Child Mortality after Discharge from a Health Facility following Suspected Pneumonia, Meningitis or Septicaemia in Rural Gambia: A Cohort Study.

OBJECTIVE: To measure mortality and its risk factors among children discharged from a health centre in rural Gambia. METHODS: We conducted a cohort study between 12 May 2008 and 11 May 2012. Children aged 2-59 months, admitted with suspected pneumonia, sepsis, or meningitis after presenting to primary and secondary care facilities, were followed for 180 days after discharge. We developed models associating post-discharge mortality with clinical syndrome on admission and clinical risk factors. FINDINGS: One hundred and five of 3755 (2.8%) children died, 80% within 3 months of discharge. Among children aged 2-11 and 12-59 months, there were 30 and 29 deaths per 1000 children per 180 days respectively, compared to 11 and 5 respectively in the resident population. Children with suspected pneumonia unaccompanied by clinically severe malnutrition (CSM) had the lowest risk of post-discharge mortality. Mortality increased in children with suspected meningitis or septicaemia without CSM (hazard ratio [HR] 2.6 and 2.2 respectively). The risk of mortality greatly increased with CSM on admission: CSM with suspected pneumonia (HR 8.1; 95% confidence interval (CI) 4.4 to 15), suspected sepsis (HR 18.4; 95% CI 11.3 to 30), or suspected meningitis (HR 13.7; 95% CI 4.2 to 45). Independent associations with mortality were: mid-upper arm circumference (MUAC) of 11.5-13.0 cm compared to >13.0 cm (HR 7.2; 95% CI 3.0 to 17.0), MUAC 10.5-11.4 cm (HR 24; 95% CI 9.4 to 62), and MUAC <10.5 cm (HR 44; 95% CI 18 to 108), neck stiffness (HR 10.4; 95% CI 3.1 to 34.8), non-medical discharge (HR 4.7; 95% CI 2.0 to 10.9), dry season discharge (HR 2.0; 95% CI 1.2 to 3.3), while greater haemoglobin (HR 0.82; 0.73 to 0.91), axillary temperature (HR 0.71; 95% CI 0.58 to 0.87), and oxygen saturation (HR 0.96; 95% CI 0.93 to 0.99) were associated with reduced mortality. CONCLUSION: Gambian children experience increased mortality after discharge from primary and secondary care. Interventions should target both moderately and severely malnourished children

Child Mortality after Discharge from a Health Facility Following Suspected Pneumonia, Meningitis and Septicaemia in Rural Gambia

Background Two years away from 2015, the decline in child mortality is not fast enough to reach Millennium Development Goal 4. The Integrated Management of Childhood Illness (IMCI) is a strategy that simplifies management of child health. Beyond effective disease management, IMCI recommendations for care following illnesses are based on limited evidence from the field. The aim of this project was to find (1) the magnitude of and (2) risk factors for child mortality following discharge from a health facility in a low-income setting. Methods This study used an established population-based surveillance system for suspected invasive pneumococcal disease in Upper River Region, The Gambia, West Africa. Children that survived admission for suspected pneumonia, meningitis or septicaemia at the Region’s only referral centre (Basse Major Health Centre, Upper River Region) were followed for 180 days after discharge. Vitality status monitored by the DSS informed time-to-death information in a survival analysis that identified predictors of post-discharge mortality. Two multivariable Cox proportional hazards models were constructed. Model A described the clinical syndrome on admission (provisional diagnosis) and risk of post-discharge mortality. Model B used a reverse step-wise approach to find pre-discharge risk factors for mortality following discharge. Results The cohort that survived admission had higher mortality rates than the background rate in the community. Overall, 105 (2.8%) of 3735 patients died during the 6 months of follow-up. Half of the deaths occurred within 45 days of discharge. Approximately half as many patients died in the six months following discharge as died during hospital admission. Age stratified post-discharge mortality rates were three to six times higher than community mortality rates. In addition to demonstrating the protective effect of increasing age at discharge (HR 0.98 [95%CI: 0.96, 0.99] for every month increase in age), Model A showed that, compared to pneumonia alone, a provisional diagnosis of: pneumonia with visible signs of severe malnutrition had a HR 8.74 (95%CI: 4.93, 15.49); meningitis with visible signs of severe malnutrition had a HR of 13.90 (95%CI: 5.43, 35.58); sepsis with visible signs of severe malnutrition had a HR 18.79 (95%CI: 11.65, 30.32). Model B showed independent risk factors associated with post-discharge mortality were: the presence of neck stiffness on assessment (HR 17.60 [95%CI: 7.36, 42.10]); low mid-upper arm circumference (MUAC) (<10.5cm, HR 11.52 [4.59, 28.90]); visible signs of severe malnutrition (HR 3.94 [95%CI: 2.11, 7.36]); non- medical discharge (HR 6.22 [95%CI: 2.98, 13.01]); discharge during dry season (HR 2.33 [95%CI: 1.44, 3.77]); decreasing peripheral arterial haemoglobin oxygen saturation (HR 0.95 [95%CI: 0.93, 0.98] per percent increase); decreasing haemoglobin concentration (HR 0.82 [95%CI: 0.74, 0.90]) per unit g/dL increase); and decreasing axillary temperature (HR 0.70 [0.58, 0.84] per unit oC increase). Conclusion Gambian children in Upper River Region with suspected invasive pneumococcal disease are at increased risk of death following discharge from a health facility, and most of these deaths occur early. There are identifiable risk factors for death, including neck stiffness, low MUAC, visible signs of severe malnutrition, non-medical discharge, discharge during dry season, decreasing peripheral arterial haemoglobin oxygen saturation, decreasing haemoglobin concentration and decreasing axillary temperature. These data add to the evidence base needed to inform the development key guidelines and may be helpful towards development of a tool with clinical utility to identify children for intervention after discharge from hospital

Kaplan-Meier survival estimates for 105 deaths during 180 day follow-up after discharge of 3735 children from Basse Health Centre, by categories of (A) clinically severe malnutrition and (B) mid-upper arm circumference.

<p>Clinically severe malnutrition was defined as the presence of visible wasting of the buttocks, characteristic skin or hair changes, or bilateral pedal oedema. Fifty-five patients exited alive from the Basse HDSS during 180 day follow-up. Numbers of events refer to the number of post-discharge deaths in each category. Total numbers refer to numbers of children in each category at the beginning of follow-up. Abbreviations: MUAC, mid-upper arm circumference (measured in centimetres).</p

Flow diagram showing the study profile of patient enrolment, inclusion and exclusion, and loss-to-follow-up.

<p>This flowchart shows the numbers of participants who were screened, met criteria for enrolment, discharged alive and included in analysis. ^aBasse Health and Demographic Surveillance System (Basse HDSS).</p

Multi-variable Cox regression model for the hazard of post-discharge mortality associated with clinical characteristics, anthropometry using mid-upper arm circumference.

<p>^a Mean (Standard Deviation).</p><p>^b Dry season (Dec-Jun). Note: Due to exclusion of participants with missing values 2013/3735 participants contributed to the final model.</p><p>Multi-variable Cox regression model for the hazard of post-discharge mortality associated with clinical characteristics, anthropometry using mid-upper arm circumference.</p

Multi-variable Cox regression model for the hazard of post-discharge mortality associated with different clinical syndromes.

<p>^a Mean (Standard Deviation).</p><p>^b (CSM) Clinically severe malnutrition defined as visible wasting of the buttocks, characteristic skin or hair changes, or bilateral pedal oedema.</p><p>Multi-variable Cox regression model for the hazard of post-discharge mortality associated with different clinical syndromes.</p

Temporal distribution of 105 deaths during 180 day follow-up after discharge from Basse Health Centre.

<p>Fifty-five patients exited alive from the Basse HDSS during 180 day follow-up.</p