Marked progress has been made in reducing the mortality burden in children aged 5–14 years over the past 26 years in the WHO European Region. More deaths could be prevented, especially in CIS countries, through intervention and prevention efforts focusing on the leading causes of death, which are road injuries, drowning, and lower respiratory infections. The findings of our study could be used as a baseline to assess the effect of implementation of programmes and policies on child mortality burden.

For children aged 5–9 years, all-cause mortality rates (per 100 000 population) were estimated to be 46·3 (95% uncertainty interval [UI] 45·1–47·5) in 1990 and 19·5 (18·1–20·9) in 2016, reflecting a 58·0% (54·7–61·1) decline. For children aged 10–14 years, all-cause mortality rates (per 100 000 population) were 37·9 (37·3–38·6) in 1990 and 20·1 (18·8–21·3) in 2016, reflecting a 47·1% (43·8–50·4) decline. In 2016, we estimated 10 740 deaths (95% UI 9970–11 542) in children aged 5–9 years and 10 279 deaths (9652–10 897) in those aged 10–14 years in the WHO European Region. Injuries (road injuries, drowning, and other injuries) caused 4163 deaths (3820–4540; 38·7% of total deaths) in children aged 5–9 years and 4468 deaths (4162–4812; 43·5% of total) in those aged 10–14 years in 2016. Neoplasms caused 2161 deaths (1872–2406; 20·1% of total deaths) in children aged 5–9 years and 1943 deaths (1749–2101; 18·9% of total deaths) in those aged 10–14 years in 2016. Notable differences existed in cause-specific mortality rates between the European subregions, from a two-times difference for leukaemia to a 20-times difference for lower respiratory infections between the Commonwealth of Independent States (CIS) and EU15 (the 15 member states that had joined the European Union before May, 2004).

We used data from vital registration systems, cancer registries, and police records from 1980 to 2016 to estimate cause-specific mortality using the Cause of Death Ensemble model.

The mortality burden in children aged 5–14 years in the WHO European Region has not been comprehensively studied. We assessed the distribution and trends of the main causes of death among children aged 5–9 years and 10–14 years from 1990 to 2016, for 51 countries in the WHO European Region.

Although the mortality burden in children aged 5–14 years has been reduced substantially between 1990 and 2016 in the WHO European Region, marked difference in levels and causes of death still exists between countries. More efforts are needed to reduce mortality from the leading causes of death that are highly preventable or amenable to health care, particularly road injuries, drowning, lower respiratory infections, self-harm, and congenital birth defects. Concerted efforts are needed to reduce the massive inequalities in mortality between countries in the region.

This analysis provides a comprehensive assessment of the distribution and trends of the main causes of death among children aged 5–9 years and 10–14 years for 51 countries in the WHO European Region from 1990 to 2016. To our knowledge, this is the first study to show comparable age-specific and sex-specific trends in cause-specific mortality rates for these age groups across countries, using all available data. Our findings will help countries to identify priority areas for interventions and will also serve as a baseline for analysing the effectiveness of programmes and policies over time.

Mortality rates in children aged 5–14 years have been estimated by the Global Burden of Diseases, Injuries, and Risk Factors Study 2013 and 2016, and the United Nations Inter-Agency Group for Child Mortality Estimation. However, the burden in this age group across countries in the WHO European Region has not been comprehensively assessed. We did a PubMed search on Nov 10, 2017, using the following search terms: “child mortality[MeSH] AND (trend OR trends) AND Europe[MeSH]”, which yielded 82 results. We identified 12 studies that reported trends in mortality due to a single cause in this age group. An additional five studies reported trends in all-cause mortality and cause-specific mortality, but these studies focused on a single country in Europe and the most recent period of estimation was 2011. We found no studies that reported comparable all-cause and cause-specific mortality estimates over time across countries in the WHO European Region.

Substantial diversity exists between countries in the WHO European Region in terms of socioeconomic and political conditions and health risks.For example, the highest country-specific under-5 mortality rates are 25 times higher than the lowest rates.Little information is available about variations in mortality rates for older children across countries in the European Region. In 2014, the 53 member states of the WHO European Region adopted a new strategy that aims to reduce the burden of avoidable disease and mortality in children of all ages,and the 5–14 years age group has been identified as one of its topmost priorities. For the planning of intervention and prevention efforts, information on region-specific and country-specific leading causes of death in these children is essential. In this Article, we aim to identify the main causes of death in children aged 5–9 years and 10–14 years in the WHO European Region, and summarise their distributions and trends from 1990 to 2016 for 51 of the 53 countries in the Region (the Global Burden of Disease [GBD] study produces estimates only for locations with a population greater than 50 000; therefore, Monaco and San Marino are not included in this analysis).

Mortality rates in children younger than 5 years and the variations between countries in the WHO European Region are well studied and documented.However, the mortality burden in older children (aged 5–14 years) is less well known. Increasing attention is being paid to older children,but no studies thus far have provided a comprehensive assessment of the mortality burden in the 5–14 years age group in the European Region.

Global and national burden of diseases and injuries among children and adolescents between 1990 and 2013: findings from the Global Burden of Disease 2013 study.

Some authors are employed by WHO and had a role in all aspects of the study. The GBD enterprise is supported by funding from the Bill & Melinda Gates Foundation, which had no role in study design, data collection and analysis, interpretation of data, decision to publish, or preparation of the manuscript. The corresponding author had full access to all data in the study and had final responsibility for the decision to submit for publication.

In this study, we classified European countries into four subregions based on the official groupings formally agreed by member states of the WHO European Region, which are socioeconomically and politically diverse ( figure 1 ). These subregions are EU15, the 15 Member States that had joined the European Union before May, 2004 (Austria, Belgium, Denmark, Finland, France, Germany, Greece, Ireland, Italy, Luxembourg, the Netherlands, Portugal, Spain, Sweden, and the UK); EU13, Member States that have joined the European Union since May, 2004 (Bulgaria, Croatia, Cyprus, Czechia, Estonia, Hungary, Latvia, Lithuania, Malta, Poland, Romania, Slovakia, and Slovenia); the South Eastern Europe Health Network (SEEHN; Albania, Bosnia and Herzegovina, Bulgaria, Croatia, Israel, Macedonia, Montenegro, Romania, Republic of Moldova, and Serbia); and the Commonwealth of Independent States (CIS; Armenia, Azerbaijan, Belarus, Kazakhstan, Kyrgyzstan, Republic of Moldova, Russian Federation, Tajikistan, Turkmenistan, Ukraine, and Uzbekistan). Andorra, Georgia, Iceland, Norway, Switzerland, and Turkey are not included in the subregion groups. This study complies with the Guidelines for Accurate and Transparent Health Estimates Reporting (GATHER) recommendations.

Andorra, Georgia, Iceland, Norway, Switzerland, and Turkey are not included in the subregion groups. Bulgaria, Croatia, Romania, and Republic of Moldova belong to more than one subregion. CIS=commonwealth of independent states. EU13=countries that joined the European Union after May, 2004. EU15=countries that joined the European Union before May, 2004. SEEHN=South Eastern Europe Health Network.

The Cause of Death Ensemble model (CODEm)was used to estimate cause-specific mortality for most causes. The CODEm strategy explored a diverse set of plausible models that apply different functional forms, including mixed-effects models and spatiotemporal Gaussian process regression for mortality rates and cause fractions, with varying combinations of covariates ( appendix ). All models for each cause of death were assessed using out-of-sample predictive validity tests and combined into an ensemble of models that perform best. For a few causes with a very small number of deaths or no deaths (eg, upper respiratory infection and diphtheria), we used negative binomial regression to deal with the overdispersion in the data.

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.

Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010.

GBD 2013 Mortality and Causes of Death Collaborators Global, regional, and national age–sex specific all-cause and cause-specific mortality for 240 causes of death, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013.

Details of the design and methods of the GBD have been reported previously.Briefly, GBD 2016 included 264 causes of death; the International Classification of Diseases (ICD) codes for the GBD 2016 cause list are shown in the appendix . Cause-specific mortality in the WHO European Region was estimated using data from vital registration systems, cancer registries, verbal autopsy data (for Turkey only), and police records (for road injuries and homicide only) from 1980 to 2016. The quality and comparability of the cause-of-death data were assessed and enhanced through multiple steps, which included adjustment of data from vital registration systems for incompleteness; conversion of causes found in the original data to the GBD 2016 cause list; identification of garbage codes (ie, deaths assigned to causes that were not underlying causes of death) and redistribution to underlying causes; age–sex splitting of deaths that were reported in aggregated categories; and smoothing random fluctuations. The detailed methods for each step are available in the appendix of a previous GBD paper.Country-year-age-sex-specific raw data versus enhanced data and model estimates are shown in the online data visualisation of the cause-of-death database . We assessed the overall data quality for each country based on completeness, garbage coding, cause-list detail, and time periods covered, and assigned a quality score ranging from 0 stars (poorest) to 5 stars (best). Causes of death data used, the years for which data are available, vital registration completeness, data quality rating, and the percentage of garbage codes by country in the WHO European Region are shown in the appendix

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.

Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010.

GBD 2013 Mortality and Causes of Death Collaborators Global, regional, and national age–sex specific all-cause and cause-specific mortality for 240 causes of death, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013.

The rankings of the leading causes of death in each country in the WHO European Region in 2016 are shown on a dashboard for each age group ( Figure 4 Figure 5 ). For children aged 5–9 years, the leading cause of death was road injuries in 24 countries, brain and nervous system cancer in nine countries, congenital birth defects in six countries, drowning in six countries, lower respiratory infections in four countries, and leukaemia in two countries ( figure 4 ). For the 10–14 years age group, the leading cause of death was road injuries in 38 countries, drowning in five countries, lower respiratory infections in four countries, leukaemia in one country, brain and nervous system cancer in one country, and congenital birth defects in one country ( figure 5 ). Lower respiratory infections were the first or second leading cause of death in several CIS countries in both age groups, whereas this cause was much lower in the ranking for the remaining groups of countries ( Figure 4 Figure 5 ).

Mortality rates from other causes of death also show varying degrees of differences within the European Region ( table 3 ). In 2016, mortality rates for lower respiratory infections, the most common cause of communicable disease death, were about 20 times higher in CIS than EU15 countries. Encephalitis mortality rates in CIS countries were eight times greater than in EU15 countries ( appendix ). The mortality rate for congenital birth defects was 2·6 times higher and that for epilepsy was about 4·5 times higher in CIS than in EU15 countries.

In 2016, neoplasms caused 2161 deaths (95% UI 1872–2406; 20·1% of total deaths) in children aged 5–9 years and 1943 deaths (1749–2101; 18·9% of total deaths) in those aged 10–14 years ( Table 1 Table 2 ). Neoplasm mortality rates were 29·4% higher in boys than girls in the 5–9 years age group and 30·3% higher in boys than girls in the 10–14 years age group ( appendix ). Leukaemia was the leading cause of deaths due to neoplasms, followed by brain and nervous system cancer in both age groups. Between 1990 and 2016, leukaemia mortality rates decreased by 55·9% (95% UI 47·0–63·9) in the 5–9 years age group and 47·1% (38·6–54·7) in the 10–14 years age group ( Figure 2 Figure 3 ), while the percentage decrease in mortality rates for brain and nervous system cancer was much smaller in both age groups (26·3% [95% UI 8·7–44·0] in children aged 5–9 years and 19·9% [5·5–33·8] in those aged 10–14 years; Figure 2 Figure 3 ). The decreases in mortality rates were not markedly different across subregions for leukaemia and brain and nervous system cancer. Leukaemia death rates were 45·4% higher in boys than girls aged 5–9 years and 60·0% higher in boys than girls aged 10–14 years ( appendix ). Brain and nervous system cancer mortality rates were not markedly different between boys and girls. The mortality rate for leukaemia was about two times higher in CIS than EU15 in 2016 ( table 3 ).

In children aged 10–14 years, the percentage decrease in mortality rate for self-harm between 1990 and 2016 (25·8%; 95% UI 11·7–39·4) was much smaller than those for road injuries (59·6%; 54·9–64·6) and drowning (64·4%; 59·1–68·8; figure 3 ). At the subregion level, the decline in self-harm mortality rates was much smaller in CIS (12·5%) than the remaining three subregions, in which the decreases were all greater than 40% ( appendix ). In 2016, the mortality rate due to self-harm was more than six times higher in CIS than EU15 in children aged 10–14 years old. Self-harm mortality rates for children aged 10–14 years in 2016 varied greatly between countries, with a 20-times difference between the lowest (Greece; 0·2 per 100 000) and the highest (Kazakhstan; 4·0 per 100 000; appendix ).

Mortality rates due to drowning, another notable contributor to injury mortality rates in children, also showed large decreases between 1990 and 2016, with a 72·2% (95% UI 68·0–75·7) decrease in children aged 5–9 years and 64·4% (59·1–68·8) decrease in the those aged 10–14 years ( Figure 2 Figure 3 ). The decline in drowning mortality rates varied across subregions from 73·6% (95% UI 70·2–76·7) in EU13 to 63·3% (58·4–67·6) in CIS in children aged 5–14 years ( appendix ). In 2016, the mortality rate in children aged 5–14 years for drowning was 14 times higher in CIS than EU15 ( table 3 ), with even greater variation at the country level: a nearly 45-times difference between Luxembourg (0·2 per 100 000 children) and Tajikistan (9·0 per 100 000 children; table 3 ).

The leading causes of death were similar between the two age groups ( Table 1 Table 2 ). Injuries caused 4163 deaths (95% UI 3820–4540; 38·7% of total deaths) in children aged 5–9 years and 4468 deaths (4162–4812; 43·5% of total) in those aged 10–14 years in 2016 ( Table 1 Table 2 ). Injury mortality rates were almost twice as high in boys as in girls in both age groups ( appendix ). Road injuries remained a major contributor to injury mortality rates in both age groups in 2016 ( Table 1 Table 2 ), despite a large decline of approximately 60% between 1990 and 2016 ( Figure 2 Figure 3 ). The decrease in deaths due to road injuries from 1990 to 2016 varies throughout the European Region from a 79·1% (95% UI 76·9–81·0) decrease in EU15 to a 56·7% (51·1–62·0) decrease in CIS ( appendix ); in 2016, road injury mortality rates were four times higher in CIS than in EU15 ( table 3 appendix ). Even larger variations exist across individual countries: for example, road injury mortality rates (per 100 000 population) varied from 0·5 (95% UI 0·4–0·7) in Malta to 6·1 (4·4–8·3) in Kazakhstan (nearly a 12-times difference) in children 5–9 years old ( appendix ).

Andorra, Georgia, Iceland, Norway, Switzerland, and Turkey are not included in the subregion groups. Bulgaria, Croatia, Romania, and Republic of Moldova belong to more than one subregion. EU13=countries that joined the European Union after May, 2004. EU15=countries that joined the European Union before May, 2004. SEEHN=South Eastern Europe Health Network. CIS=commonwealth of independent states.

Mortality rates for the top ten leading causes of death in 2016 globally and in the WHO European Region (51 countries and four subregions), ages 5–14 years, both sexes

Table 3 Mortality rates for the top ten leading causes of death in 2016 globally and in the WHO European Region (51 countries and four subregions), ages 5–14 years, both sexes

In 2016, we estimated 10 740 deaths (95% uncertainty interval [UI] 9970–11 542) in children aged 5–9 years and 10 279 deaths (9652–10 897) in those aged 10–14 years in the WHO European Region. In 1990, the numbers of deaths were 29 994 (29 239–30 788) and 24 133 (23 722–24 562), reflecting a 64·2% (95% UI 61·4–66·8) decline in the number of all-cause deaths in children aged 5–9 years and a 57·4% (54·7–60·1) decrease in children aged 10–14 years ( Table 1 appendix ). In 2016, mortality rates (per 100 000 people) were 19·5 (95% UI 18·1–20·9) in children aged 5–9 years and 20·1 (18·8–21·3) in those aged 10–14 years. In 1990, the death rates were 46·3 (45·1–47·5) and 37·9 (37·3–38·6), reflecting a 58·0% (95% UI 54·7–61·1) decline in all-cause mortality rates in children aged 5–9 years and a 47·1% (43·8–50·4) decline in children aged 10–14 years ( Table 1 appendix ). The decrease in all-cause death rate was about four times greater in the 5–9 years age group than in the 10–14 years age group during the years 1990–2000 ( appendix ). The decreases in death rates were similar between the two age groups during the years 2000–16 (50·8% [46·6–54·5] in ages 5–9 years vs 45·2% [41·8–48·5] in ages 10–14 years; appendix ).

Discussion

19 Eurostat

Amenable and preventable deaths statistics. Substantial progress has been made in reducing mortality in children aged 5–14 years in the WHO European Region over the past 26 years. Despite the decline, deaths from causes that are preventable or amenable to high-quality health care (eg, injuries, congenital anomalies, leukaemia, and lower respiratory infections)remain large contributors to mortality among these children in 2016. Large differences in cause-specific mortality rates between EU15 and CIS countries are notable, ranging from a two-times difference in leukaemia to a 20-times difference in lower respiratory infections.

20 Sethi D

Towner E

Vincenten J

Segui-Gomez M

Racioppi F European report on child injury prevention. , 21 Sethi D Inequality in injury risks. , 22 McKee M

Zwi A

Koupilova I

Sethi D

Leon D Health policy-making in central and eastern Europe: lessons from the inaction on injuries?. 23 WHO regional Office for Europe

European facts and the global status report on road safety 2015. 23 WHO regional Office for Europe

European facts and the global status report on road safety 2015. Road injuries were the main contributors to injury death rates for children aged 5–14 years, with death rates in CIS four times higher than EU15 in 2016. In CIS countries, child injury mortality rates increased substantially in the early 1990s as a consequence of political and economic transitions.Progress has been made in reducing the injury death rates over time but the decline could be accelerated further by concerted efforts. For example, according to a 2015 report by the WHO European Region,road safety laws addressing the key behavioural risk factors (speed, drunk driving, and not using helmets, seatbelts, and child car restraints) can reduce road injury deaths, but many countries have laws addressing only a subset of these risk factors. Having comprehensive laws addressing all five risk factors is therefore crucial to speed up the decline in road injury mortality rates. Furthermore, adherence to international vehicle safety standards and safer road infrastructure designs are also important to overcome premature deaths from road crashes. Many countries, especially those in the CIS group, have had rapid increases between 2010 and 2013, in motor vehicle ownership,and thus more organised efforts of society through legislation, enforcement, and social marketing are necessary to improve safety on the roads.

20 Sethi D

Towner E

Vincenten J

Segui-Gomez M

Racioppi F European report on child injury prevention. , 24 Naci H

Baker TD Drowning rates in the newly independent states & Russian Federation: a call for research and action. 25 WHO

Global report on drowning: preventing a leading killer. Drowning was a notable contributor to injury mortality rates in both age groups. Mortality rates from drowning were especially high in Tajikistan, Kazakhstan, Uzbekistan, Azerbaijan, Kyrgyzstan, and Turkmenistan. The high risk of drowning was not specific to children aged 5–14 years, but was also common in children younger than 5 years. Widespread irrigation practices, exposure to large expanses of unprotected waterways, the inability to swim, and scarce supervision might contribute to high drowning rates among children in these countries.Intersectoral action is needed to implement effective interventions such as fencing, supervision, flotation devices, and water skills training.

26 UNICEF

UNICEF annual report 2013—Kazakhstan. 27 Hawton K

Bergen H

Simkin S

et al. Long term effect of reduced pack sizes of paracetamol on poisoning deaths and liver transplant activity in England and Wales: interrupted time series analyses. 28 WHO

Preventing suicide: a global imperative. 28 WHO

Preventing suicide: a global imperative. Self-harm was one of the top five causes of death among children aged 10–14 years in many countries in the European Region in 2016, with the highest mortality rate in Kazakhstan. A study by UNICEF in Kazakhstan reported that mental health conditions (especially depression) were key risk factors for youth suicides, and that specialised mental health services were not available in the country.Kyrgyzstan, Russian Federation, and Uzbekistan were also among the countries with the highest self-harm mortality rates in 2016. Self-poisoning with medication is a widely used method of suicide in many European countries,and prohibition of access to the medications commonly used in suicide has been shown to effectively prevent suicide.National suicide prevention strategies include multiple components such as restricting access to common lethal means and promoting access to mental health and other services, but such strategies are not present in most countries.

29 European Lung Foundation

Acute lower respiratory infections. Sheffield: European Lung Foundation. , 30 GBD 2015 Risk Factors Collaborators

Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015. 29 European Lung Foundation

Acute lower respiratory infections. Sheffield: European Lung Foundation. 31 Wald NJ Folic acid and the prevention of neural-tube defects. 32 Higashi H

Barendregt JJ

Kassebaum NJ

Weiser TG

Bickler SW

Vos T The burden of selected congenital anomalies amenable to surgery in low and middle-income regions: cleft lip and palate, congenital heart anomalies and neural tube defects. , 33 WHO

Birth defects. World Health Organization Sixty-third World Health Assembly. 34 European Surveillance of Congenital Anomalies

Special report: prenatal screening policies in Europe 2010. Other leading causes of death in children aged 5–14 years are also highly preventable or amenable to high-quality health care. For example, lower respiratory infections, the leading cause of death mostly in CIS countries, are preventable through vaccination and reduction of exposure to risk factors,and amenable to timely antimicrobial treatment.Certain congenital birth defects are preventable (eg, by folic acid supplementation for preventing neural tube defects)or amenable to surgical care (eg, congenital heart anomalies and neural tube defects).About half of the deaths from congenital anomalies in children aged 5–14 years in 2016 were from congenital heart defects. Mortality rates from congenital anomalies vary widely across countries in the European Region. This might be partly explained by differences in prenatal screening policies and laws concerning termination of pregnancy for fetal anomaly in different countries.

35 Karachunskiy A

Herold R

von Stackelberg A

et al. Results of the first randomized multicentre trial on childhood acute lymphoblastic leukaemia in Russia. Despite a general decline in mortality in both age groups over the past 26 years, the rate of decline varies vastly across countries. For instance, leukaemia mortality rates show a stagnant trend or a slow decline in some countries (eg, Azerbaijan and Turkmenistan) but a sharp decline in others (eg, Russian Federation and Ukraine). The fast decline in the Russian Federation, for example, could be tracked to the successful implementation of treatment protocols tailored to the local conditions of the Russian health-care system.

11 GBD 2013 Mortality and Causes of Death Collaborators

Global, regional, and national age–sex specific all-cause and cause-specific mortality for 240 causes of death, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. , 12 Wang H

Liddell CA

Coates MM

et al. Global, regional, and national levels of neonatal, infant, and under-5 mortality during 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. , 15 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. The challenges and limitations of the GBD approach in estimating all-cause and cause-specific mortality have been described extensively elsewhere,and we provide a brief summary of some of them here. First, although our systematic approach to redistributing garbage codes enhances the comparability of the cause-of-death data, this approach can cause our results to differ from countries' official statistics (even from those with complete vital registration systems). Second, we did not include any intermediate causes of death (eg, heart failure) in the cause list. They were treated as garbage codes and were reassigned to the possible underlying cause. Although the idea was to assign each cause uniquely to an underlying cause, this approach could mask intermediate causes that are important to note for purposes of health service delivery. In future research, we aim to report mortality estimates for intermediate causes as supplemental information. Third, for a very small number of locations and years with few or no data, we used covariates, borrowing strength across space and time to generate the mortality estimates; the scarcity of data in a particular location is reflected in the wide uncertainty intervals. Finally, time trends for some causes of death such as cancer might be influenced by changes in diagnostic technology; they were probably underdiagnosed in the past when diagnostic tests were done less frequently. Despite these limitations, our study used all available data and robust methods to produce comparable all-cause and cause-specific mortality estimates for children aged 5–9 years and 10–14 years over time across countries in the WHO European Region. A separate analysis of the GBD data focusing on the mortality burden in older adolescents and young adults could be complementary to this Article, and could provide a better picture of the health of children and young adults in the European Region.

In conclusion, our findings show large variations in trends in cause-specific mortality rates in children aged 5–14 years between 1990 and 2016 and across different countries in the WHO European Region. Differences between highest and lowest mortality rates ranged from a two-times difference to a 20-times difference for the leading causes of death across countries. Many causes of death are preventable or amenable to health care; although progress has been made in reducing mortality over time, the decline could be accelerated further through coordinated efforts between governments and stakeholders, such as legislators, local authorities, health-care professionals, and community members. Understanding the trends in causes of death in children allows governments and public health officials to identify priorities. Moreover, these findings could be used as a baseline to establish whether programmes and policies are effective in reducing the mortality burden in children aged 5–14 years in future.