Abstract

This study investigated the magnitude and trends of cause-specific mortality among children 5 to 14 years of age in the state of Rio de Janeiro (RJ) from 2000 to 2019. We performed an ecological study, using data from the Mortality Information System (MIS). We calculated mortality rates per 100,000 children by chapters, groups, and categories of causes of death (ICD-10). Trends were estimated by joinpoint regression. Mortality rates among children aged 10 to 14 years were higher than those among children 5 to 9. The five leading causes of death were the same in both age groups, but they ranked differently. The two leading ones were external causes and neoplasms (31% and 15% among children aged 5 to 9 years; 45% and 11% among children aged 10 to 14 years). Among children 5 to 9 years, the mortality trend showed an annual decline (8%) from 2011 to 2015. Among children aged 10 to 14 years, the annual decline was 1.3% from 2000 to 2019. Mortality due to external causes decreased in both age groups, except for the category “Assault by unspecified firearm” (boys, 10 to 14 years) and “Unspecified drowning and submersion” (boys, 5 to 9 years). Mortality caused by neoplasms remained steady in both age groups. Infectious and respiratory diseases decreased differently between the two groups. Most causes of death are preventable or treatable, indicating the need for health and intersectoral investments.

Key words:
Cause of death; Children; Age-specific mortality rates; Time series

Introduction

Until recently, mortality among children aged 5 to 14 years did not receive the same attention as that of children under 5 years, despite an estimated number of one million annual deaths in the former group. This lack of attention has resulted in an important gap in knowledge on child health¹³13 O'Donovan S, van den Huevel C, Baldock M, Byard RW. Factors involved in the assessment of paediatric traffic injuries and deaths. Med Sci Law 2018; 58(4):210-215.. In recent years, rates among children 5 to 14 years have not decreased as much as those of children under 5 years. Between 2000 and 2016, the relative decrease of deaths among children aged 1 to 11 months, 1 to 4 years, 5 to 9 years and 10 to 14 years was respectively 50%, 59%, 40% and 13% worldwide⁴4 Strong KL, Pedersen J, White Johansson E, Cao B, Diaz T, Guthold R, You D, Requejo J, Liu L. Patterns, and trends in causes of child and adolescent mortality 2000-2016: setting the scene for child health redesign. BMJ Glob Health 2021; 6(3):e004760..

Causes of death are diverse or of various sizes among different age groups and geographic regions, depending on the socioeconomic level and political scenario⁴4 Strong KL, Pedersen J, White Johansson E, Cao B, Diaz T, Guthold R, You D, Requejo J, Liu L. Patterns, and trends in causes of child and adolescent mortality 2000-2016: setting the scene for child health redesign. BMJ Glob Health 2021; 6(3):e004760.. In 2016, the global leading causes of death among children aged 1 to 4 years were lower respiratory infections, diarrhea, malaria, injuries and drowning. Among those aged 5 to 9 years, the five leading causes were diarrhea, lower respiratory infections, injuries, traffic accidents and malaria. In the 10-14 age group, leading causes included injuries, traffic accidents, HIV/AIDS, drowning and lower respiratory infections. This description is mainly influenced by the epidemiological profiles of Africa and Asia, which show the highest number of deaths and whose leading causes are infections⁴4 Strong KL, Pedersen J, White Johansson E, Cao B, Diaz T, Guthold R, You D, Requejo J, Liu L. Patterns, and trends in causes of child and adolescent mortality 2000-2016: setting the scene for child health redesign. BMJ Glob Health 2021; 6(3):e004760.. In Latin America, traffic accidents predominate among the 5-9 age group, followed by drowning, interpersonal violence, collective violence/legal intervention and respiratory infections. The major causes among the 10-14 age group included interpersonal violence, congenital anomalies, lower respiratory infections, drowning and traffic accidents⁴4 Strong KL, Pedersen J, White Johansson E, Cao B, Diaz T, Guthold R, You D, Requejo J, Liu L. Patterns, and trends in causes of child and adolescent mortality 2000-2016: setting the scene for child health redesign. BMJ Glob Health 2021; 6(3):e004760..

In Brazil, few studies have examined these age groups. The “Inter-agency Group for Child Mortality Estimation” by the United Nations (UN-IGME) estimated a 50% reduction in mortality rates among the 5-14 age group from 1990 to 2019, which decreased from 4 to 2 per 1,000 children in Brazil, which still corresponds to 7,000 deaths per year³3 United Nations Children's Fund (UNICEF), World Health Organization (WHO), World Bank Group, United Nations. Levels & Trends in Child Mortality: Report 2020. New York: UNICEF; 2020.. According to an analysis by the Brazilian Ministry of Health (MoH)⁵5 Brasil. Ministério da Saúde (MS). Secretaria de Vigilância em Saúde. Principais causas específicas de mortalidade no Brasil. In:Ministério da Saúde. Saúde Brasil 2015/2016: uma análise da situação de saúde e da epidemia pelo vírus Zika e por outras doenças transmitidas pelo Aedes aegypti. Brasília: MS; 2017. p. 73., in 2006, land accidents ranked first among both sexes, followed by drowning. Among boys, physical attacks and lymphatic neoplasms ranked third and fourth respectively and, among girls, pneumonia and lymphatic neoplasms. In 2014, the first two positions included land accidents and assaults (homicides) in both sexes. The other causes remained the same among girls. Regarding boys, neoplasms and pneumonia came next⁵5 Brasil. Ministério da Saúde (MS). Secretaria de Vigilância em Saúde. Principais causas específicas de mortalidade no Brasil. In:Ministério da Saúde. Saúde Brasil 2015/2016: uma análise da situação de saúde e da epidemia pelo vírus Zika e por outras doenças transmitidas pelo Aedes aegypti. Brasília: MS; 2017. p. 73.. Another MoH publication reveals a drop in mortality from preventable causes in both groups (5 to 9 and 10 to 14 years) and in both sexes from 2010 to 2017⁶6 Brasil. Ministério da Saúde (MS). Secretaria de Vigilância em Saúde. Análise da mortalidade por causas evitáveis no Brasil, 2010 a 2017. In: Ministério da Saúde. Saúde Brasil 2019: uma análise da situação de saúde com enfoque nas doenças imunopreveníveis e na imunização. Brasília: MS; 2019. p. 102..

Fadel et al.⁷7 Fadel SA, Boschi-Pinto C, Yu S, Reynales-Shigematsu LM, Menon GR, Newcombe L, Strong KL, Wang Q, Jha P. Trends in cause-specific mortality among children aged 5-14 years from 2005 to 2016 in India, China, Brazil, and Mexico: an analysis of nationally representative mortality studies. Lancet 2019; 393(10176):1119-1127. showed that external causes predominated among boys and were the second leading cause of death among girls in Brazil in 2016. Noncommunicable diseases were the leading cause among girls⁷7 Fadel SA, Boschi-Pinto C, Yu S, Reynales-Shigematsu LM, Menon GR, Newcombe L, Strong KL, Wang Q, Jha P. Trends in cause-specific mortality among children aged 5-14 years from 2005 to 2016 in India, China, Brazil, and Mexico: an analysis of nationally representative mortality studies. Lancet 2019; 393(10176):1119-1127..

To address the crucial lack of knowledge on mortality in older children and considering how essential knowledge on the causes of death is to support preventive actions and to tackle the lack of studies on this age group, this study aimed to investigate the magnitude and the trend in time of mortality among groups of children aged 5 to 9 and 10 to 14 years according to sex and leading causes in the state of Rio de Janeiro from 2000 to 2019.

Methods

We conducted an ecological study on the time trend of mortality and its leading causes among children aged between 5 and 14 years living in the state of Rio de Janeiro (RJ), according to age group (5-9 and 10-14 years) and sex from 2000 to 2019.

We obtained mortality data from the Mortality Information System (MIS) made available by Rio de Janeiro’s State Health Department⁸8 Estado do Rio de Janeiro. Secretaria Estadual de Saúde. Informações de Saúde. Sistema de Informações sobre Mortalidade [Internet]. [acessado 2021 maio 5]. Disponível em: http://sistemas.saude.rj.gov.br/tabnet/deftohtm.exe?sim/obito.def
http://sistemas.saude.rj.gov.br/tabnet/d... . Population data were obtained from two censuses (2000 and 2010) and from estimates for subsequent years performed by the Interagency Health Information Network (Ripsa), which were also made available by Rio de Janeiro’s Health Department⁹9 Estado do Rio de Janeiro. Secretaria Estadual de Saúde. Informações de Saúde. População estimada residente [Internet]. [acessado 2021 maio 5]. Disponível em: http://sistemas.saude.rj.gov.br/tabnetbd/dhx.exe? populacao/pop_populacao_estimada.def
http://sistemas.saude.rj.gov.br/tabnetbd... . Based on these data, we calculated proportional mortality by causes and mortality rates per 100,000 children according to chapters, groups and categories of the International Statistical Classification of Diseases and Related Health Problems - 10th revision (ICD-10). The Joinpoint regression method was used to analyze the trend of mortality rates by cause, sex and age group from 2000 to 2019, as it identifies trend changes (inflection points) and adjusts linear trends on a logarithmic scale¹⁰10 National Cancer Institute Division of Cancer Control and Population Sciences. Joinpoint regression program, version 4.7.0.0; 2019 [Internet]. [cited 2019 set 15]. Available from: https://surveillance.cancer.gov/joinpoint/
https://surveillance.cancer.gov/joinpoin... . The annual percentage change (APC) and respective 95% confidence intervals were estimated as well. Models were evaluated with and without autocorrelation term. The Monte Carlo permutation method was used as statistical test for adjustment.

To enable the performance of disaggregated analyses by groups and categories, only causes that accounted for at least 100 deaths during the analyzed period were included in the trend analysis. Considering that in a period of 20 years, events occurred that resulted in excessive mortality, such as disasters and epidemics, isolated points showing atypical values (outliers) were identified and investigated. Trend analyses were performed with and without outliers (replaced by the mean of mortality coefficients at t-1 and t+1). In such situations, both trends are presented.

This study is part of a research titled “Causes of death among children aged 5 to 14 years in European, Latin American and Asian countries”. It was approved by the Research Ethics Committee of the Medical School of the Fluminense Federal University (UFF), decision number 3.250.608 of April 08, 2019.

Results

In the last two decades, there were 14,707 deaths among children aged 5 to 14 years in the state of Rio de Janeiro: 8,935 (61%) among male children and 8,495 (58%) among children aged 10 to 14 years. Mortality rates among the 10-14 age group were higher than those among the 5-9 age group during the analyzed period of time (Table 1).

The five leading causes of death, as per ICD-10 chapters, were the same in both age groups, but they ranked differently. The two leading causes of death in both age groups were external causes and neoplasms, i.e., 31% and 15% in the 5-9 age group and 45% and 11% in the 10-14 age group. Among children aged 5 to 9 years, the other three causes were infectious-parasitic, respiratory and nervous system diseases, each of which accounted for approximately 10%. In the 10-14 age group, they ranked as follows: nervous system diseases (9%), respiratory system diseases (around 6%) and infectious-parasitic diseases (around 6%). Ill-defined causes were registered in 6% of deaths in each age group (Graph 1).

Mortality rates of external causes among young adolescents were approximately twice as high as those of children aged 5 to 9 years and higher among males in both age groups (Table 1). Among external causes, the category with the highest mortality of the 5-9 age group in both sexes was “Pedestrian traumatized in unspecified accidents”, i.e., run over by unspecified vehicle. Among male children, the second cause was “Unspecified drowning and submersion”; among females, the second cause was “Accident involving an unspecified motor vehicle”. In the 10-14 age group, the main external cause was “Assault by unspecified firearm”, representing virtually one fourth of the deaths in this chapter, followed by being run over by vehicle and drowning. Both sexes showed a similar pattern, except for the third rank of females, which was “accident caused by vehicle” (data not shown in table). Approximately 75% of deaths from external causes in this age group occurred in males (Table 1).

Regarding neoplasms, their magnitude was similar in both age groups (total mortality rate about 4 per 100,000). “Malignant neoplasm of the brain” was the most frequent cause of death in both age groups, followed by “Lymphoid leukemia” and “Myeloid leukemia” which together exceeded brain neoplasms (Table 1).

Infectious and parasitic diseases showed a total rate of 2.8 per 100,000 among children aged 5-9 years and 2.1 per 100,000 among children aged 10-14 years. In both age groups and genders, the category “Other sepsis” was the most frequent one, followed by “Meningococcal infection” in the 5-9 age group and HIV in the 10-14 age group (Table 1).

Deaths caused by diseases of the respiratory system showed rates of 2.5 and 2.2 per 100,000 in the 5-9 and 10-14 age groups, respectively. The leading category was “Pneumonia caused by unspecified microorganisms”, which accounted for 55% of all deaths in this chapter, i.e., 616 deaths among children aged 5 to 14 years in the last two decades.

Diseases of the nervous system were the fifth leading cause of death in the 5-9 age group (2.5/100,000) and the third one in the 10-14 age group (3.0/100,000). Among these, the main categories were cerebral palsy and other brain disorders, both of which showed low absolute numbers of annual deaths, ranging from 6 to 25 deaths (data not shown).

In the 5-9 age group, time trend of total mortality rates was volatile and showed a significant annual decline (8%) from 2011 to 2015. Males showed an annual decline of 1.2% from 2000 to 2012 and of 8.4% from 2012 to 2015; in females, rates remained steady (Table 2). The trend of mortality from external causes showed variations, i.e., two periods of decrease (2000-2008 and 2011-2015) that alternated with periods of stability. In males, there was a decreasing trend during the full time period. In females, stability predominated. There was an important increase in the number of deaths in 2011, which was due to an increase of the “Cataclysmic storm victims” category. Replacing the atypical value of 2011 with the calculated mean value has not resulted in any considerable change in trends (Table 2). Neoplasms remained steady throughout the analyzed period in all categories (Table 2).

A high outlier was observed in 2008 among infectious and parasitic diseases due to the “Dengue hemorrhagic fever” category. Mortality rates of the total number of children and of males decreased throughout the period and remained stationary in females. The trend analysis with outliers replaced by the mean value showed a constant decline in all groups throughout the period. However, decline was more important among boys (Table 2).

Diseases of the respiratory system showed a decline in total mortality, but not when disaggregated by sex. Mortality rates of diseases of the nervous system remained steady. There was a drop in the number of ill-defined causes in the analyzed time period (Table 2).

The 10-14 age group, both sexes, showed a steady decline in total mortality from 2000 to 2019 (Table 3). An annual decline of approximately 3% was found in external causes in all categories throughout the period. There were no differences between the original results and those without outliers (Table 3). Among the main categories of causes of death, a stable pattern was found in mortality from gunshot wounds in males. In males, categories with a decrease in mortality included “run over” and “drowning” and in females “shooting with a firearm” and “run over” (Table 4).

“Mortality from neoplasms” remained steady throughout the analyzed period in the total age group and in both sexes, just as “diseases of the nervous system” (Table 3). Diseases of the respiratory system remained steady among males and females, but regarding the total number of children, a slight and permanent annual decreasing trend of 1.2% was found throughout the analyzed period (Table 3).

Mortality rates from infectious diseases showed an increase in the first half of the analyzed period and a decrease in the second half. Similar to what happened among children aged 5-9 years, atypical values were found in 2008 that were also related to “Dengue hemorrhagic fever”. After smoothing these peak values, the trend became stationary, except for a declining trend in males for a short period of three years (2016-2019) (Table 3). Ill-defined causes showed a declining trend in the period, except in males from 2014 to 2019, when they had a stationary trend.

No significant autocorrelation of errors was detected in any of the Joinpoint regression models of the historical series.

Discussion

The last two decades showed a 35% reduction in the number of deaths among children aged 5 to 14 years in the state of Rio de Janeiro. That figure gets close to the estimates of 36% (World) and 38% (Latin-America) for the 2000-2018 period¹¹11 United Nations Children's Fund (UNICEF), World Health Organization (WHO), World Bank Group, United Nations. Levels & trends in child mortality: report 2019. New York: UNICEF; 2019.. The proportional distribution of these deaths between the two age groups varies according to the development level of countries. In the state of Rio de Janeiro, 58% of deaths occurred in the 10-14 age group, which matches the profiles of developed countries¹¹11 United Nations Children's Fund (UNICEF), World Health Organization (WHO), World Bank Group, United Nations. Levels & trends in child mortality: report 2019. New York: UNICEF; 2019..

As for the proportional distribution of causes of death, the state of Rio de Janeiro shows a pattern that closely matches the Latin American⁴4 Strong KL, Pedersen J, White Johansson E, Cao B, Diaz T, Guthold R, You D, Requejo J, Liu L. Patterns, and trends in causes of child and adolescent mortality 2000-2016: setting the scene for child health redesign. BMJ Glob Health 2021; 6(3):e004760. and Brazilian⁵5 Brasil. Ministério da Saúde (MS). Secretaria de Vigilância em Saúde. Principais causas específicas de mortalidade no Brasil. In:Ministério da Saúde. Saúde Brasil 2015/2016: uma análise da situação de saúde e da epidemia pelo vírus Zika e por outras doenças transmitidas pelo Aedes aegypti. Brasília: MS; 2017. p. 73.

6 Brasil. Ministério da Saúde (MS). Secretaria de Vigilância em Saúde. Análise da mortalidade por causas evitáveis no Brasil, 2010 a 2017. In: Ministério da Saúde. Saúde Brasil 2019: uma análise da situação de saúde com enfoque nas doenças imunopreveníveis e na imunização. Brasília: MS; 2019. p. 102.^-77 Fadel SA, Boschi-Pinto C, Yu S, Reynales-Shigematsu LM, Menon GR, Newcombe L, Strong KL, Wang Q, Jha P. Trends in cause-specific mortality among children aged 5-14 years from 2005 to 2016 in India, China, Brazil, and Mexico: an analysis of nationally representative mortality studies. Lancet 2019; 393(10176):1119-1127. ones. Most deaths were due to external causes, which remained at the top of the list throughout the analyzed period, although they decreased over time, except in girls aged 5 to 9 years. Mortality rates of most causes were higher in males in Brazil, but not in other countries such as India and China⁷7 Fadel SA, Boschi-Pinto C, Yu S, Reynales-Shigematsu LM, Menon GR, Newcombe L, Strong KL, Wang Q, Jha P. Trends in cause-specific mortality among children aged 5-14 years from 2005 to 2016 in India, China, Brazil, and Mexico: an analysis of nationally representative mortality studies. Lancet 2019; 393(10176):1119-1127..

In the 5-9 age group, pedestrian accidents were the main category of external causes. As in other risk situations, there are gender differences in the behavior of pedestrians, even in children¹²12 Wang H, Schwebel DC, Tan D, Shi L, Miao L. Gender differences in children's pedestrian behaviors: developmental effects. J Safety Res 2018; 67(1):127-133.. Boys accounted for higher death rates than girls, but rates decreased in both sexes. Since the leading category is “unspecified accident conditions”, it was not possible to suggest which interventions could have successfully reduced deaths. Deaths caused by traffic accidents are generally related to commuting to school, population density, traffic speed, the presence of traffic guards and the monitoring of children by parents or caregivers¹³13 O'Donovan S, van den Huevel C, Baldock M, Byard RW. Factors involved in the assessment of paediatric traffic injuries and deaths. Med Sci Law 2018; 58(4):210-215.. There is a consensus that children under 10 years of age need supervision to cross streets until they fully develop that skill¹⁴14 Barton BK, Huston J. The roles of child, parent, and environmental factors in pedestrian supervision. Int J Inj Contr Saf Promot 2012; 19(2):153-162.^,1515 National Highway Traffic Safety Administration (NHTSA). Prevent pedestrian crashes: parents and caregivers of elementary school children [Internet]. [cited 2021 jul 15]. Available from: https://www.nhtsa.gov/sites/nhtsa.gov/files/811027.pdf
https://www.nhtsa.gov/sites/nhtsa.gov/fi... . On the other hand, regulatory traffic safety laws could effectively reduce traffic deaths¹⁶16 World Health Organization (WHO). World report on child injury prevention. Genebra: WHO; 2008., especially in terms of speed control and the prohibition of driving under the influence of alcohol (“Dry Law”) and may have at least partially contributed to reduce mortality, especially in this age group.

Drowning, which showed steady rates among boys in the state of Rio de Janeiro, has recently received increased attention from the WHO, since it is a frequent cause of death associated with the lack of adult supervision and protective measures¹⁷17 Meddings DR, Scarr JP, Larson K, Vaughan J, Krug EG. Drowning prevention: turning the tide on a leading killer. Lancet Public Health 2021; 6(9):e692-e695.^,1818 Tyler MD, Richards DB, Reske-Nielsen C, Saghafi O, Morse EA, Carey R, Jacquet GA. The epidemiology of drowning in low- and middle-income countries: a systematic review. BMC Public Health 2017; 17(1):413.. A cost-effective preventive measure would be increasing investments in early childhood education (day care centers / schools) to ensure safe environments while parents are at work. Mandatory swimming lessons would be an additional preventive measure, but they are difficult to implement¹⁷17 Meddings DR, Scarr JP, Larson K, Vaughan J, Krug EG. Drowning prevention: turning the tide on a leading killer. Lancet Public Health 2021; 6(9):e692-e695.. Broader measures to reduce deaths caused by traffic accidents and drownings need to be defined by a National Plan in a multisectoral way that involves parents and family members.

The 10-14 age group showed higher mortality rates from external causes than the 5-9 age group, which were predominantly related to violence. “Assaults by firearm” was the main cause category and did not decrease significantly among boys, corroborating Brazil’s “portrait of wounded adolescences”¹⁹19 Pinto IV, Ribeiro AP, Santos APD, Bevilacqua P, Lachtim SAF, Pereira VOM, Malta DC. Adolescências feridas: retrato das violências com arma de fogo notificadas no Brasil. Rev Bras Epidemiol 2020; 23(1):e200002.. A project by the State Security Department of the state of Rio de Janeiro to implement Pacification Police Units (PPU) in communities contributed to a considerable decrease in the rates of lethal violence²⁰20 Cano I, Borges D, Ribeiro E, organizadores. Os donos do morro: uma avaliação exploratória do impacto das Unidades de Polícia Pacificadora (UPPs) no Rio de Janeiro. São Paulo/Rio de Janeiro: Fórum Brasileiro de Segurança Pública/Laboratório de Análise da Violência; 2012.. However, no temporal synchronicity was found between the implementation of that program as of 2009 and the reduction of mortality rates in boys aged 10 to 14 years, who are the most affected ones by this type of violence. There was no evidence of decline in the years following the implementation of the project, nor was there any increase in recent years after the project failed and shooting rates increased. Behavior of homicides has been discussed in the state of Rio de Janeiro²¹21 Cardoso FL, Cecchetto FR, Corrêa JS, de Souza TO. Homicídios no Rio de Janeiro, Brasil: uma análise da violência letal. Cien Saude Colet 2016; 21(4):1277-1288.^,2222 Maia IAR, Marinho A. Uma nota sobre o impacto das Unidades de Polícia Pacificadora (UPP) no município do Rio de Janeiro com o uso de controle sintético. Rev Bras de Econ 2021; 75(1):15-28. and apparently, there has been a decline as a result of the implementation of both PPUs and other public security measures, but analyses only consider the general population. The 10-14 age group might not be as susceptible to that kind of programs as the older age groups that include subjects aged 15 years of age and over.

The replacement of the mortality rate from external causes by the mean value of the rates from 2009 to 2011 for both ages in 2011 did not considerably affect its trend, though the junction point of 2008 disappeared. The peak in 2011 was due to the high number of deaths classified as victims of cataclysmic storms (ICD-10: X37). Carmo and Anzawa²³23 Carmo RL, Anazawa TM. Mortalidade por desastres no Brasil: o que mostram os dados. Cien Saude Colet 2014; 19(9):3669-3681. mention a total of 858 deaths in this ICD-10 category in the state of Rio de Janeiro, an extremely high number when compared to the average of 5 deaths per year (1996-2010) and they relate that increase to a huge disaster in Rio’s Mountain Region caused by climatic events.

Neoplasms were the second leading cause of death among children aged 5 to 14 years, reflecting the Brazilian profile according to which cancer among children, adolescents and young adults is the second leading cause of deaths in general and the leading cause of deaths from diseases²⁴24 Saraiva DDCA, Santos SDS, Monteiro GTR. Tendência de mortalidade por leucemias em crianças e adolescentes nas capitais dos estados brasileiros: 1980-2015. Epidemiol Serv Saude 2018; 27(3):e2017310.. A comparative study among four developing countries (Brazil, China, India and Mexico) showed that neoplasms were among the three leading causes of death among children aged 5 to 14 years in Brazil, China and Mexico⁷7 Fadel SA, Boschi-Pinto C, Yu S, Reynales-Shigematsu LM, Menon GR, Newcombe L, Strong KL, Wang Q, Jha P. Trends in cause-specific mortality among children aged 5-14 years from 2005 to 2016 in India, China, Brazil, and Mexico: an analysis of nationally representative mortality studies. Lancet 2019; 393(10176):1119-1127.. Our result matches the one described in the literature, according to which leukemias and brain tumors are the most common types of cancer in children²⁴24 Saraiva DDCA, Santos SDS, Monteiro GTR. Tendência de mortalidade por leucemias em crianças e adolescentes nas capitais dos estados brasileiros: 1980-2015. Epidemiol Serv Saude 2018; 27(3):e2017310.

25 Gupta S, Howard SC, Hunger SP, Antillon FG, Metzger ML, Israels T, Harif M, Rodriguez-Galindo C. Treating childhood cancer in low- and middle-income countries. In: Gelband H, Jha P, Sankaranarayanan R, Horton S, editores. Cancer: disease control priorities. Washington (DC): The International Bank for Reconstruction and Development/The World Bank; 2015. p. 121-146.

26 GBD 2017 Childhood Cancer Collaborators. The global burden of childhood and adolescent cancer in 2017: an analysis of the Global Burden of Disease Study 2017. Lancet Onco 2019; 20(9):1211-1225.

27 Malvezzi M, Santucci C, Alicandro G, Carioli G, Boffetta P, Ribeiro KB, Levi F, La Vecchia C, Negri E, Bertuccio P. Childhood cancer mortality trends in the Americas and Australasia: an update to 2017. Cancer 2021; 127(18):3445-3456.^-2828 Torres-Roman JS, Valcarcel B, Guerra-Canchari P, Santos CAD, Barbosa IR, La Vecchia C, McGlynn KA, de Souza DLB. Leukemia mortality in children from Latin America: trends and predictions to 2030. BMC Pediatr 2020; 20(1):511.. In general, pediatric neoplasms may not be prevented or identified by screening. However, most of them can be cured and their treatment is cost-effective in any scenario²⁹29 Lam CG, Howard SC, Bouffet E, Pritchard-Jones K. Science, and health for all children with cancer. Science 2019; 363(6432):1182-1186.^,3030 World Health Organization (WHO). Global Initiative for Childhood Cancer: an Overview. Genebra: WHO; 2020.. Morbidity and mortality caused by childhood cancer reflect profound inequalities, according to a country’s level of development²⁶26 GBD 2017 Childhood Cancer Collaborators. The global burden of childhood and adolescent cancer in 2017: an analysis of the Global Burden of Disease Study 2017. Lancet Onco 2019; 20(9):1211-1225.^,2727 Malvezzi M, Santucci C, Alicandro G, Carioli G, Boffetta P, Ribeiro KB, Levi F, La Vecchia C, Negri E, Bertuccio P. Childhood cancer mortality trends in the Americas and Australasia: an update to 2017. Cancer 2021; 127(18):3445-3456.. In developed countries with better access to services and treatment, more than 80% of pediatric neoplasms can be cured. In low- and middle-income countries, this proportion lies between 15% and 45%²⁹29 Lam CG, Howard SC, Bouffet E, Pritchard-Jones K. Science, and health for all children with cancer. Science 2019; 363(6432):1182-1186.. There is also a difference in the temporal trend of mortality: annual drops of 2% to 3% are seen in countries such as Japan and Australia, while rates are stable or show a minimal decrease in Latin America²⁷27 Malvezzi M, Santucci C, Alicandro G, Carioli G, Boffetta P, Ribeiro KB, Levi F, La Vecchia C, Negri E, Bertuccio P. Childhood cancer mortality trends in the Americas and Australasia: an update to 2017. Cancer 2021; 127(18):3445-3456.. In the state of Rio de Janeiro, mortality rates from neoplasms (2000-2019) remained steady, suggesting that interventions are not effective enough, neither in terms of access nor in quality of therapeutic care. Early diagnosis and access to quality treatment are factors that directly impact chances of getting cured. Therefore, reducing pediatric cancer mortality rates in the state requires general access to treatment, adoption of modern chemotherapy protocols, supportive measures against treatment toxicity and advances in radiotherapy and diagnostics techniques²⁹29 Lam CG, Howard SC, Bouffet E, Pritchard-Jones K. Science, and health for all children with cancer. Science 2019; 363(6432):1182-1186.^,3030 World Health Organization (WHO). Global Initiative for Childhood Cancer: an Overview. Genebra: WHO; 2020.. These measures depend on public policies and decentralization of pediatric oncology treatment and hospitalization services³¹31 Algayer LP, Febras LLT, Scheid BS, Signori JF, Jantsch LB. Tendência Temporal de Internações por Diagnóstico Oncológico em Crianças e Adolescentes. Rev Bras Cancerol 2020; 66(4):e-141010.. Another important aspect concerns cancer information systems. According to the Pediatric Oncology Forum of Rio de Janeiro, the Population-Based Cancer Registration System was only implemented in the state capital from 2019³²32 Instituto Desiderata. Fórum de Oncologia Pediátrica do Rio de Janeiro. Carta de Recomendações 2019-2021 [Internet]. [acessado 2021 out 5]. Disponível em: http://foprio.org.br/wordpress/wp-content/uploads/2020/02/FOP5_Carta_De_Recomendacoes.pdf.
http://foprio.org.br/wordpress/wp-conten... . Information systems are an important factor for the continuous improvement of the quality of care and for supporting informed decisions and public policies.

In Brazil, deaths from infectious and parasitic diseases among children and young adults dropped between 2000 and 2010, resulting in increased life expectancy³³33 Corrêa ERP, Miranda-Ribeiro, A. Ganhos em expectativa de vida ao nascer no Brasil nos anos 2000: impacto das variações da mortalidade por idade e causas de morte. Cien Saude Colet 2017; 22(3):1005-1015.. The mortality profile of the state of Rio de Janeiro, where infectious and parasitic diseases are responsible for 10% of deaths of children aged between 5 and 9 years and for 6% of deaths of children between 10 and 14 years, comes close to the profile of developed regions of the world. Meningococcal infections stood out among children aged 5 to 9 years and the disease caused by HIV among children aged 10 to 14 years. An excessive increase in mortality rates occurred in 2008 mainly in the male 5-9 age group, which was caused by dengue hemorrhagic fever. Replacing the atypical value of 2008 with the three-centric mean of the mortality coefficients eliminated the changes in the trend of mortality from infectious and parasitic diseases and made them stationary. Malhão et al.³⁴34 Malhão TA, Resende CM, Gamerman D, Medronho RA. Um modelo bayesiano para investigação de sobremortalidade durante epidemia de dengue na Região Metropolitana do Rio de Janeiro, Brasil, 2007-2008. Cad Saude Publica 2013; 29(10):2057-2070. not only observed an excessive mortality caused by dengue fever among children under 15 years residing in the Metropolitan Region of Rio de Janeiro, but also detected an excessive mortality rate caused by infectious diseases that are part of its differential diagnosis.

Lower respiratory diseases and infections cause a major health impact and rank among the leading causes of death worldwide³⁵35 Forum of International Respiratory Societies (FIRS). The global impact of respiratory disease - second edition. Sheffield, European Respiratory Society, 2017 [Internet]. [cited 2021 set 5]. Available from: https://www.who.int/gard/publications/The_Global_Impact_of_Respiratory_Disease.pdf. In the state of Rio de Janeiro, pneumonia caused by unspecified microorganisms killed 616 children aged 5 to 14 in the last decades, accounting for 55% of deaths in the respiratory disease group. Immunization is essential to control most respiratory infections. Development and implementation of vaccines against Streptococcus pneumoniae (pneumococcus) and Haemophilus influenza B are important tools to prevent pneumonia, just as the influenza vaccine, which is highly effective in its prevention³⁵35 Forum of International Respiratory Societies (FIRS). The global impact of respiratory disease - second edition. Sheffield, European Respiratory Society, 2017 [Internet]. [cited 2021 set 5]. Available from: https://www.who.int/gard/publications/The_Global_Impact_of_Respiratory_Disease.pdf. These vaccines are part of the National Immunization Program and are distributed by the Brazilian Public Health System. However, vaccination coverage has been decreasing since 2018 in Brazil³⁶36 Silveira MF, Tonial CT, Goretti K Maranhão A, Teixeira AMS, Hallal PC, Menezes AMB, Horta BL, Hartwig FP, Barros AJD, Victora CG. Missed childhood immunizations during the COVID-19 pandemic in Brazil: Analyses of routine statistics and of a national household survey. Vaccine 2021; 39(25):3404-3409.. In our study, this group of causes ranked fourth and fifth among the causes of death in children aged 5-9 and 10-14 years, respectively. Mortality rates in both males and females remained steady over time, but when both genders were considered together, rates decreased. In 2009, there was an increase in the number of deaths, probably due to the influenza A (H1N1) pandemic that affected Brazil³⁷37 Bellei N, Melchior TB. H1N1: pandemia e perspectiva atual. J Bras Patol Med Lab 2011; 47(6):611-617.. Due to the low number of deaths, especially when disaggregated by categories, trend analyses become unstable, limiting their interpretation. Nevertheless, it remains essential to monitor both the Severe Acute Respiratory Syndrome mortality trend and the direct and indirect impact of COVID19 on mortality in the coming years to be able to quickly implement prevention and control measures.

Nervous system diseases were the fifth leading cause of death in the 5-9 age group and the third one in the older group. A study on children and adolescents in Rio Grande do Sul covering a time period from 2000 to 2014 identified diseases of the nervous system as the third leading cause of death in both age groups and both sexes³⁸38 Agranonik M, Furstenau CR, Bandeira MD. Aspectos da mortalidade de crianças e adolescentes por causas externas no RS, em 2000-14. Indic Econ FEE 2017; 44(4):53-64.. In our study, “cerebral palsies” were the second main category of causes of mortality in this group of causes among children aged 5 to 9 years and the first one among children aged 10 to 14 years. This suggests a migration that might be due to therapeutic care progress that led to a decrease in perinatal mortality and resulted in an increased survival rate of these children³⁹39 Brasil. Ministério da Saúde (MS). Secretaria de Atenção à Saúde. Diretrizes de atenção à pessoa com paralisia cerebral. Brasília: MS; 2014.. Mortality rate of these causes remained stable in both age groups throughout the entire period of time we analyzed. However, the small number of deaths limits trend analyses and their interpretation.

Knowing and understanding the distribution and trends of the leading causes of death are essential for health managers to plan actions and public policies aimed at improving health conditions. In addition, they allow the identification of gaps and priorities and the elaboration of interventions in a multisectoral way, not only by health authorities but also by other sectors authorities such as public security, culture and education.

The vast majority of causes of mortality in the 5-14 age group are either preventable or treatable. Safety laws that address behavioral risk factors such as driving under the influence of alcohol, speed control, seat belt use, early identification, updated and quality treatments for major childhood cancer types, as well as appropriate and universal vaccination and antimicrobial treatment to fight infectious and parasitic diseases may reduce the deaths of these children in a comprehensive, equitable and fast way. The decrease in mortality from ill-defined causes found in the analyzed period may contribute to better targeting preventive measures. Additionally, we need to qualify the certification of causes of death with undefined or incomplete diagnoses, which are not very useful in public health⁴⁰40 GBD 2015 Mortality and Causes of Death Collaborators. Global, regional, and national life expectancy, all-cause mortality, and cause specific mortality for 249 causes of death, 1980-2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet 2016; 388(10053):1459-1544..

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