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Variations in mortality in children admitted with pneumonia to Kenyan hospitals

Philip Ayieko¹, Emelda A Okiro, Tansy Edwards

¹Health Services Research Group, Centre for Geographic Medicine Research - Coast, Kenya Medical Research Institute/Wellcome Trust Research Programme, Nairobi, Kenya. payieko@nairobi.kemri-wellcome.org

|November 10, 2012

Insights

Childhood pneumonia case fatality rates varied significantly between Kenyan hospitals, even after conjugate vaccine introduction. These hospital-specific variations in mortality require consideration for resource allocation to improve child health outcomes.

Area of Science:

Pediatric Infectious Diseases
Global Health Epidemiology
Health Services Research

Background:

Existing childhood pneumonia case fatality estimates in developing nations often predate widespread conjugate vaccine use.
Few studies have investigated hospital-level variations in pediatric pneumonia mortality.
This study examines pneumonia case fatality rates in Kenyan hospitals during the era of routine Hib conjugate vaccine immunization.

Purpose of the Study:

To determine if significant variations in case fatality rates for childhood pneumonia exist between nine Kenyan hospitals.
To analyze pneumonia mortality trends in relation to Hib conjugate vaccine introduction.

Main Methods:

Retrospective analysis of pneumonia admissions and outcomes in pediatric wards from 2007-2008 (9 hospitals) and 1999-2008 (1 hospital).
Fixed effect binomial regression with logit link was used to model hospital case fatality rates.
Interrupted time series design analyzed trends in pneumonia mortality before and after Hib vaccine introduction.

Main Results:

Overall hospital case fatality for childhood pneumonia was 5.9% (195 deaths).
Mortality was significantly associated with child's age and pneumonia severity.
Significant variations in mortality were observed between hospitals (p<0.001), independent of temporal changes.

Conclusions:

Substantial variations in hospital-based pneumonia case fatality exist in Kenya.
These variations are not explained by temporal trends or vaccine introduction.
Addressing these hospital-specific disparities is crucial for effective resource allocation and improving child health.

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Abstract

Background:

The existing case fatality estimates of inpatient childhood pneumonia in developing countries are largely from periods preceding routine use of conjugate vaccines for infant immunization and such primary studies rarely explore hospital variations in mortality. We analysed case fatality rates of children admitted to nine Kenyan hospitals with pneumonia during the era of routine infant immunization with Hib conjugate vaccine to determine if significant variations exist between hospitals.

Methods:

Pneumonia admissions and outcomes in paediatric wards are described using data collected over two time periods: a one-year period (2007-2008) in nine hospitals, and data from a 9.25-year period (1999-March 2008) in one of the participating hospitals. Hospital case fatality rates for inpatient pneumonia during 2007 to 2008 were modeled using a fixed effect binomial regression model with a logit link. Using an interrupted time series design, data from one hospital were analysed for trends in pneumonia mortality during the period between 1997 and March 2008.

Results:

Overall, 195 (5.9%) children admitted to all 9 hospitals with pneumonia from March 2007 to March 2008 died in hospital. After adjusting for child's sex, comorbidity, and hospital effect, mortality was significantly associated with child's age (p<0.001) and pneumonia severity (p<0.001). There was evidence of significant variations in mortality between hospitals (LR χ(2) =52.19; p<0.001). Pneumonia mortality remained stable in the periods before (trend -0.03, 95% CI -0.1 to 0.02) and after Hib introduction (trend 0.04, 95% CI -0.04 to 0.11).

Conclusions:

There are important variations in hospital-pneumonia case fatality in Kenya and these variations are not attributed to temporal changes. Such variations in mortality are not addressed by existing epidemiological models and need to be considered in allocating resources to improve child health.

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