Publ. Hlth, Lond. (1975) 89, 233-236
Mortality in Five- to Nine-year-old Children in Shiraz, Iran A. John Rezaian, M.D,* and H. Shafiee Pour, M.D.
2970 Lake Shore Drive, Chicago,///. 60657, U.S.A. Population statistics for the city of Shiraz and its geographical location were given in summary form. Cause of death among children between the ages of five to nine years for that city, for the Iranian year 1350 (21 March 1971 to 20 March 1972), were detailed. There were a total Of eighty-seven deaths. The cause of death in this age group shows infectious diseases to be the greatest killers of children. Accidents are the second greatest cause of death. These and all other causes of death were tabulated. Seasonal or temporal relationships were assessed. The most frequent causes of death were analysed. A way to prevent or reduce the big killers was sought with some suggestions and recommendations.
Introduction Shiraz, the capital city of Fars province in Iran, is situated in the southern part o f the country some 5500 feet above sea level. Its climate is dry with variable rainfall, more abundant every three to four years, but never adequate. In the Iranian year 1350 (21 M a r c h 1971 - - 2 0 M a r c h 1972) it had a population of 377 000; a birth rate of 32/1000 (totalling 12 090 births; and a death rate of 7/1000~ (totalling 2865 deaths); neonatal death rate for the same year was 17/1000. There was also a total of 1025 registered marriages for the same year. In this paper an attempt is made to find out the total number and cause of death in children in the five-to-nine years age-group, and whether there are ways to prevent or reduce the most frequent killers. Some suggestions and recommendations are offered. Materials and Method There are three hospitals in Shiraz with paediatric wards. N o t all sick children, however, are admitted to the hospitals. Therefore, it would not have been sufficient to look at the hospital registers for the cause o f death, nor to refer to the pathology departments to pick out the post-mortem diagnosis of this age group of children. Furthermore, hospital admissions are not necessarily representative o f the disease in the general population and autopsy statistics may be influenced by the type of case ~tdmitted. As well as checking all three hospitals' files, it was planned, therefore, to refer to the civil authorities and inquire how deaths are registered in the Registry of Births and Deaths for the City o f Shiraz. The problems were many. Some deaths were not reported. Some were reported as residents of the city o f Shiraz who were not resident. Certifications for the cause of death issued by a physician were often vague and general in nature. Furthermore, hospitalized deaths were mixed with non-hospitalized cases. We were then directed to a place where all dead people receive their final bath before burial. This seemed to be a better place to gather the statistics than any other source. *Family Practice Resident, St Joseph Hospital, Chicago, Illinois. Formerly of Shiraz, Medical Centre, Pahlavi University, Shiraz, Iran. tThe death rate of 7/1000 makes one feel that it is "going to lead to an enormous population explosion" and it probably is.
234
A. J. Rezaian and H. S. Pour
According to their religious belief the people of Shiraz bring all dead bodies to this sacred "bath house" to receive their final cleansing. A register is also kept here. Age, sex, cause of death, and residence are indicated in this register. However, here too it was difficult to ascertain whether those mentioned as residents of Shiraz were indeed Shirazees. There was also another problem. Not all residents of Shiraz are Moslems and other religious minorities do not bring their dead here. Finally we referred to the Office of Public Health and their Bureau of Statistics where we received ample assistance. They had the cause of death in all age groups for the City of Shiraz. They had also classified all deaths according to the international grouping of "the causes of death ." For example, group 1 includes all infectious--viral, bacterial or parasitic disease. Group l 1 includes all death occurring during pregnancy and delivery. Group 17, death due to accidents, etc. It was then decided to tabulate all deaths in the five-to-nine age-group with names,addresses, sex, age, time of year, length of hospitalization or duration of illness if not hospitalized, and the nature of the disease. In this way we could avoid the jumble of repetition and uncertainty of residence. To the best of our knowledge the total number of deaths in the age group of five-to-nine years for the City of Shiraz, for the Iranian year 1350, was 87. However, it is not an accurate figure. By no means were they all Shiraz citizens, In some cases motels and "caravanserais" were given as places of residence. So it seems the total number should be a smaller one. However, as there were some unregistered deaths, we feel this is a very good approximation. TABLE 1. Cause of death in children, aged 5-9 years (with sex differentiation), of the population in the City of Shiraz for the year 1350 (21 March, 1971 to 20 March 1972) Cause of death
Number of deaths Male Female Total
Per cent of total number of deaths
Infectious diseases Accidents Gastro-intestinal tract Respiratory tract Genito-urinary system Cardio-vascular system Anaemias Carcinomas Malnutrition Central nervous system Undiagnosed
22 4 2 3 1 5 1 0 1 2 2
15 7 4 4 1 2 4 2 0 3 2
37 11 6 7 2 7 5 2 1 5 4
42% 13 % 7 9 2 8% 6 2% 1% 6% 4%
Total
44
43
87
100%
Results As can be seen from Table 1, the biggest killer in this age group in this city were the infectious diseases of various kinds. A total of 37 children (42 % of all the children who died) died from infections rangirig from smallpox, polio, measles to meningitis, diphtheria, pneumonia, tuberculosis and typhoid (Table 2). There was no relationship to time of year or sex. There was little correlation shown with age either, although the number of deaths was less in eight- and nine-year-old children. A total of 11 (13 % of all deaths) died from accidents, ranging from burns to car accidents. Here again age range was unremarkable. Other causes of death are shown in Table 1 v~ith more detailed analyses of the infectious diseases in Table 2.
Mortality in five-to-nine-year-old children
235
Discussion Shiraz is a town with a university, an administration centre for the province of Fars, with industries ranging from electronics to oil, to carpet weaving, to other trades and professions. The per capita income is average for Iran. The office of public health, in co-operation with Pahlavi Medical School and various other institutions and physicians in town, deliver health services to the population. Smallpox vaccination is administered admirably well by the health workers. The authors' residences had been called on repeatedly and persistently for inoculation by the health workers who call on all the houses in Shiraz to see that everyone is well protected. Unfortunately, however, there were four deaths due to smallpox in 1350 in the age group under study. The diligence in vaccination against smallpox applies to a great extent to other immunization. But the city has not instituted preventive measures against measles to the same extent and, as can be observed in Table 2, a total of five children died with the complications of this disease. We found this to be not through the fault of, nor the lack of willingness by any of the health workers, but purely owing to the high cost and short supply of the vaccine. TABLE2. The specific disease which killed children in the age group 5-9 years of the City of Shiraz who died of an infectious disease in the year 1350
Disease Polio Measles Smallpox Meningitis Diphtheria Bacterial pneumonia Viral pneumonia Tuberculosis Typhoid Paratyphoid Undiagnosed infections Total
Number of deaths
Per cent of total number of deaths from infectious diseases
2 5 4 7 4 6 3 1 1 1 3
5% 13 % 11 19 % 11 16 % 8% 3% 3 3 8
37
100
Diphtheria also took a toll of four. Diphtheria, pertussis and tetanus vaccine, although available at every family physician's surgery and routinely administered to those who attend, is not actively administered to the mass as is smallpox vaccine. It is, however, given to those who refer to the many free clinics situated all round the city. We noted that a number of families, having received the first inoculation at these clinics, did not report back on time for the second or third injections. The clinics lacked facilities to remind or recall these families or to send someone to their houses to administer the second or third injection. This is totally due to the shortage of health workers and other suitable personnel. Polio killed two. This is despite free and frequent administration of oral polio vaccine. Seven children died with meningitis and nine with bacterial or viral pneumonia. Although not by public health measures, some of these deaths could have been prevented with better care and diligence by the parents and with earlier reference to a physician, a clinic or a hospital. Some of these cases were brought to the hospital just before they died. Poverty as well as ignorance is among the causes of not seeking medical advice.
236
A. J. Rezaian and H. S. Pour
Other infectious diseases, tuberculosis, typhoid, and para-typhoid, claimed the lives of three children, while the same number died with unspecified and undiagnosed infections. There is no need to say that in more advanced countries such catastrophics would not be caused by infection. This is not simply because a variety of antibiotics is available to the physicians in these countries. In the armamentorium of our medical practitioners all preventive and curative measures are provided. We do not lack medicines for curing or effectively treating any of these diseases. It is the public health measures which we need to improve in order to reduce or prevent damage and death to our children. The five deaths due to measles in this age group could well have been prevented had measles vaccine been administered as freely as is smallpox vaccine. One may question then why four children died with smallpox. We were told that the difficulties in ensuring that everyone gets smallpox vaccine in the rural areas and villages are insurmountable. With the available facilities and the lack of willingness by some families, it is almost impossible to vaccinate every child in every village in Fars Province, and it is some of these children who get infected, who come to Shiraz Hospitals, and register as Shirazees. We were reassured that efforts are being made to improve this situation. We believe that part of these efforts should be directed towards orientating people to practising health and hygiene. Accidents took the second greatest toll in this age group, accounting for 11 deaths (13 ~ of the total deaths). Knowing that almost all of the deaths due to infectious diseases were preventable, this then is in keeping with the rest of the world. Unfortunately neither Iran nor other countries of the world are able to provide adequate preventive measures or solutions. Yet one cannot disregard the importance of preventive measures. Accidents do not happen, they are caused. Ways can be sought to prevent accidents. In the year under our study two children were drowned, one in a shallow river and one in a water well. We noticed that many wells are kept without barriers. A simple barrier on the well where one child met his death could have saved his life. Car accidents caused the deaths of five children. We believe that appeals to drivers to exercise more caution are among the ways to reduce car accidents. The Iranians are highly emotional people and we believe that an appeal to their finer emotions may be very effective in making them more careful drivers. Signs saying "Drive safely and save lives", followed a few miles later by, "The life you save may be your own", are effective in the United States. But here we need the invocation of the finer altruistic emotions of the Iranians by saying for example: "Let the driver have his right of way, yours too, otherwise the child he hits may be yours." Anomalies of the gastro-intestinal tract, respiratory tract and genito-urinary system cannot be highly affected by public health measures, nor can the public health authorities prevent deaths due to neoplasms. But one should feel sorry to live in a society where malnutrition and iron deficiency anaemia can cause the death of children. Two deaths were attributed to ischaemic heart disease. Both were caused by profound severe anaemia. Central nervous system diseases were the registered cause of death in five children. Everyone we spoke to was aware of the potential measures that could be implemented to reduce death and destruction by the central nervous system diseases. But here in Shiraz we are faced with the same problems that exist in other cities in the advanced countries of the world, namely lack of adequate hospitals and health workers.
Acknowledgement We sincerely thank the members of the Department of the Statistics of the Public Health Office in Shiraz for their co-operation in the preparation of this paper.
Mortality in Five- to Nine-year-old Children in Shiraz, Iran A. John Rezaian, M.D,* and H. Shafiee Pour, M.D.
2970 Lake Shore Drive, Chicago,///. 60657, U.S.A. Population statistics for the city of Shiraz and its geographical location were given in summary form. Cause of death among children between the ages of five to nine years for that city, for the Iranian year 1350 (21 March 1971 to 20 March 1972), were detailed. There were a total Of eighty-seven deaths. The cause of death in this age group shows infectious diseases to be the greatest killers of children. Accidents are the second greatest cause of death. These and all other causes of death were tabulated. Seasonal or temporal relationships were assessed. The most frequent causes of death were analysed. A way to prevent or reduce the big killers was sought with some suggestions and recommendations.
Introduction Shiraz, the capital city of Fars province in Iran, is situated in the southern part o f the country some 5500 feet above sea level. Its climate is dry with variable rainfall, more abundant every three to four years, but never adequate. In the Iranian year 1350 (21 M a r c h 1971 - - 2 0 M a r c h 1972) it had a population of 377 000; a birth rate of 32/1000 (totalling 12 090 births; and a death rate of 7/1000~ (totalling 2865 deaths); neonatal death rate for the same year was 17/1000. There was also a total of 1025 registered marriages for the same year. In this paper an attempt is made to find out the total number and cause of death in children in the five-to-nine years age-group, and whether there are ways to prevent or reduce the most frequent killers. Some suggestions and recommendations are offered. Materials and Method There are three hospitals in Shiraz with paediatric wards. N o t all sick children, however, are admitted to the hospitals. Therefore, it would not have been sufficient to look at the hospital registers for the cause o f death, nor to refer to the pathology departments to pick out the post-mortem diagnosis of this age group of children. Furthermore, hospital admissions are not necessarily representative o f the disease in the general population and autopsy statistics may be influenced by the type of case ~tdmitted. As well as checking all three hospitals' files, it was planned, therefore, to refer to the civil authorities and inquire how deaths are registered in the Registry of Births and Deaths for the City o f Shiraz. The problems were many. Some deaths were not reported. Some were reported as residents of the city o f Shiraz who were not resident. Certifications for the cause of death issued by a physician were often vague and general in nature. Furthermore, hospitalized deaths were mixed with non-hospitalized cases. We were then directed to a place where all dead people receive their final bath before burial. This seemed to be a better place to gather the statistics than any other source. *Family Practice Resident, St Joseph Hospital, Chicago, Illinois. Formerly of Shiraz, Medical Centre, Pahlavi University, Shiraz, Iran. tThe death rate of 7/1000 makes one feel that it is "going to lead to an enormous population explosion" and it probably is.
234
A. J. Rezaian and H. S. Pour
According to their religious belief the people of Shiraz bring all dead bodies to this sacred "bath house" to receive their final cleansing. A register is also kept here. Age, sex, cause of death, and residence are indicated in this register. However, here too it was difficult to ascertain whether those mentioned as residents of Shiraz were indeed Shirazees. There was also another problem. Not all residents of Shiraz are Moslems and other religious minorities do not bring their dead here. Finally we referred to the Office of Public Health and their Bureau of Statistics where we received ample assistance. They had the cause of death in all age groups for the City of Shiraz. They had also classified all deaths according to the international grouping of "the causes of death ." For example, group 1 includes all infectious--viral, bacterial or parasitic disease. Group l 1 includes all death occurring during pregnancy and delivery. Group 17, death due to accidents, etc. It was then decided to tabulate all deaths in the five-to-nine age-group with names,addresses, sex, age, time of year, length of hospitalization or duration of illness if not hospitalized, and the nature of the disease. In this way we could avoid the jumble of repetition and uncertainty of residence. To the best of our knowledge the total number of deaths in the age group of five-to-nine years for the City of Shiraz, for the Iranian year 1350, was 87. However, it is not an accurate figure. By no means were they all Shiraz citizens, In some cases motels and "caravanserais" were given as places of residence. So it seems the total number should be a smaller one. However, as there were some unregistered deaths, we feel this is a very good approximation. TABLE 1. Cause of death in children, aged 5-9 years (with sex differentiation), of the population in the City of Shiraz for the year 1350 (21 March, 1971 to 20 March 1972) Cause of death
Number of deaths Male Female Total
Per cent of total number of deaths
Infectious diseases Accidents Gastro-intestinal tract Respiratory tract Genito-urinary system Cardio-vascular system Anaemias Carcinomas Malnutrition Central nervous system Undiagnosed
22 4 2 3 1 5 1 0 1 2 2
15 7 4 4 1 2 4 2 0 3 2
37 11 6 7 2 7 5 2 1 5 4
42% 13 % 7 9 2 8% 6 2% 1% 6% 4%
Total
44
43
87
100%
Results As can be seen from Table 1, the biggest killer in this age group in this city were the infectious diseases of various kinds. A total of 37 children (42 % of all the children who died) died from infections rangirig from smallpox, polio, measles to meningitis, diphtheria, pneumonia, tuberculosis and typhoid (Table 2). There was no relationship to time of year or sex. There was little correlation shown with age either, although the number of deaths was less in eight- and nine-year-old children. A total of 11 (13 % of all deaths) died from accidents, ranging from burns to car accidents. Here again age range was unremarkable. Other causes of death are shown in Table 1 v~ith more detailed analyses of the infectious diseases in Table 2.
Mortality in five-to-nine-year-old children
235
Discussion Shiraz is a town with a university, an administration centre for the province of Fars, with industries ranging from electronics to oil, to carpet weaving, to other trades and professions. The per capita income is average for Iran. The office of public health, in co-operation with Pahlavi Medical School and various other institutions and physicians in town, deliver health services to the population. Smallpox vaccination is administered admirably well by the health workers. The authors' residences had been called on repeatedly and persistently for inoculation by the health workers who call on all the houses in Shiraz to see that everyone is well protected. Unfortunately, however, there were four deaths due to smallpox in 1350 in the age group under study. The diligence in vaccination against smallpox applies to a great extent to other immunization. But the city has not instituted preventive measures against measles to the same extent and, as can be observed in Table 2, a total of five children died with the complications of this disease. We found this to be not through the fault of, nor the lack of willingness by any of the health workers, but purely owing to the high cost and short supply of the vaccine. TABLE2. The specific disease which killed children in the age group 5-9 years of the City of Shiraz who died of an infectious disease in the year 1350
Disease Polio Measles Smallpox Meningitis Diphtheria Bacterial pneumonia Viral pneumonia Tuberculosis Typhoid Paratyphoid Undiagnosed infections Total
Number of deaths
Per cent of total number of deaths from infectious diseases
2 5 4 7 4 6 3 1 1 1 3
5% 13 % 11 19 % 11 16 % 8% 3% 3 3 8
37
100
Diphtheria also took a toll of four. Diphtheria, pertussis and tetanus vaccine, although available at every family physician's surgery and routinely administered to those who attend, is not actively administered to the mass as is smallpox vaccine. It is, however, given to those who refer to the many free clinics situated all round the city. We noted that a number of families, having received the first inoculation at these clinics, did not report back on time for the second or third injections. The clinics lacked facilities to remind or recall these families or to send someone to their houses to administer the second or third injection. This is totally due to the shortage of health workers and other suitable personnel. Polio killed two. This is despite free and frequent administration of oral polio vaccine. Seven children died with meningitis and nine with bacterial or viral pneumonia. Although not by public health measures, some of these deaths could have been prevented with better care and diligence by the parents and with earlier reference to a physician, a clinic or a hospital. Some of these cases were brought to the hospital just before they died. Poverty as well as ignorance is among the causes of not seeking medical advice.
236
A. J. Rezaian and H. S. Pour
Other infectious diseases, tuberculosis, typhoid, and para-typhoid, claimed the lives of three children, while the same number died with unspecified and undiagnosed infections. There is no need to say that in more advanced countries such catastrophics would not be caused by infection. This is not simply because a variety of antibiotics is available to the physicians in these countries. In the armamentorium of our medical practitioners all preventive and curative measures are provided. We do not lack medicines for curing or effectively treating any of these diseases. It is the public health measures which we need to improve in order to reduce or prevent damage and death to our children. The five deaths due to measles in this age group could well have been prevented had measles vaccine been administered as freely as is smallpox vaccine. One may question then why four children died with smallpox. We were told that the difficulties in ensuring that everyone gets smallpox vaccine in the rural areas and villages are insurmountable. With the available facilities and the lack of willingness by some families, it is almost impossible to vaccinate every child in every village in Fars Province, and it is some of these children who get infected, who come to Shiraz Hospitals, and register as Shirazees. We were reassured that efforts are being made to improve this situation. We believe that part of these efforts should be directed towards orientating people to practising health and hygiene. Accidents took the second greatest toll in this age group, accounting for 11 deaths (13 ~ of the total deaths). Knowing that almost all of the deaths due to infectious diseases were preventable, this then is in keeping with the rest of the world. Unfortunately neither Iran nor other countries of the world are able to provide adequate preventive measures or solutions. Yet one cannot disregard the importance of preventive measures. Accidents do not happen, they are caused. Ways can be sought to prevent accidents. In the year under our study two children were drowned, one in a shallow river and one in a water well. We noticed that many wells are kept without barriers. A simple barrier on the well where one child met his death could have saved his life. Car accidents caused the deaths of five children. We believe that appeals to drivers to exercise more caution are among the ways to reduce car accidents. The Iranians are highly emotional people and we believe that an appeal to their finer emotions may be very effective in making them more careful drivers. Signs saying "Drive safely and save lives", followed a few miles later by, "The life you save may be your own", are effective in the United States. But here we need the invocation of the finer altruistic emotions of the Iranians by saying for example: "Let the driver have his right of way, yours too, otherwise the child he hits may be yours." Anomalies of the gastro-intestinal tract, respiratory tract and genito-urinary system cannot be highly affected by public health measures, nor can the public health authorities prevent deaths due to neoplasms. But one should feel sorry to live in a society where malnutrition and iron deficiency anaemia can cause the death of children. Two deaths were attributed to ischaemic heart disease. Both were caused by profound severe anaemia. Central nervous system diseases were the registered cause of death in five children. Everyone we spoke to was aware of the potential measures that could be implemented to reduce death and destruction by the central nervous system diseases. But here in Shiraz we are faced with the same problems that exist in other cities in the advanced countries of the world, namely lack of adequate hospitals and health workers.
Acknowledgement We sincerely thank the members of the Department of the Statistics of the Public Health Office in Shiraz for their co-operation in the preparation of this paper.
