Childhood mortality during and after acute illness in sub-Saharan Africa and South Asia - The CHAIN cohort study
Authors: Diallo Abdoulaye Hama , Sayeem Bin Shahid Abu Sadat Mohammad , Khan Al Fazal , Saleem Ali Faisal , Singa Benson O. , Gnoumou Blaise Siézan , Tigoi Caroline , Achieng Catherine , Bourdon Celine , Oduol Chris , Lancioni Christina L. , Manyasi Christine , McGrath Christine J. , Maronga Christopher , Lwanga Christopher , Brals Daniella , Ahmed Dilruba , Mondal Dinesh , Denno Donna M. , Mangale Dorothy I. , Chimezi Emmanuel , Mbale Emmie , Mupere Ezekiel , Mamun Gazi Md. Salauddin , Ouédraogo Issaka , Berkley James A. , Njirammadzi Jenala , Mukisa John , Thitiri Johnstone , Carreon Joseph D. , Walson Judd L. , Jemutai Julie , Tickell Kirkby D. , Shahrin Lubaba , Mallewa MacPherson , Hossain Md. Iqbal , Chisti Mohammod Jobayer , Timbwa Molly , Mburu Moses , Ngari Moses , Ngao Narshion , Aber Peace , Harawa Philliness Prisca , Sukhtankar Priya , Bandsma Robert H. J. , Bamouni Roseline Maïmouna , Molyneux Sassy , Mwaringa Shalton , Shaima Shamsun Nahar , Ali Syed Asad , Afsana Syeda Momena , Banu Syera , Ahmed Tahmeed , Voskuijl Wieger P. , Kazi Zaubina 
Published: November 2021

Objectives

Mortality during acute illness among children in low- and middle-income settings remain unacceptably high and there is increasing recognition of the importance of post-discharge mortality. A comprehensive understanding of pathways underlying mortality among acutely ill children is needed to develop interventions and improve guidelines. We aimed to determine the incidence, timing and contributions of proximal and underlying exposures for mortality among acutely ill young children from admission to hospital until 6 months after discharge in sub-Saharan Africa and South Asia in the context of guideline-based care.

Design

A prospective stratified cohort study recruiting acutely ill children at admission to hospital with follow up until 180 days after discharge from hospital (November 2016-July 2019).

Setting

Nine urban and rural hospitals in sub-Saharan Africa and South Asia across a range of facility levels, and local prevalences of HIV and malaria.

Participants

Inclusion criteria were age 2-23 months, admission to hospital with acute, non-traumatic medical illness and stratified into three groups by anthropometry. Children were excluded if currently receiving pulmonary resuscitation, had a known condition requiring surgery within 6 months or known terminal illness with death expected within 6 months.

Main outcome measures

Acute mortality occurring within 30-days from admission; post-discharge mortality within 180-days from discharge; characteristics with direct and indirect associations with mortality within a multi-level a priori framework including demographic, clinical, anthropometric characteristics at admission and discharge from hospital, and pre-existing child-, caregiver- and household-level characteristics.

Results

Of 3101 participants (median age 11 months), 1218 were severely wasted/kwashiorkor, 763 moderately wasted and 1120 were not wasted. Of 350 deaths, 182 (52%) occurred during index admission, 234 (67%) within 30-days of admission and 168 (48%) within 180-days post-discharge. Ninety (54%) post-discharge deaths occurred at home. The ratio of inpatient to post-discharge mortality was consistent across anthropometric strata and sites. Large high and low risk groups could be disaggregated for both early and post-discharge mortality. Structural equation models identified direct pathways to mortality and multiple socioeconomic, clinical and nutritional domains acting indirectly through anthropometric status.

Conclusions

Among diverse sites in Africa and South Asia, almost half of mortality occurs post-discharge. Despite being highly predictable, these deaths are not addressed in current guidelines. A fundamental shift to a risk-based approach to inpatient and post-discharge management is needed to further reduce childhood mortality and clinical trials of these approaches with outcomes of mortality, readmission and cost are warranted.

Trial Registration

ClinicalTrials.gov: NCT03208725