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Post-discharge mortality in suspected pediatric sepsis: Insights from rural and urban healthcare settings in Rwanda
Christian Umuhoza1,2, Anneka Hooft3, Cherri Zhang4
1Department of Pediatrics, University Teaching Hospital of Kigali, Kigali, Rwanda.
Insights
Post-discharge deaths are a significant concern for children under five in Rwanda. This study identified key risk factors, including malnutrition and limited maternal education, to inform targeted interventions and reduce pediatric mortality.
Area of Science:
- Pediatric Infectious Diseases
- Epidemiology
- Global Health
Background:
- Post-discharge mortality is a critical yet understudied aspect of pediatric mortality in sub-Saharan Africa.
- Rwanda lacks specific data on post-discharge mortality among children admitted with suspected sepsis.
- Understanding these outcomes is vital for effective resource allocation and policy development.
Purpose of the Study:
- To determine the incidence of post-discharge mortality in children under five admitted with suspected sepsis in Rwanda.
- To identify risk factors associated with post-discharge mortality in both rural and urban Rwandan healthcare settings.
- To provide evidence for interventions aimed at reducing pediatric mortality.
Main Methods:
- Prospective, epidemiologic cohort study involving 1218 children aged 0-60 months admitted for suspected or confirmed infection.
- Data collection included clinical, laboratory, and sociodemographic information, with follow-up vital statistics at 2, 4, and 6 months post-discharge.
- Comparison of mortality rates and risk factors between rural (Ruhengeri) and urban (Kigali) settings, and across age cohorts (0-6 months vs. 6-60 months).
Main Results:
- Overall post-discharge mortality was 4.7% (58/1218), with half of all deaths occurring after hospital discharge.
- Mortality was higher in the 0-6 month age cohort (10%) compared to the 6-60 month cohort (3.5%), and in the urban setting (Kigali, 10.3%) versus the rural setting (Ruhengeri, 2.7%).
- Risk factors included malnutrition (weight-for-age z-score < -3) and lower maternal education in the 0-6 month cohort, and abnormal Blantyre Coma Scale, longer travel time to care, and referral for higher care in the 6-60 month cohort.
Conclusions:
- Post-discharge mortality remains a significant challenge for young children in Rwanda, particularly those under two months.
- Interventions focusing on caregiver counseling, follow-up visits, and community health worker engagement are crucial.
- Addressing malnutrition and improving access to care are key strategies to mitigate post-discharge deaths in Rwandan children.
Abstract:
Post-discharge death is a key contributor to pediatric mortality in sub-Saharan Africa. To address this period's morbidity and mortality, evidence is needed to inform resource prioritization and policy development. No studies have been conducted in Rwanda, limiting understanding of post-discharge mortality. This study aimed to determine the incidence of and risk factors for post-discharge mortality among children under five admitted with suspected sepsis in Rwanda's rural and urban healthcare settings. We conducted a prospective, epidemiologic cohort study of post-discharge mortality in children ages 0-60 months admitted for suspected or confirmed infection in two Rwandan hospitals, one rural (Ruhengeri) and one urban (Kigali), from May 2022 to February 2023. We collected clinical, laboratory, and sociodemographic data on admission and follow-up vital statistics at 2-, 4-, and 6-months post-discharge. Of 1218 children enrolled, 115 (9.4%) died, with half in-hospital (n = 57, 4.7%) and half post-discharge (n = 58, 4.7%). Post-discharge mortality was lower in the 6-60-month cohort (n = 30, 3.5%) than in the 0-6-month cohort (10%) and higher in Kigali (n = 37, 10.3%) vs. Ruhengeri (n = 21, 2.7%). Median time to post-discharge death was 38 days (IQR: 16-97.5) in the 0-6-month cohort and 33 days (IQR: 12-76) in the 6-60-month cohort. In the 0-6 months' cohort, malnutrition (weight-for-age z-score < -3) increased the odds of post-discharge death (aOR 3.31, 95% CI 1.28-8.04), while higher maternal education was protective (aOR 0.15, 95% CI 0.03-0.85). Significant factors in the 6-60-month cohort included an abnormal Blantyre Coma Scale (aOR 3.28, 95% CI 1.47-7.34), travel time to care >;1 hour (aOR 3.54, 95% CI 1.26-9.93), and referral for higher care (aOR 4.13, 95% CI 1.05-16.27). Children aged <2 months within the 0-6 month cohort exhibited the highest cumulative mortality risk. Post-discharge mortality among Rwandan children remains a challenge, requiring interventions like caregiver counselling, follow-up visits, and community health worker monitoring to reduce mortality rates.
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