Epidemiology of pediatric post-discharge mortality in 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. This study aims to describe the epidemiology of post-discharge mortality in a group of children admitted for suspected sepsis in Rwanda. 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. Findings: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. Ethics Declaration: 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).

背景：在撒哈拉以南非洲（Sub-Saharan Africa），儿科出院后死亡已被越来越多地认为是儿童死亡的重要诱因之一。为管控此阶段的发病率与死亡率，在整个撒哈拉以南非洲地区构建具有代表性的证据基础，用以指导资源优先级配置、政策制定与指南完善，至关重要。截至目前，卢旺达境内尚未开展相关研究，这限制了学界对该地区出院后死亡流行病学特征的认知。本研究旨在描述卢旺达因疑似脓毒症（suspected sepsis）住院的儿童群体的出院后死亡流行病学特征。
方法：本研究于2022年5月至2023年2月期间，在卢旺达的两家医疗机构前瞻性招募0~60月龄的疑似脓毒症住院儿童：分别为位于穆桑泽的鲁亨盖里转诊医院（农村地区），以及位于基加利的基加利大学教学医院（城市地区）。研究人员在患儿入院时收集其临床、实验室及社会人口学变量。患儿出院后，研究团队对其进行最长6个月的随访，以明确其生存状态与就医行为。本研究预先设定两个年龄分层队列：0~6月龄组与6~60月龄组，并分别进行数据分析。采用多因素logistic回归分析识别出院后死亡的危险因素；采用年龄分层的Kaplan-Meier曲线（Kaplan-Meier Curve）估算6个月出院后死亡的累积风险。
结果：本研究共纳入1218名儿童，其中115例死亡（占比11%）：50%为住院期间死亡（n=57），50%为出院后死亡（n=58）。0~6月龄队列的出院后死亡率（28/274，10%）高于6~60月龄队列（30/850，4%）；基加利院区的出院后死亡率（37/413，9%）高于鲁亨盖里院区（21/805，3%）。出院后死亡的中位时间约为1个月（0~6月龄组为38天，6~60月龄组为33天）。在两个队列中，年龄别体重Z评分（weight-for-age z-score）<-3均与出院后死亡风险升高显著相关（0~6月龄组：比值比（Odds Ratio, OR）=3.16，95%置信区间（95%CI）1.26~7.93；6~60月龄组：OR=7.44，95%CI 2.93~18.89）；而母亲受教育程度较高则为保护因素（0~6月龄组：OR=0.15，95%CI 0.03~0.85；6~60月龄组：OR=0.09，95%CI 0.02~0.75）。在6~60月龄组中，异常昏迷评分（OR=3.29，95%CI 1.47~7.38）、往返就医时间>2小时（OR=4.63，95%CI 1.40~15.22）以及转诊至更高层级医疗机构（OR=4.09，95%CI 1.04~16.12）均为出院后死亡的独立危险因素。年龄更小的儿童累积死亡风险最高。
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（审批号：411/CMHS IRB/2021）、基加利大学教学医院（审批号：EC/CHUK/005/2022）、加州大学旧金山分校（审批号：381688）以及不列颠哥伦比亚大学（审批号：H21-02795）的伦理批准。