Excess child mortality after discharge from hospital in Kilifi, Kenya: a retrospective cohort analysis (original) (raw)
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Mortality during and following hospital admission among school-aged children: a cohort study
Wellcome Open Research
Background: Far less is known about the reasons for hospitalization or mortality during and after hospitalization among school-aged children than among under-fives in low- and middle-income countries. This study aimed to describe common types of illness causing hospitalisation; inpatient mortality and post-discharge mortality among school-age children at Kilifi County Hospital (KCH), Kenya. Methods: A retrospective cohort study of children 5−12 years old admitted at KCH, 2007 to 2016, and resident within the Kilifi Health Demographic Surveillance System (KHDSS). Children discharged alive were followed up for one year by quarterly census. Outcomes were inpatient and one-year post-discharge mortality. Results: We included 3,907 admissions among 3,196 children with a median age of 7 years 8 months (IQR 74−116 months). Severe anaemia (792, 20%), malaria (749, 19%), sickle cell disease (408, 10%), trauma (408, 10%), and severe pneumonia (340, 8.7%) were the commonest reasons for admissio...
BMJ Open, 2023
Objectives To describe admission trends and estimate inpatient and post-discharge mortality and its associated exposures, among young infants (YI) admitted to a county hospital in Kenya. Design Retrospective cohort study. Setting Secondary level hospital. Participants YI aged less than 60 days admitted to hospital from January 2009 to December 2019: 12 271 admissions in 11 877 individuals. YI who were resident within a Kilifi Health and Demographic Surveillance System (KHDSS): n=3625 with 4421 admissions were followed-up for 1 year after discharge. Primary and secondary outcome measures Inpatient and 1-year post-discharge mortality, the latter in KHDSS residents. Results Of 12 271 YI admissions, 4421 (36%) were KHDSS-resident. Neonatal sepsis, preterm complications and birth asphyxia accounted for 83% of the admissions. The proportion of YI among under-5s admissions increased from 19% in 2009 to 34% in 2019 (P trend =0.02). Inpatient case fatality was 16%, with 66% of the deaths occurring within 48 hours of admission. The introduction of free maternity care in 2013 was not associated with a change in admissions or inpatient mortality among YI. During 1-year post-discharge, 208/3625 (5.7%) YI died, 64.3 (95% CI 56.2 to 73.7) per 1000 infant-years. 49% of the post-discharge deaths occurred within 1 month of discharge, and 49% of post-discharge deaths occurred at home. Both inpatient and post-discharge deaths were associated with low admission weight. Inpatient mortality was associated with clinical signs of disease severity, while postdischarge mortality was associated with the length of hospitalisation, leaving against advice and referral to a specialised hospital. Conclusions YIs accounted for an increasing proportion of paediatric admissions and their overall mortality remains high. Post-discharge mortality accounts for a lower proportion of deaths but mortality rate is higher than among children aged 2-59 months. Services to address post-discharge mortality are needed and should focus on infants at higher risk.
Tropical Medicine & International Health, 2007
Objectives (1) To determine whether mortality rates were raised in sick children in the 30 days after visiting first-level health facilities in an area under demographic surveillance in western Kenya, (2) to identify the types of illnesses associated with increased mortality and (3) to estimate the effectiveness of appropriate treatment.Methods All sick children (2–59 months of age) who attended one of the seven participating first-level health facilities from May to August 2003 were identified. A standardized mortality ratio was computed to compare their mortality rate in the 30 days after a sick visit with that of the community under active demographic and health surveillance. A multivariate Cox Proportional Hazards model was used to identify illnesses associated with death and to estimate the protective effectiveness of appropriate treatment for potentially life-threatening diseases.Results A total of 1383 eligible children made 1697 sick visits; 33 (2.4%) died within 30 days. Compared with children 2–59 months in the general population, sick children had a 5.3 times greater mortality rate [95% confidence interval (CI) 3.8–7.5]. In a multivariate survival analysis, significant risk factors for mortality included age <24 months [Hazard Ratio (HR) 4.4, 95% CI 1.5–12.6], malnutrition (HR 15.5, 95% CI 6.1–39.8), severe pneumonia (HR 12.9, 95% CI 3.0–56.4) and anaemia (HR 3.3, 95% CI 1.5–7.2). Appropriate treatment for a child’s most severe illness reduced mortality by 78% (95% CI 57–89%).Conclusion We estimate that improvements in diagnosis and appropriate treatment at first-level health facilities for children 2–59 months could reduce overall under-5 mortality in the area by 12–14%.Objectifs (1) Déterminer si les taux de mortalitéétaient plus élevés chez les enfants malades dans les 30 jours après une visite dans des services de santé primaires dans une région sous surveillance démographique dans l’ouest du Kenya, (2) identifier les types de maladies associées à la mortalité accrue et (3) estimer l’efficacité d’un traitement approprié.Méthodes Tous les enfants malades (de 2 à 59 mois d’âge) présentés dans un des 7 services de santé primaire inclus dans l’étude de mai à août 2003 ont été identifiés. Un rapport normalisé de mortalité a été calculé pour comparer leur taux de mortalité dans les 30 jours après une visite de santéà celui de la communauté correspondante sous contrôle sanitaire et démographique actif. Un modèle proportionnel multivarié de risques de Cox a été utilisé pour identifier les maladies associées à la mort et pour estimer l’efficacité protectrice d’un traitement approprié pour les maladies représentant un danger potentiel pour la vie.Résultats Au total, 1383 enfants éligibles ont effectué 1697 visites de santé; 33 (2,4%) d’entre eux sont décédés dans les 30 jours. Comparés aux enfants de 2 à 59 mois dans la population générale, les enfants malades avaient un taux de mortalité 5,3 fois plus élevé (intervalle de confiance à 95% [IC]: 3,8–7,5). Dans une analyse multivariée de survie, les facteurs de risque significatifs pour la mort comprenaient: l’âge <24 mois (rapport de risque [HR] = 4,4; IC95%: 1,5–12,6), la malnutrition (HR = 15,5; IC95%: 6,1–39,8), la pneumonie grave (HR = 12,9 = IC95%: 3,0–56,4) et l’anémie (HR = 3,3; IC95%: 1,5–7,2). Un traitement approprié pour la maladie la plus sévère d’un enfant réduisait la mortalité de 78% (IC95%: 57–89).Conclusion Nous estimons que des améliorations du diagnostic et le traitement approprié dans les services de santé primaire pour les enfants de 2 à 59 mois pourraient réduire la mortalité globale des moins de 5 ans de 12 à 14% dans cette région.Objectifs (1) Déterminer si les taux de mortalitéétaient plus élevés chez les enfants malades dans les 30 jours après une visite dans des services de santé primaires dans une région sous surveillance démographique dans l’ouest du Kenya, (2) identifier les types de maladies associées à la mortalité accrue et (3) estimer l’efficacité d’un traitement approprié.Méthodes Tous les enfants malades (de 2 à 59 mois d’âge) présentés dans un des 7 services de santé primaire inclus dans l’étude de mai à août 2003 ont été identifiés. Un rapport normalisé de mortalité a été calculé pour comparer leur taux de mortalité dans les 30 jours après une visite de santéà celui de la communauté correspondante sous contrôle sanitaire et démographique actif. Un modèle proportionnel multivarié de risques de Cox a été utilisé pour identifier les maladies associées à la mort et pour estimer l’efficacité protectrice d’un traitement approprié pour les maladies représentant un danger potentiel pour la vie.Résultats Au total, 1383 enfants éligibles ont effectué 1697 visites de santé; 33 (2,4%) d’entre eux sont décédés dans les 30 jours. Comparés aux enfants de 2 à 59 mois dans la population générale, les enfants malades avaient un taux de mortalité 5,3 fois plus élevé (intervalle de confiance à 95% [IC]: 3,8–7,5). Dans une analyse multivariée de survie, les facteurs de risque significatifs pour la mort comprenaient: l’âge <24 mois (rapport de risque [HR] = 4,4; IC95%: 1,5–12,6), la malnutrition (HR = 15,5; IC95%: 6,1–39,8), la pneumonie grave (HR = 12,9 = IC95%: 3,0–56,4) et l’anémie (HR = 3,3; IC95%: 1,5–7,2). Un traitement approprié pour la maladie la plus sévère d’un enfant réduisait la mortalité de 78% (IC95%: 57–89).Conclusion Nous estimons que des améliorations du diagnostic et le traitement approprié dans les services de santé primaire pour les enfants de 2 à 59 mois pourraient réduire la mortalité globale des moins de 5 ans de 12 à 14% dans cette région.Objectivos (1) Determinar si las tasas de mortalidad eran altas en niños enfermos en los 30 días después de visitar servicios de salud primaria en un área bajo vigilancia demográfica en el occidente de Kenia, (2) identificar los tipos de enfermedades asociadas con alta mortalidad y (3) estimar la efectividad de tratamientos apropiados.Métodos Todos los niños enfermos (2 a 59 meses de edad) que asistieron a uno de los siete facilidades de salud primaria incluidos en el estudio entre mayo y agosto del 2003 fueron identificados. Una razón de mortalidad estandarizada fue calculada para comparar la tasa de mortalidad en las 30 días después de una visita medica para atender una enfermedad con la de la comunidad bajo vigilancia activa demográfica y de salud. El modelo de Cox de riesgo proporcional fue usado para identificar enfermedades asociadas con defunciones y para estimar la efectividad protectiva de tratamientos apropiados para enfermedades potencialmente letales.Resultados Un total de 1383 niños elegibles hicieron 1697 visitas medicas para atender una enfermedad; 33 (2.4%) de ellos se murieron en los 30 días luego de la visita. La tasa de mortalidad resultó 5.3 veces mas alta (95% intervalo de confianza [IC] 3.8–7.5) en los niños enfermos comparado con niños de 2 a 59 meses de edad en la población general En un análisis multivariable de supervivencia, los factores de riesgo significativos para mortalidad incluyeron edad < 24 meses (razón de riesgo [HR] 4.4, 95% IC 1.5–12.6), malnutrición (HR 15.5, 95% IC 6.1–39.8), neumonía severa (HR 12.9, 95% IC 3.0–56.4) y anemia (HR 3.3, 95% IC 1.5–7.2). Recibir tratamiento apropiado para la enfermedad mas grave de un niño redujo la mortalidad un 78% (95% IC 57–89%).Conclusión Estimamos que mejorar los servicios de diagnósticos y tratamiento en los servicios de salud primaria para niños de 2 a 59 meses de edad pudiera reducir la tasa de mortalidad en esta población de entre 12 a 14%.Objectivos (1) Determinar si las tasas de mortalidad eran altas en niños enfermos en los 30 días después de visitar servicios de salud primaria en un área bajo vigilancia demográfica en el occidente de Kenia, (2) identificar los tipos de enfermedades asociadas con alta mortalidad y (3) estimar la efectividad de tratamientos apropiados.Métodos Todos los niños enfermos (2 a 59 meses de edad) que asistieron a uno de los siete facilidades de salud primaria incluidos en el estudio entre mayo y agosto del 2003 fueron identificados. Una razón de mortalidad estandarizada fue calculada para comparar la tasa de mortalidad en las 30 días después de una visita medica para atender una enfermedad con la de la comunidad bajo vigilancia activa demográfica y de salud. El modelo de Cox de riesgo proporcional fue usado para identificar enfermedades asociadas con defunciones y para estimar la efectividad protectiva de tratamientos apropiados para enfermedades potencialmente letales.Resultados Un total de 1383 niños elegibles hicieron 1697 visitas medicas para atender una enfermedad; 33 (2.4%) de ellos se murieron en los 30 días luego de la visita. La tasa de mortalidad resultó 5.3 veces mas alta (95% intervalo de confianza [IC] 3.8–7.5) en los niños enfermos comparado con niños de 2 a 59 meses de edad en la población general En un análisis multivariable de supervivencia, los factores de riesgo significativos para mortalidad incluyeron edad < 24 meses (razón de riesgo [HR] 4.4, 95% IC 1.5–12.6), malnutrición (HR 15.5, 95% IC 6.1–39.8), neumonía severa (HR 12.9, 95% IC 3.0–56.4) y anemia (HR 3.3, 95% IC 1.5–7.2). Recibir tratamiento apropiado para la enfermedad mas grave de un niño redujo la mortalidad un 78% (95% IC 57–89%).Conclusión Estimamos que mejorar los servicios de diagnósticos y tratamiento en los servicios de salud primaria para niños de 2 a 59 meses de edad pudiera reducir la tasa de mortalidad en esta población de entre 12 a 14%.
The Lancet Global Health
Background Mortality among children with acute illness in low-income and middle-income settings remains unacceptably high and the importance of post-discharge mortality is increasingly recognised. We aimed to explore the epidemiology of deaths among young children with acute illness across sub-Saharan Africa and south Asia to inform the development of interventions and improved guidelines. Methods In this prospective cohort study, we enrolled children aged 2-23 months with acute illness, stratified by nutritional status defined by anthropometry (ie, no wasting, moderate wasting, or severe wasting or kwashiorkor), who were admitted to one of nine hospitals in six countries across sub-Saharan Africa and south Asia between Nov 20, 2016, and Jan 31, 2019. We assisted sites to comply with national guidelines. Co-primary outcomes were mortality within 30 days of hospital admission and post-discharge mortality within 180 days of hospital discharge. A priori exposure domains, including demographic, clinical, and anthropometric characteristics at hospital admission and discharge, as well as child, caregiver, and household-level characteristics, were examined in regression and survival structural equation models. Findings Of 3101 children (median age 11 months [IQR 7−16]), 1120 (36•1%) had no wasting, 763 (24•6%) had moderate wasting, and 1218 (39•3%) had severe wasting or kwashiorkor. Of 350 (11•3%) deaths overall, 234 (66•9%) occurred within 30 days of hospital admission and 168 (48•0%) within 180 days of hospital discharge. 90 (53•6%) post-discharge deaths occurred at home. The proportion of children who died following discharge was relatively preserved across nutritional strata. Numerically large high-risk and low-risk groups could be disaggregated for early mortality and postdischarge mortality. Structural equation models identified direct pathways to mortality and multiple socioeconomic, clinical, and nutritional domains acting indirectly through anthropometric status. Interpretation Among diverse sites in Africa and south Asia, almost half of mortality occurs following hospital discharge. Despite being highly predictable, these deaths are not addressed in current guidelines. A fundamental shift to a childcentred, risk-based approach to inpatient and post-discharge management is needed to further reduce childhood mortality, and clinical trials of these approaches with outcomes of mortality, readmission, and cost are warranted. Funding The Bill & Melinda Gates Foundation.
Ethiopian Journal of Health Development, 2016
Background: Patterns of disease vary across time depending on changes in human health activities and lifestyle, environmental factors and disease epidemiology. Health facility-based studies can provide information on the burden of disease within the community. Having information on the main causes of childhood morbidity and mortality enables planners to more effectively design, implement, and evaluate prevention-focused interventions. Objective: To describe the disease pattern of patients admitted in the pediatric emergency unit at Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia and identify the main causes of admissions and deaths. Methodology: A cross-sectional retrospective study of admissions to the pediatric emergency unit of Tikur Anbessa Specialized Hospital was made for a period of one year from April 2012 to March 2013. Results: A total of 1796 patients were admitted from April 2012 to March 2013, out of which 1044 (58%) were males while 752 (42%) were females, a male to female ratio of 1.4:1. The mean age of the study subjects was 3.4 years for males and 3.7 years for females. The mean length of stay in the emergency unit was 4.7 days. Out of 1796 patients, 116 (6.5%) died. The most common cause of admission was severe pneumonia (24.7%) and also among the 116 deaths pneumonia was the leading cause of death (23.3%), followed by late onset sepsis (11.3%) and acute gastroenteritis (9.5 %). Conclusion: Interventions targeting prevention of pneumonia, sepsis, acute gastroenteritis, acquired heart disease and meningitis have paramount importance in reducing childhood illnesses and deaths. Since most of the causes of death in the unit could be avoidable by improving early case detection and management. [Ethiop.
The American Journal of Tropical Medicine and Hygiene, 2019
In low-resource settings, many children are severely ill at arrival to hospital. The risk factors for mortality among such ill children are not well-known. Understanding which of these patients are at the highest risk could assist in the allocation of limited resources to where they are most needed. A cohort study of severely ill children treated in the resuscitation room of the pediatric emergency department at Queen Elizabeth Central Hospital in Malawi was conducted over a 6-month period in 2017. Data on signs and symptoms, vital signs, blood glucose levels, and nutritional status were collected and linked with in-hospital mortality data. The factors associated with in-hospital mortality were analyzed using multivariable logistic regression. Data for 1,359 patients were analyzed and 118 (8.7%) patients died. The following factors were associated with mortality: presence of any severely deranged vital sign, unadjusted odds ratio (UOR) 2.6 (95% CI 1.7-4.0) and adjusted odds ratio (AOR) 3.2 (95% CI 2.0-5.0); severe dehydration, UOR 2.6 (1.4-5.1) and AOR 2.8 (1.3-6.0); hypoglycemia glycemia (< 5 mmol/L), UOR 3.6 (2.2-5.8) and AOR 2.7 (1.6-4.7); and severe acute malnutrition, UOR 5.8 (3.5-9.6) and AOR 5.7 (3.3-10.0). This study suggests that among severely sick children, increased attention should be given to those with hypo/low glycemia, deranged vital signs, malnutrition, and severe dehydration to avert mortality among these high-risk patients.
Background: Substantial mortality occurs after hospital discharge in children under 5 years old with suspected sepsis. A better understanding of its epidemiology is needed for effective interventions aimed at reducing child mortality in resource limited settings. Methods: In this prospective observational cohort study, we recruited 0 to 60 month old children admitted with suspected sepsis from the community to the paediatric wards of six Ugandan hospitals. The primary outcome was six-month post discharge mortality among those discharged alive. We evaluated the interactive impact of age, time of death, and location of death on risk factors for mortality. Findings: 6,545 children were enrolled, with 6,191 discharged alive. The median (interquartile range) time from discharge to death was 32 (10 to 92) days, with a six-month post-discharge mortality rate of 5.5%, constituting 51% of total mortality. Deaths occurred at home (45%), in transit to care (18%), or in hospital (37%) during a ...
2021
ObjectivesMortality during acute illness among children in low- and middle-income settings remain unacceptably high and there is increasing recognition of the importance of post-discharge mortality. A comprehensive understanding of pathways underlying mortality among acutely ill children is needed to develop interventions and improve guidelines. We aimed to determine the incidence, timing and contributions of proximal and underlying exposures for mortality among acutely ill young children from admission to hospital until 6 months after discharge in sub-Saharan Africa and South Asia in the context of guideline-based care.DesignA prospective stratified cohort study recruiting acutely ill children at admission to hospital with follow up until 180 days after discharge from hospital (November 2016-July 2019).SettingNine urban and rural hospitals in sub-Saharan Africa and South Asia across a range of facility levels, and local prevalences of HIV and malaria.ParticipantsInclusion criteria ...