title: Mortality and its risk factors in Malawian children admitted to hospital with clinical pneumonia, 2001-12: a retrospective observational study.
abstract: BACKGROUND
  Few studies have reported long-term data on mortality rates for children admitted to hospital with pneumonia in Africa. We examined trends in case fatality rates for all-cause clinical pneumonia and its risk factors in Malawian children between 2001 and 2012.
  
  
  METHODS
  Individual patient data for children (<5 years) with clinical pneumonia who were admitted to hospitals participating in Malawi's Child Lung Health Programme between 2001 and 2012 were recorded prospectively on a standardised medical form. We analysed trends in pneumonia mortality and children's clinical characteristics, and we estimated the association of risk factors with case fatality for children younger than 2 months, 2-11 months of age, and 12-59 months of age using separate multivariable mixed effects logistic regression models.
  
  
  RESULTS
  Between November, 2012, and May, 2013, we retrospectively collected all available hard copies of yellow forms from 40 of 41 participating hospitals. We examined 113 154 pneumonia cases, 104 932 (92·7%) of whom had mortality data and 6903 of whom died, and calculated an overall case fatality rate of 6·6% (95% CI 6·4-6·7). The case fatality rate significantly decreased between 2001 (15·2% [13·4-17·1]) and 2012 (4·5% [4·1-4·9]; ptrend<0·0001). Univariable analyses indicated that the decrease in case fatality rate was consistent across most subgroups. In multivariable analyses, the risk factors significantly associated with increased odds of mortality were female sex, young age, very severe pneumonia, clinically suspected Pneumocystis jirovecii infection, moderate or severe underweight, severe acute malnutrition, disease duration of more than 21 days, and referral from a health centre. Increasing year between 2001 and 2012 and increasing age (in months) were associated with reduced odds of mortality. Fast breathing was associated with reduced odds of mortality in children 2-11 months of age. However, case fatality rate in 2012 remained high for children with very severe pneumonia (11·8%), severe undernutrition (15·4%), severe acute malnutrition (34·8%), and symptom duration of more than 21 days (9·0%).
  
  
  CONCLUSIONS
  Pneumonia mortality and its risk factors have steadily improved in the past decade in Malawi; however, mortality remains high in specific subgroups. Improvements in hospital care may have reduced case fatality rates though a lack of sufficient data on quality of care indicators and the potential of socioeconomic and other improvements outside the hospital precludes adequate assessment of why case-fatality rates fell. Results from this study emphasise the importance of effective national systems for data collection. Further work combining this with data on trends in the incidence of pneumonia in the community are needed to estimate trends in the overall risk of mortality from pneumonia in children in Malawi.
  
  
  BACKGROUND
  Bill & Melinda Gates Foundation.
authors.affiliation: WHO Collaborating Centre for Maternal and Child Health, Institute for Maternal and Child Health IRCCS Burlo Garofolo, Trieste, Italy. Electronic address: marzia.lazzerini@burlo.trieste.it.
authors.forename: Marzia
authors.initials: M
authors.lastname: Lazzerini
authors.affiliation: Institute for Global Health, University College London, London, UK.
authors.forename: Nadine
authors.initials: N
authors.lastname: Seward
authors.affiliation: Acute Respiratory Infection Control Programme, Community Health Sciences Unit, Lilongwe, Malawi.
authors.forename: Norman
authors.initials: N
authors.lastname: Lufesi
authors.affiliation: Parent and Child Health Initiative (PACHI), Lilongwe, Malawi.
authors.forename: Rosina
authors.initials: R
authors.lastname: Banda
authors.affiliation: Parent and Child Health Initiative (PACHI), Lilongwe, Malawi.
authors.forename: Sophie
authors.initials: S
authors.lastname: Sinyeka
authors.affiliation: Parent and Child Health Initiative (PACHI), Lilongwe, Malawi.
authors.forename: Gibson
authors.initials: G
authors.lastname: Masache
authors.affiliation: Institute for Global Health, University College London, London, UK.
authors.forename: Bejoy
authors.initials: B
authors.lastname: Nambiar
authors.affiliation: Parent and Child Health Initiative (PACHI), Lilongwe, Malawi.
authors.forename: Charles
authors.initials: C
authors.lastname: Makwenda
authors.affiliation: Institute for Global Health, University College London, London, UK.
authors.forename: Anthony
authors.initials: A
authors.lastname: Costello
authors.affiliation: Institute for Global Health, University College London, London, UK; Johns Hopkins School of Medicine, Department of Pediatrics, Division of Pulmonology, Baltimore, MD, USA.
authors.forename: Eric D
authors.initials: ED
authors.lastname: McCollum
authors.affiliation: Institute for Global Health, University College London, London, UK. Electronic address: t.colbourn@ucl.ac.uk.
authors.forename: Tim
authors.initials: T
authors.lastname: Colbourn
mesh_terms: D002648:Child; D002675:Child, Preschool; D005260:Female; D006760:Hospitalization; D006801:Humans; D015994:Incidence; D007223:Infant; D007231:Infant, Newborn; D008295:Malawi / Q000453:epidemiology; D008297:Male; D009026:Mortality / Q000639:trends; D017063:Outcome Assessment, Health Care / Q000379:methods; D011014:Pneumonia / Q000145:classification / Q000401:mortality*; D012189:Retrospective Studies; D012307:Risk Factors; D012720:Severity of Illness Index