A research conducted by the Medical Research Council and its partners to measure mortality and its risk factors among children discharged from a health centre in rural Gambia, have revealed that “Gambian children experience increased mortality after discharge from primary and secondary care.
The study which was published on September 9 on the online site of Plos One, a science journal that publishes the work of more than one hundred thousand researchers around the world, said their findings showed that “risk of mortality greatly increased among children admitted with clinically severe malnutrition”.
“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… Gambian children experience increased mortality after discharge from primary and secondary care. Interventions should target both moderately and severely malnourished children,” the report stated.
“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)…
“In total, 7646 children presented to the health facilities in the BHDSS and met the surveillance criteria for clinician review (Fig 1). Sixty-one (0.8%) patients were not reviewed by a clinician and the residential status of 102 (1.3%) was undetermined. Of 6310 patients with suspected pneumonia, meningitis, or septicemia, 2358 (37%) were treated as outpatients and 3952 were admitted. Of those admitted, 155 (3.9%) died as inpatients. Twenty-four (0.6%) patients without an outcome measure and 38 (1.0%) with inadequate records were excluded with 3735 of 3797 eligible admissions (98%) remaining in the final analysis. Of those included in the analysis, 1602 (43%) were screened at peripheral primary care facilities outside Basse. During the 180 day follow-up period, there were 105 deaths among the 3735 (2.8%) admissions. Fifty-five patients exited alive from the BHDSS during 180 day follow-up, 22 in the first 90 days and 33 in the second 90 days. In the 2–11 month age group 47 of 1605 (2.9%) children died; in the 12–23 month age group 39 of 1127 (3.5%) died and there were 19 deaths among 1003 (1.9%) children aged 24–59 months. The crude mortality rate was 28.5 deaths/1000 discharges/180 days of follow-up.
“The mortality rate was 29.8 deaths/1000/180 days for children 2–11 months of age and 27.6 for children aged 12–59 months. The mortality rates in the background BHDSS populations aged 2–11 and 12–59 months during the period of the study were 11 and 5 deaths/1000/180 days respectively. Fifty-eight deaths (55%) occurred within 45 days of discharge and 81 (77%) occurred in the first 90 days. On univariate analysis, children who died were more likely than children who survived to present in Basse than peripheral clinics, have a longer duration of illness, have no cough or difficulty breathing, have prostration, diarrhea, lower temperature, lower heart rate, lower respiratory rate, lower oxygen saturation, lower hemoglobin concentration, lower values of nutritional indices, lethargy, an absence of chest wall indrawing, nasal flaring, crackles, and wheeze, but have neck stiffness, a longer duration of admission, a standardised diagnosis of septicemia rather than pneumonia, multiple clinical diagnoses, bacteremia, be transferred from Basse, be not recovering on discharge and be discharged against medical advice.
“The risk of death was reduced by 2% with each increasing month of age. Clinically severe malnutrition was present in 52 of 105 (50%) children who died and 300 of 3630 (8.3%) who survived. The increased risk of death associated with CSM was greatest in the first 2 months after discharge but remained during months 2 to 6 of follow-up. The multivariable model using clinical syndrome on admission showed that children with suspected pneumonia without CSM had the lowest risk of post-discharge mortality. This risk was increased approximately two fold in children with suspected meningitis or septicaemia without CSM. The risk of post-discharge mortality was increased substantially in children with CSM. Compared to children with the clinical syndrome of pneumonia without CSM, those with pneumonia and CSM had 8 times (95% CI 4 to 15) the risk of death, those with suspected sepsis and CSM had 18 times (95% CI 11 to 30) the risk of death and those with suspected meningitis and CSM had 14 times (95% CI 4 to 45) the risk of death.”
The research was funded by Bill & Melinda Gates Foundation, Medical Research Council (UK), and the University of Otago.
The study was jointly done by Centre for International Health, University of Otago, Dunedin, New Zealand, Medical Research Council (UK), The Gambia Unit, Fajara, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, United Kingdom and Infection & Immunity Theme, Murdoch Childrens Research Institute, Melbourne, Australia.
The title of the research article is “Child Mortality after Discharge from a Health Facility following Suspected Pneumonia, Meningitis or Septicaemia in Rural Gambia: A Cohort Study”
The researchers said the Millennium Development Goal 4 goal of reducing under-5 mortality by two-thirds by 2015 is unlikely to be met in many countries, especially West Africa where “Infectious diseases are responsible for nearly two-thirds of these deaths and under-nutrition is a contributing factor in at least a third”.
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