DOI: 10.14288/1.0422389
title: Mortality after hospital discharge among children younger than 5 years admitted with suspected sepsis in Uganda: a prospective, multisite, observational cohort study

description: &lt;br /&gt;&lt;strong&gt;Background:&lt;/strong&gt; Substantial mortality occurs after hospital discharge in children younger than 5 years with suspected sepsis, especially in low-income countries. A better understanding of its epidemiology is needed for effective interventions to reduce child mortality in these countries. We evaluated risk factors for death after discharge in children admitted to hospital for suspected sepsis in Uganda, and assessed how these differed by age, time of death, and location of death. &lt;br /&gt; &lt;br /&gt;&lt;strong&gt;Methods:&lt;/strong&gt; In this prospective observational cohort study, we recruited 0-60-month-old children admitted with suspected sepsis from the community to the paediatric wards of six Ugandan hospitals. The primary outcome was six-month post-discharge mortality among those discharged alive. We evaluated the interactive impact of age, time of death, and location of death on risk factors for mortality.&lt;br /&gt; &lt;br /&gt;&lt;strong&gt;Findings:&lt;/strong&gt; 6,545 children were enrolled, with 6,191 discharged alive. The median (interquartile range) time from discharge to death was 28 (9-74) days, with a six-month post-discharge mortality rate of 5·5%, constituting 51% of total mortality. Deaths occurred at home (45%), in-transit to care (18%), or in hospital (37%) during a subsequent readmission. Post-discharge death was strongly associated with weight-for-age z-scores &lt; -3 (adjusted risk ratio [aRR] 4·7, 95% CI 3·7–5·8 vs a Z score of &gt;–2), referral for further care (7·3, 5·6–9·5), and unplanned discharge (3·2, 2·5–4·0). The hazard ratio of those with severe anaemia increased with time since discharge, while the hazard ratios of discharge vulnerabilities (unplanned, poor feeding) decreased with time. Age influenced the effect of several variables, including anthropometric indices (less impact with increasing age), anaemia (greater impact), and admission temperature (greater impact).&lt;br /&gt; &lt;br /&gt;&lt;strong&gt;Data Collection Methods:&lt;/strong&gt; All data were collected at the point of care using encrypted study tablets and these data were then uploaded to a Research Electronic Data Capture (REDCap) database hosted at the BC Children’s Hospital Research Institute (Vancouver, Canada). At admission, trained study nurses systematically collected data on clinical, social and demographic variables. Following discharge, field officers contacted caregivers at 2 and 4 months by phone, and in-person at 6 months, to determine vital status, post-discharge health-seeking, and readmission details. Verbal autopsies were conducted for children who had died following discharge.&lt;br /&gt; &lt;br /&gt;&lt;strong&gt;Data Processing Methods:&lt;/strong&gt; For this analysis, data from both cohorts (0-6 months and 6-60 months) were combined and analysed as a single dataset. We used periods of overlapping enrolment (72% of total enrolment months) between the two cohorts to determine site-specific proportions of children who were 0-6 and 6-60 months of age. These proportions were used to weight the cohorts for the calculation of overall mortality rate. Z-scores were calculated using height and weight. Hematocrit was converted to hemoglobin. Distance to hospital was calculated using latitude and longitude. Extra symptom and diagnosis categories were created based on text field in these two variables. BCS score was created by summing all individual components.&lt;br /&gt; &lt;br /&gt;&lt;strong&gt;Abbreviations:&lt;/strong&gt;&lt;br /&gt; MUAC -mid upper arm circumference&lt;br /&gt; wfa – weight for age&lt;br /&gt; wfl – weight for length&lt;br /&gt; bmi – body mass index&lt;br /&gt; lfa – length for age&lt;br /&gt; abx - antibiotics&lt;br /&gt; hr – heart rate&lt;br /&gt; rr – respiratory rate&lt;br /&gt; antimal - antimalarial&lt;br /&gt; sysbp – systolic blood pressure&lt;br /&gt; diasbp – diastolic blood pressure&lt;br /&gt; resp – respiratory&lt;br /&gt; cap - capillary&lt;br /&gt; BCS - Blantyre Coma Scale&lt;br /&gt; dist- distance&lt;br /&gt; hos - hospital&lt;br /&gt; ed - education&lt;br /&gt; disch - discharge&lt;br /&gt; dis -discharge&lt;br /&gt; fu – follow-up&lt;br /&gt; pd – post-discharge&lt;br /&gt; loc - location&lt;br /&gt; materl - maternal&lt;br /&gt; &lt;br /&gt;&lt;strong&gt;Ethics Declaration:&lt;/strong&gt; This study was approved by the Mbarara University of Science and Technology Research Ethics Committee (No. 15/10-16), the Uganda National Institute of Science and Technology (HS 2207), and the University of British Columbia / Children & Women’s Health Centre of British Columbia Research Ethics Board (H16-02679). This manuscript adheres to the guidelines for STrengthening the Reporting of OBservational studies in Epidemiology (STROBE).&lt;br /&gt; &lt;br /&gt;&lt;strong&gt;Study Protocol & Supplementary Materials:&lt;/strong&gt; &lt;br /&gt; &lt;a href = "https://borealisdata.ca/dataset.xhtml?persistentId=doi%3A10.5683%2FSP3%2FQRUMNQ&version=1.0"&gt;Smart Discharges to improve post-discharge health outcomes in children: A prospective before-after study with staggered implementation &lt;/a&gt;&lt;br /&gt;