Predicting Mortality among Hospitalized Children with Respiratory Illness in Western Kenya, 2009–2012

<div><p>Background</p><p>Pediatric respiratory disease is a major cause of morbidity and mortality in the developing world. We evaluated a modified respiratory index of severity in children (mRISC) scoring system as a standard tool to identify children at greater risk of death from respiratory illness in Kenya.</p><p>Materials and Methods</p><p>We analyzed data from children <5 years old who were hospitalized with respiratory illness at Siaya District Hospital from 2009–2012. We used a multivariable logistic regression model to identify patient characteristics predictive for in-hospital mortality. Model discrimination was evaluated using the concordance statistic. Using bootstrap samples, we re-estimated the coefficients and the optimism of the model. The mRISC score for each child was developed by adding up the points assigned to each factor associated with mortality based on the coefficients in the multivariable model.</p><p>Results</p><p>We analyzed data from 3,581 children hospitalized with respiratory illness; including 218 (6%) who died. Low weight-for-age [adjusted odds ratio (aOR) = 2.1; 95% CI 1.3–3.2], very low weight-for-age (aOR = 3.8; 95% CI 2.7–5.4), caretaker-reported history of unconsciousness (aOR = 2.3; 95% CI 1.6–3.4), inability to drink or breastfeed (aOR = 1.8; 95% CI 1.2–2.8), chest wall in-drawing (aOR = 2.2; 95% CI 1.5–3.1), and being not fully conscious on physical exam (aOR = 8.0; 95% CI 5.1–12.6) were independently associated with mortality. The positive predictive value for mortality increased with increasing mRISC scores.</p><p>Conclusions</p><p>A modified RISC scoring system based on a set of easily measurable clinical features at admission was able to identify children at greater risk of death from respiratory illness in Kenya.</p></div

Bivariate associations between demographic characteristics, hospital admission clinical signs and clinical symptoms and mortality among children <5 years hospitalized with a respiratory illness in Siaya District Hospital, August 2009–July 2012.

a<p>Defined as per the WHO IMCI case definition: Cough or difficult breathing and elevated respiratory rate;</p>b<p>Defined as per the WHO IMCI case definition: Cough or difficult breathing and any general danger sign or chest in-drawing or stridor in calm child;</p>c<p>Elevated respiratory rate for age based on WHO IMCI algorithm; <2 months, >60 breaths/minute; 2–11 months, >50 breaths/minute;12–59 months, >40 breaths/minute;</p>d<p>Combines responds to voice commands, responds to mild pain and unresponsive/unconscious;</p><p>*All admissions including deaths;</p>Ŧ<p>Enrolled in research studies conducted by KEMRI/CDC (Malaria and TB studies);</p>¥<p>Variables that were not statistically significant at α = 0.05 are not shown on the table.</p

Demographic and clinical characteristics associated with shigellosis on bivariate and multivariate analysis among patients seen in study clinic, 1^st Jan 2007 to 31^st Dec 2011, Kibera.

*<p>Significant variables on bivariate analysis included into multivariate model</p>**<p>Significant characteristics on bivariate analysis but not significant on multivariate model hence excluded from final multivariate model</p

Formula for adjusted incidence rate calculations.

<p>Formula for adjusted incidence rate calculations.</p

Drug susceptibility patterns for <i>Shigella</i> isolated, Kibera, Kenya.

*<p>low denominator due to stock out of Amoxicillin/clavulanic acid disks</p><p> `40 isolates did not have drug susceptibility tests done as antibiotics were not available when they were being tested</p

Modified Respiratory Index of Severity in Children (mRISC) scoring.

<p>Modified Respiratory Index of Severity in Children (mRISC) scoring.</p

Children included in, and excluded from, the evaluation of mRISC score.

<p>Children included in, and excluded from, the evaluation of mRISC score.</p

Person years of observation, crude and adjusted incidence of <i>Shigella</i> by age category, sex, zone and year, 1 May 2008 to 31 Dec 2010, Kibera, Kenya.

*<p>Adjusted incidence rates by zone not shown</p

Receiver operating curve (ROC) for the scoring model.

<p>Receiver operating curve (ROC) for the scoring model.</p

Proportions of patients meeting the case definitions providing stool sample by age category.

<p>Proportions of patients meeting the case definitions providing stool sample by age category.</p