Child Health and Mortality Prevention Surveillance

In the lowest-resource settings with the highest child mortality, information about the causes of death is severely lacking. Many children die without ever seeing a health provider, diagnostic testing is rarely available, and surveillance systems are extremely limited. In the past, some studies have used verbal autopsies—interviews with caregivers about visible symptoms—to identify causes of death, but these results could be imprecise or even inaccurate. Causes of child mortality were typically grouped into large categories such as "pneumonia" or "prematurity", and placing children within these categories involved guesswork. As a result, there was a shortage of evidence to inform the global health agenda, which led in turn to suboptimal child-survival strategies in the places where they were most needed.

To start addressing this problem, researchers developed minimally invasive tissue sampling (MITS) to collect small amounts of postmortem tissue (e.g., brain, liver, lung) and bodily fluids (e.g., blood, cerebrospinal fluid, stool) that was then tested in various ways to determine causes of death with accuracy and precision. MITS was first used in small research studies, but in 2015, the Gates Foundation partnered with the Emory Global Health Institute to create the Child Health and Mortality Prevention Surveillance (CHAMPS) network to apply MITS, as well as microbiological and pathology testing, more broadly. CHAMPS, a sentinel surveillance system, gathers accurate data on the causes of child mortality and has operated in nine high-mortality countries, Bangladesh, Ethiopia, Kenya, Mali, Mozambique, Nigeria, Pakistan, Sierra Leone, and South Africa.

The testing and analysis done at CHAMPS sites helps a panel of experts not only determine causes of death but also identify specific subtypes of pathogens, providing policymakers with vital information to inform a wide range of decisions, from setting programmatic priorities locally to shaping the R&D agenda globally. And by providing clear baseline data, CHAMPS helps researchers and policymakers track the impact of various interventions on child mortality, allowing them to pinpoint and fill programmatic gaps.

Examples of CHAMPS-derived insights include:

• The CHAMPS site in Ethiopia found that prenatal neural-tube defects like spina bifida or anencephaly were a common cause of stillbirth and infant death, so researchers proposed fortifying salt with folate (in many other countries, flour is fortified, but in Ethiopia that approach isn’t workable because so much flour is locally produced).
• CHAMPS recently showed that HIV remains an important cause of death in young children. Furthermore, the data revealed that in many cases, the mother does not know she is infected, and the child's death is the first time the diagnosis is made, suggesting important unrecognized weaknesses in HIV prevention programs. Findings about residual malaria deaths in several countries have similarly pointed toward potential adjustments to malaria-control programs.
• CHAMPS has found a significant burden of RSV mortality in children in the first six months of life who die before getting admitted to the hospital, leading to global calls for the rapid introduction of maternal immunization to prevent RSV in infants.
• CHAMPS has also revealed a significant burden of pneumococcal disease caused by serotypes not included in current pneumococcal vaccines, a finding that will inform the development of the next generation of pneumococcal vaccines.
• Similarly, Klebsiella, a bacterial pathogen notorious for antimicrobial resistance, turns out to be the leading cause of infectious death across the network, especially among newborns. But for CHAMPS, the prevalence of Klebsiella and another multidrug resistant pathogen, Acinetobacter, would have remained hidden.
• CHAMPS data have informed many global vaccine recommendations and national vaccine introductions, supporting the work of groups like the WHO's Strategic Advisory Group of Experts on Immunization (SAGE) and the Gavi Alliance to make sure vaccines reach the communities that need them.