Post-Discharge Mortality in Suspected Pediatric Sepsis: Insights from Rural and Urban Healthcare Settings in Rwanda

<br/><strong>Background:</strong>Post-discharge death is a key contributor to pediatric mortality in sub-Saharan Africa. To address this period’s morbidity and mortality, evidence is needed to inform resource prioritization and policy development. No studies have been conducted in Rwanda, limiting understanding of post-discharge mortality. This study aimed to determine the incidence of and risk factors for post-discharge mortality among children under five admitted with suspected sepsis in Rwanda’s rural and urban healthcare settings.<br />

<br /><strong>Methods:</strong> We conducted a prospective, epidemiologic cohort study of post-discharge mortality in children ages 0–60 months admitted for suspected or confirmed infection in two Rwandan hospitals, one rural (Ruhengeri) and one urban (Kigali), from May 2022 to February 2023. We collected clinical, laboratory, and sociodemographic data on admission and follow-up vital statistics at 2-, 4-, and 6-months post-discharge.<br />

<br /><strong>Findings:</strong>Of 1218 children enrolled, 115 (9.4%) died, with half in-hospital (n = 57, 4.7%) and half post-discharge (n = 58, 4.7%). Post-discharge mortality was lower in the 6–60-month cohort (n = 30, 3.5%) than in the 0–6-month cohort (10%) and higher in Kigali (n = 37, 10.3%) vs. Ruhengeri (n = 21, 2.7%). Median time to post-discharge death was 38 days (IQR: 16-97.5) in the 0–6-month cohort and 33 days (IQR: 12–76) in the 6–60-month cohort. In the 0–6 months’ cohort, malnutrition (weight-for-age z-score < -3) increased the odds of post-discharge death (aOR 3.31, 95% CI 1.28-8.04), while higher maternal education was protective (aOR 0.15, 95% CI 0.03-0.85). Significant factors in the 6–60-month cohort included an abnormal Blantyre Coma Scale (aOR 3.28, 95% CI 1.47-7.34), travel time to care >;1 hour (aOR 3.54, 95% CI 1.26-9.93), and referral for higher care (aOR 4.13, 95% CI 1.05-16.27). Children aged <2 months within the 0–6 month cohort exhibited the highest cumulative mortality risk.<br />

<br /><strong>Interpretation:</strong>Post-discharge mortality among Rwandan children remains a challenge, requiring interventions like caregiver counselling, follow-up visits, and community health worker monitoring to reduce mortality rates. <br />

<br /><strong>Data Processing:</strong>For this analysis, data from both cohorts (0-6 months and 6-60 months) were combined and analysed as a single dataset. Z-scores were calculated using height and weight. Hematocrit was converted to hemoglobin. BCS score was created by summing all individual components. 

<br />Analyses were conducted in R version 4.1.3 (R Foundation for Statistical Computing, Vienna, Austria), and RStudio version 2022.2.3 (RStudio, Boston, MA). <br />

<br /><strong>Ethics Declaration:</strong> Ethical approval was obtained from the University of Rwanda College of Medicine and Health Sciences (No 411/CMHS IRB/2021); University Teaching Hospital of Kigali (EC/CHUK/005/2022), University of California San Francisco (381688) and the University of British Columbia (H21-02795).<br />

研究背景：出院后死亡是撒哈拉以南非洲地区儿科死亡的重要诱因之一。为有效应对该阶段的发病与死亡负担，亟需相关研究证据为资源优化配置与政策制定提供科学依据。目前卢旺达尚未开展相关研究，这极大限制了学界对出院后死亡情况的全面认知。本研究旨在明确卢旺达城乡医疗机构中，因疑似脓毒症（sepsis）收治的5岁以下儿童的出院后死亡率及其独立危险因素。

研究方法：我们于2022年5月至2023年2月间，针对卢旺达两家医疗机构（乡村医院鲁亨盖里（Ruhengeri）与城市医院基加利（Kigali））收治的0~60月龄疑似或确诊感染儿童，开展了一项关于出院后死亡的前瞻性流行病学队列研究。研究收集了患儿入院时的临床、实验室检查及社会人口学相关数据，并在患儿出院后2、4、6个月开展生命体征随访。

研究结果：本研究共纳入1218名儿童，其中115例（9.4%）发生死亡，院内死亡与出院后死亡各占一半，分别为57例（4.7%）与58例（4.7%）。6~60月龄队列的出院后死亡率（30例，3.5%）低于0~6月龄队列（10%）；基加利队列的出院后死亡率（37例，10.3%）高于鲁亨盖里队列（21例，2.7%）。0~6月龄队列的出院后死亡中位时间为38天（四分位间距（Interquartile Range, IQR）：16~97.5天），6~60月龄队列则为33天（IQR：12~76天）。在0~6月龄队列中，营养不良（年龄别体重Z评分＜-3）会显著升高出院后死亡风险（调整后优势比（adjusted Odds Ratio, aOR）=3.31，95%置信区间（Confidence Interval, CI）：1.28~8.04），而较高的母亲受教育程度则具有保护作用（aOR=0.15，95%CI：0.03~0.85）。6~60月龄队列的显著危险因素包括布兰泰尔昏迷量表（Blantyre Coma Scale, BCS）结果异常（aOR=3.28，95%CI：1.47~7.34）、就诊往返时间＞1小时（aOR=3.54，95%CI：1.26~9.93）以及转诊至上级医疗机构（aOR=4.13，95%CI：1.05~16.27）。0~6月龄队列中，月龄＜2个月的儿童累积死亡风险最高。

研究解读：卢旺达儿童的出院后死亡仍是一项亟待解决的公共卫生挑战，需通过照护者咨询指导、定期随访复诊与社区卫生工作者监测等干预措施，以降低出院后死亡率。

数据处理：本次分析将两个队列（0~6月龄与6~60月龄）的数据合并为单一数据集开展分析。利用身高与体重数据计算Z评分，将血细胞比容（Hematocrit）转换为血红蛋白（Hemoglobin）水平，并通过累加各分项得分构建布兰泰尔昏迷量表（BCS）评分。数据分析采用R 4.1.3版本（奥地利维也纳R统计计算基金会）与RStudio 2022.2.3版本（美国马萨诸塞州波士顿RStudio公司）完成。

伦理声明：本研究已获得卢旺达大学医学院与健康科学学院（批准号：411/CMHS IRB/2021）、基加利大学教学医院（批准号：EC/CHUK/005/2022）、加州大学旧金山分校（批准号：381688）以及不列颠哥伦比亚大学（批准号：H21-02795）的伦理审查批准。