 145 (58)

Female 32 (40) 52 (46) 20 (37) 104 (42) Race

Black 48 (59) 66 (58) 23 (42) 137 (55)

White 33 (41) 48 (42) 30 (56) 111 (45)

All other 0 (0) 0 (0) 1 (2) 1 (<1)

Ethnicityt

Hispanic origins 11 (22) 20 (27) 8 (27) 39 (25)

Non-Hispanic origin 38 (78) 54 (73) 22 (73) 114 (75)

Region

Northeast 43 (53) 63 (55) 22 (40) 128 (51)

Midwest 5 (6) 9 (8) 6 (11) 20 (8)

South 27 (33) 39 (34) 15 (28) 81 (33)

West 6 (18) 3 (3) 11 (21) 20 (8)

* Data are given as number (%) and are based on deaths assigned to category nos.

044. Source: National Center for Health Statistics, Centers for Disease Control.

t Deaths for persons of Hispanic origin were compiled from 26 states and the District of

Columbia only.

:1:

All 39 children of Hispanic origin were white.

042-TABLE 2. Death Rates for Huma n Immunodeficiency

Virus/Acquired Immunodeficiency Syndrome Among Children Younger Than 15 Years, by Age and Race,

United States, 1988*

Race <1 y 1-4 y 5-14 y Total

Black 8.1 3.0 0.4 1.7

White 1.1 0.4 0.1 0.3

Total 2.1 0.8 0.2 0.5

* Death rates per 100 000 population, children younger

than 15 years. Data are based on deaths assigned to

category nos. 042-044, underlying cause. Source:

Na-tional Center for Health Statistics, Centers for Disease Control.8

children younger than 15 years of age that included any mention of HIV/AIDS (Nos. 042 through 044).

In 249 (92%) of these deaths, HIV/AIDS was

as-signed as the underlying cause of death. Conditions within the AIDS surveillance definition (excluding recurrent or multiple bacterial infections) were listed as an underlying or multiple cause on 30%

(82/270) of these death certificates (Table 3). The

frequency of some of these conditions within the surveillance definition differed by age group. For infants, Pneumocystis

carinii

pneumonia was listed on 27% of the certificates. For children 5 through 14 years of age,

P carinii

pneumonia was listed on only 3% of the certificates and the most frequently listed condition within the AIDS definition was mycobacterial infections (excluding Mycobacterium tuberculosis). For conditions not in the surveillance definition, the most frequently listed cause of death was pneumonia (excluding

P

carinii pneumonia), which was listed on 17% of the death certificates

for children younger than 15 years of age. Other

causes associated with HIV-related deaths included

septicemia, noninfectious respiratory conditions (which included nonspecific diagnoses such as pul-monary insufficiency), blood disorders (excluding

hemophilia), and other infectious diseases.

Hemo-philia was listed on 15% of the death certificates among children 5 through 14 years of age.

Comparison

With National

AIDS Surveillance

There were 276 deaths among children younger than 15 years of age that occurred in 1988 and were reported to national AIDS surveillance through November 1990. This compares with 249 deaths among children younger than 15 years of age re-ported in 1988 to national vital statistics with HIV/ AIDS assigned as the underlying cause of death and 270 deaths with HIV/AIDS mentioned on the certificate. The distributions of deaths by sex and region were similar in both systems.

Based on AIDS surveillance, the vast majority of infants (94%) and children 1 through 4 years of age (93%) who died of AIDS were infected perinatally. For children 5 through 14 years of age, 23% had hemophilia or other coagulation disorders, 26% had histories of blood transfusion, and 48% were in-fected perinatally.

DISCUSSION

(4)

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1980 1981 1982 1983 1984 1983 1986 1987 9811

Year

TABLE 3. Associated Causes of Death

Acquired Immunodeficiency Syndrome (

on HIV/

Certificates

AIDS) in Ch

With Any Mention

ildren Younger Than

of Human Immunodeficiency Virus/

15 Years of Age, 1988, United States*

Cause <1 y (n = 90) 1-4 y (n = 119) 5-14 y (n = 61) Total (n = 270)

Conditions in the AIDS definitiont 34 26 33 30

PCP 27 15 3 16

LIPS 1 2 0 1

CMVII 9 0 3 4

HIV encephalopathy 1 8 3 4

Mycobacterial infection 0 0 18 4

Pneumonia 23 15 11 17

Septicemia 12 11 7 10

Noninfectious respiratory diseasesli 8 8 10 8

Blood disorders, including anemias 6 10 2 7

Other infectious diseases 10 5 7 8

Perinatal conditions 7 3 3 4

Hemophilia 0 0 15 3

* Results are given as percentages and are based on deaths assigned to category nos. 042-044 (listed as underlying or

multiple cause).

t Excluding recurrent bacterial infections.

:1:

Pneurnocystia carinii pneumonia.

§

Lymphoid interstitial pneumonitis.

II

Cytomegalovirus disease.

#{182}Excluding LIP.

AIDS as a cause of death was most striking in the

1 through 4 year age group and in black and

His-panic children, particularly in the Northeast. The number of new cases of AIDS in children continues to increase (during 1989 and 1990, 1399 new cases were reported in children younger than 15 years of age’); consequently, deaths due to HIV/AIDS in children will continue to rise. This increase in deaths due to HIV/AIDS is in striking contrast to other causes of death in children, which have remained relatively stable over the last dec-ade (Figure).

Moreover, the number of deaths attributable to HIV/AIDS in national vital statistics underesti-mate the full extent of HIV-related mortality. For example, the 1988 death rate included 249 deaths

that had HIV/AIDS (codes 042 through 044)

spec-ified as the underlying cause of death but excluded

21 deaths that listed HIV/AIDS as an associated,

but not the underlying, cause of death. If these

deaths are included as deaths attributable to HIV/

AIDS, the total number of deaths would increase

by 8%. In addition, mortality studies in adults have

identified several causes of death that have in-creased in association with the HIV epidemic,4’5”3”4 including septicemia and pneumonia (excluding

P

carinii pneumonia). Many of these deaths may re-flect the spectrum of infectious complications or immune defects caused by HIV infection, variations in reporting HIV-related conditions on death

cer-tificates, or unrecognized cases of HIV infection.4

A wide variety of causes of death were listed in

association with HIV/AIDS in children. Although

conditions in the AIDS surveillance definition were

Figure. Death rates for human immunodeficiency

vi-rus/acquired immunodeficiency syndrome (HIV/AIDS)

and other leading causes in children 1 through 4 years of

age 1980 through 1988. HIV/AIDS = ICD-9 category no.

279.1 (1980-1986); category nos. 042-044 (1987-1988).

listed most frequently, other conditions were also noted, including pneumonia, septicemia, and

non-infectious respiratory diseases. Clearly, causes of

death do not reflect the entire clinical spectrum of HIV infection in children,’5”6 and death certificates do not provide the same level of clinical detail as medical records. Conditions that are not considered a cause of death (eg, encephalopathy, oral candidi-asis, failure to thrive, otitis media) may not be listed on death certificates. However, 93% of all HIV-related deaths had more than one condition listed,

suggesting that many of the most serious conditions

related to death were recorded.

The number of HIV-related deaths detected through vital records was similar to the number

reported through national surveillance of AIDS

(5)

perspectives, with the former providing information on diagnoses that are listed on death certificates

and the latter providing information on children

who meet surveillance criteria during the course of their HIV disease. For example, while there were only 82 children in 1988 whose death certificates specifically listed conditions in the AIDS definition (in addition to “HIV infection” or “AIDS”), there were 276 deaths in 1988 among children who met the definition and were reported through AIDS surveillance.

Differences in racial/ethnic and regional distri-bution by age group reflect differences in the route of transmission. Based on AIDS surveillance, 92% of infants and children 1 through 4 years of age are infected with HIV perinatally. Black and Hispanic children account for 85% of all perinatally acquired

AIDS cases, with cumulative AIDS incidence rates

21 and 13 times, respectively, the incidence rate in white children.17 In children 5 through 14 years of age, a larger proportion are infected from blood transfusion (25%) or from blood products used to treat hemophilia (32%).’ With routine screening of

donated blood and heat treatment of clotting factor

concentrates since 1985, the proportion of pediatric

AIDS cases associated with HIV-contaminated

blood or blood products will decrease markedly and mother-to-child transmission will become virtually the only source of new infection in children in the United States.

The problem of HIV infection and AIDS in

chil-dren is increasing as more children become infected each year. With an estimated 1500 to 2000 HIV-infected children born in 1989,18 the impact of HIV on mortality in children will become more severe. While certain therapies under evaluation may slow

the course of HIV disease, HIV infection is likely

to remain a highly fatal condition. Prevention of most AIDS cases in children requires prevention of infection in women.’9 Counseling and testing pro-grams for women should be offered, and readily available, in health facilities that serve reproduc-tive-age women at high risk of HIV infection.20’2’

Women who are already infected should be advised

to consider the risk of perinatal HIV transmission in making reproductive choices. These programs are urgently needed, especially in areas with high

incidence of perinatally acquired HIV infection.

ACKNOWLEDGMENTS

We thank Marth F. Rogers, MD, and James W.

Cur-ran, MD, for their valuable comments and suggests.

REFERENCES

1. Centers for Disease Control. HIV/AIDS Surveillance Report. January 1990:1-22

2. Kilbourne BW, Buehler JW, Rogers MF. AIDS as a cause of death in children, adolescents, and young adults. Am J Public Health. 1990;80:499-500

3. FinalReport of the Secretary’s Work Group on Pediatric HIV

Infection and Disease. US Dept of Health and Human Serv-ices, November 18, 1988. Washington, DC: US Government Printing Office; 1989

4. Buehler JW, Devine OJ, Berkelman RL, Chevarley FM. Impact of the human immunodeficiency virus epidemic on

mortality trends in young men, United States. Am J Public

Health. 1990;80:1080-1086

5. Chu SY, Buehler JW, Berkelman RL. Impact of the human immunodeficiency virus epidemic on mortality in women of reproductive age, United States. JAMA. 1990;264:225-229 6. National Center for Health Statistics. Catalog of public use

data tapes. Hyattsville, MD: US Dept of Health and Human Services, Public Health Service; 1989

7. Irwin R. 1980-1988 Intercensal population estimates by race, sex, and age (machine-readable data file). Alexandria, VA: Demo-Detail; 1989

8. National Center for Health Statistics. Advance report of

final mortality statistics, 1988. Monthly Vita.! Statistics

Re-port. 1990:39 (7 suppl)

9. US Bureau of the Census, Current Population Reports, Series P.25, No. 1040-RD-i. Population estimates by race and Hispanic origin for states, metropolitan areas, and selected counties: 1980 to 1985. Washington, DC: US Gov-ernment Printing Office; 1989

10. US Bureau of the Census, Current Population Reports, Series P-25, No. 995. Projections ofthe Hispanic population:

1983 to 2080. Washington, DC: US Government Printing Office; 1986

ii. Centers for Disease Control. Human immunodeficiency

vi-rus (HIV) infection codes: official authorized addendum ICD-9-CM (Revision No. 1)-effective January 1, 1988. MMWR. 1987;36(suppl 7):i-24

12. International Classification of Diseases. Manual of the

Inter-national Statistical Classification of Diseases, Injuries, and Causes of Death. 9th revision. Geneva, Switzerland: World Health Organization; i977

13. Selwyn PA, Hartel D, Wasserman W, Drucker E. Impact of the AIDS epidemic on morbidity and mortality among in-travenous drug users in a New York City methadone main-tenance program. Am J Public Health. 1989;79:i358-1362

14. Stoneburner RL, DesJarlais DC, Benezra D, et al. A larger spectrum of severe HIV-i-related disease in intravenous

drug users in New York City. Science. 1988;242:9i6-919

15. Scott GB, Hutto C, Makuch RW, et al. Survival in children with perinatally acquired human immunodeficiency virus

type 1 infection. N Engi J Med. 1989;32i:i79i-1796

16. Falloon J, Eddy J, Wiener L, Pizzo PA. Human immuno-deficiency virus infection in children. J Pediatr. 1989;114:1-30

17. Oxtoby MJ. Perinatally acquired human immunodeficiency

virus infection. Pediatr Infect Dis J. i990;9:609-619

18. Gwinn M, Pappaioanou M, George JR, et al. Prevalence of HIV infection in childbearing women in the United States: surveillance using newborn blood samples. JAMA. 1991. In press

19. Rogers MF. The epidemiology of pediatric HIV infections. In: Wormser GP, Stahl RE, Bottone EJ, eds. AIDS and

Other Manifestations of HIV Infection. Park Ridge, NJ: Noyes Publications; 1987:36-47

20. Centers for Disease Control. Public Health Service guide-lines for counseling and antibody testing to prevent HIV infection and AIDS. MMWR. 1987;36:509-515

(6)

1991;87;806

Pediatrics

Susan Y. Chu, James W. Buehler, Margaret J. Oxtoby and Barbara W. Kilbourne

United States

Impact of the Human Immunodeficiency Virus Epidemic on Mortality in Children,

Services

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1991;87;806

Pediatrics

Susan Y. Chu, James W. Buehler, Margaret J. Oxtoby and Barbara W. Kilbourne

United States

Impact of the Human Immunodeficiency Virus Epidemic on Mortality in Children,

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