Child Mortality after Discharge from a Health Facility following Suspected Pneumonia, Meningitis or Septicaemia in Rural Gambia: A Cohort Study.
OBJECTIVE
To measure mortality and its risk factors among children discharged from a health centre in rural Gambia.


METHODS
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.


RESULTS
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). Independent associations with mortality were: mid-upper arm circumference (MUAC) of 11.5-13.0 cm compared to >13.0 cm (HR 7.2; 95% CI 3.0 to 17.0), MUAC 10.5-11.4 cm (HR 24; 95% CI 9.4 to 62), and MUAC <10.5 cm (HR 44; 95% CI 18 to 108), neck stiffness (HR 10.4; 95% CI 3.1 to 34.8), non-medical discharge (HR 4.7; 95% CI 2.0 to 10.9), dry season discharge (HR 2.0; 95% CI 1.2 to 3.3), while greater haemoglobin (HR 0.82; 0.73 to 0.91), axillary temperature (HR 0.71; 95% CI 0.58 to 0.87), and oxygen saturation (HR 0.96; 95% CI 0.93 to 0.99) were associated with reduced mortality.


CONCLUSIONS
Gambian children experience increased mortality after discharge from primary and secondary care. Interventions should target both moderately and severely malnourished children.
Centre for International Health, University of Otago, Dunedin, New Zealand.
Aakash Varun
AV
Chhibber
Centre for International Health, University of Otago, Dunedin, New Zealand.
Philip C
PC
Hill
Medical Research Council (UK), The Gambia Unit, Fajara, The Gambia.
James
J
Jafali
Medical Research Council (UK), The Gambia Unit, Fajara, The Gambia.
Momodou
M
Jasseh
Medical Research Council (UK), The Gambia Unit, Fajara, The Gambia.
Mohammad Ilias
MI
Hossain
Medical Research Council (UK), The Gambia Unit, Fajara, The Gambia.
Malick
M
Ndiaye
Medical Research Council (UK), The Gambia Unit, Fajara, The Gambia.
Jayani C
JC
Pathirana
Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, United Kingdom.
Brian
B
Greenwood
Medical Research Council (UK), The Gambia Unit, Fajara, The Gambia; Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, United Kingdom; Infection & Immunity Theme, Murdoch Childrens Research Institute, Melbourne, Australia.
Grant A
GA
Mackenzie
D002648:Child; D046688:Child Mortality; D015362:Child Nutrition Disorders; D002675:Child, Preschool; D015331:Cohort Studies; D005260:Female; D005714:Gambia; D006760:Hospitalization; D006801:Humans; D007223:Infant; D008297:Male; D008581:Meningitis / Q000401:mortality* / Q000503:physiopathology; D010351:Patient Discharge; D011014:Pneumonia / Q000401:mortality* / Q000503:physiopathology; D012424:Rural Population; D018805:Sepsis / Q000401:mortality* / Q000503:physiopathology