Senior-Lecturer University of Rwanda Kigali, Kigali, Rwanda
Background: In Sub-Saharan Africa, pediatric post-discharge death is increasingly recognized as an important contributor to mortality. To address morbidity and mortality during this period, it is critical to generate a representative evidence base throughout sub-Saharan Africa to inform resource prioritization, as well as policy and guideline development. To date, no studies have been conducted in Rwanda, limiting the understanding of the epidemiology of post-discharge mortality in this region. Objective: This study aims to describe the epidemiology of post-discharge mortality in a group of children admitted for suspected sepsis in Rwanda. Design/Methods: We prospectively recruited children aged 0-60 months admitted for suspected sepsis at two sites in Rwanda: Ruhengeri Referral Hospital in Musanze, Rwanda (rural) and University Hospital of Kigali in Kigali, Rwanda (urban) from May 2022 - February 2023. Clinical, laboratory and social variables were collected at admission. Following discharge, participants were followed up to 6 months to determine vital status and health-seeking. We analyzed data in two age-specific cohorts, defined a priori: 0-6m and 6-60m. Multivariate logistic regression was used to identify risk factors. Age-stratified Kaplan-Meier curves were used to estimate the cumulative hazard of 6-month post-discharge mortality. Results: Of 1218 children enrolled, 115 died (11%): 50% in-hospital (n=57) and 50% after discharge (n=58). Post-discharge mortality was higher in 0-6m cohort (n=28/274, 10%) than in those 6-60m (30/850, 4%), and in Kigali (n=37/413, 9%) vs Ruhengeri (n=21/805, 3%). Median time to post-discharge death was ~1 month (38d in 0-6m; 33d in 6-60m). In both cohorts, increased odds of post-discharge death were associated with weight-for-age z-score <-3 (OR=3.16 (1.26-7.93), 0-6m; OR=7.44 (2.93-18.89), 6-60m) while higher maternal education was protective (OR=0.15 (0.03-0.85), 0-6m; OR=0.09 (0.02-0.75), 6-60m). Abnormal coma scale (OR=3.29 (1.47-7.38)), travel time of >2h (OR=4.63 (1.40-15.22)) and being referred for higher level of care (OR=4.09 (1.04-16.12)) were significant in 6-60 months. Younger children were at highest risk of cumulative mortality.
Conclusion(s): Pediatric post-discharge death is common in Rwanda, particularly in children under age 6 months, and associated with risk factors present on admission. Mortality rates varied substantially between a rural referral hospital and an urban university hospital, suggesting more studies are needed in Rwanda and similar contexts to understand post-discharge death and inform hospital-based and public health strategies for prevention.
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