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Epidemiology of pediatric post-discharge mortality in Rwanda
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Umuhoza, Christian; Zhang, Cherri; Hooft, Anneka; Trawin, Jessica; Uwiragiye, Emmanuel; Mfuranziza, Cynthia Grace; Nguyen, Vuong; Lewis, Peter; Kornblith, Aaron E; Kenya-Mughisha, Nathan; Wiens, Matthew O — 2024-04-18 <br/><strong>Background:</strong>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.<br /> <br /><strong>Methods:</strong> 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.<br /> <br /><strong>Findings:</strong>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.<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 />
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Validation of a risk-prediction model for pediatric post-discharge mortality at two hospitals in Rwanda
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Hooft, Anneka; Kornblith, Aaron E; Umhoza, Christian; Trawin, Jessica; Mfuranziza, Cynthia Grace; Uwiragiye, Emmanuel; Zhang, Cherri; Nguyen, Vuong; Lewis, Peter; Wiens, Matthew O — 2024-04-11 <br /><strong>NOTE for restricted files:</strong> If you are not yet a CoLab member, please complete our <a href = "https://rc.bcchr.ca/redcap/surveys/?s=EDCYL7AC79">membership application survey</a> to gain access to restricted files within 2 business days. <br />Some files may remain restricted to CoLab members. These files are deemed more sensitive by the file owner and are meant to be shared on a case-by-case basis. Please contact the CoLab coordinator at <a href = mailto:sepsiscolab@bccchr.ca>sepsiscolab@bcchr.ca</a> or visit our <a href = "https://wfpiccs.org/pediatric-sepsis-colab/">website</a>. <br/><strong>Background:</strong>Mortality following hospital discharge remains a significant threat to child health, particularly in resource-limited settings. In Uganda, the Smart Discharges risk-prediction models have demonstrated success in their ability to predict those at highest risk of death after discharge and use this to guide a risk-based approach to post-discharge care in children admitted with suspected sepsis. Respective prediction models for post-discharge mortality in ages 0-6 months and ages 6-60 months were developed in this cohort but have not yet been validated outside of Uganda. This study aimed to externally validate existing risk prediction models for pediatric post-discharge mortality within the Rwandan context.<br /> <br /><strong>Methods:</strong> Prospective cohort of children 0d-60 mos admitted with suspected sepsis at two hospitals in Rwanda: Ruhengeri Referral Hospital in Musanze (rural) and University Hospital of Kigali in Kigali (urban) from May 2022 to February 2023. Vital status follow up was conducted at 2-, 4- and 6-months post-discharge.<br /> <br />Five existing models from Smart Discharges Uganda were validated in this cohort: two models for children 0-6 months, and three for children 6-60 months. Models were applied to each participant in the Rwanda cohort to obtain a risk score which was then used to calculate predicted probability of post-discharge death. Model performance was evaluated by comparing to observed outcomes and to determine sensitivity, specificity, and AUROC. Threshold was set at 80% sensitivity. .<br /> <br /><strong>Findings:</strong>In a cohort of 1218 children, 1123 children (96.7%) completed follow up. The overall rate of post-discharge mortality was 4.8% (n=58). The highest performing models had an AUROC of 0.75 (0-6 mos) and 0.74 (6-60mos), respectively. All five prediction models tested achieved an AUROC greater than 0.7 (range 0.706 - 0.738). Model degradation (determined by the percent reduction in AUC between the original model and the derived model) was relatively low, ranging from from 1.1% to 7.7%. Calibration plots showed good calibration for all models at predicted probabilities below 10%. There were too few outcomes to assess calibration among those at higher levels of predicted risk. <br /> <br /><strong>Data Processing Methods:</strong> <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 />
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Smart Discharges to improve post-discharge health outcomes in children in Rwanda
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Umuhoza, Christian; Hooft, Anneka; Uwiragiye, Emmanuel; Kornblith, Aaron; Wiens, Matthew O — 2024-07-22 <p><strong>Background:</strong> The Smart Discharges studies in Uganda have enrolled over 10,000 children under-five with sepsis and have shown that death after hospital discharge occurs in 5-8% of patients, which is as common as death during the primary admission. The Smart Discharges evidence-based risk-prediction tool guides clinical interventions focused on education and post-discharge follow-up and improves healthcare-seeking behaviors and essential medical interventions among vulnerable children. Most importantly, these studies have preliminarily demonstrated that the prediction tool paired with these clinical interventions may substantially reduce post-discharge mortality up to 20-30%; however, these findings have not been validated outside of Uganda. The Smart Discharges project is now ready to expand the project borders and begin external validation research of the prediction tool in Rwanda. <br> <br><strong>Objective(s):</strong> This study aims to: (1) characterize the epidemiology of post-discharge mortality among a representative cohort of 1000 children under 5 years of age from two hospitals in Rwanda; and (2) externally validate the Smart Discharges risk-prediction tool in a representative cohort of children from Rwanda. <br> <br><strong>Methods:</strong> This study is a prospective observational cohort study that will be conducted between February 2022 and May 2023 at 2 hospitals in Northern and Central Rwanda, the University Teaching Hospital of Kigali (CHUK) in Nyarugenge District and Ruhengeri Referral Hospital in Musanze District. The study will enroll 1,000 children under 5 years of age between the two study sites. Following enrollment a research nurse will obtain and record clinical and demographic variables required for model validation including vital signs, oxygen saturation, anthropometric data, prior care seeking, co-morbidities and diagnoses. A rapid diagnostic test using blood, which will require a finger prick to collect < 0.5ml of blood, will be conducted to assess the patient's HIV status, malaria parasitemia, lactate, and hemoglobin (hemocue). All enrolled children will receive phone follow-up from study staff at 2-, 4- and 6 months following hospital discharge for research purposes. Verbal autopsies, often used in this context to determine cause of death, will be conducted for all children who die following discharge.<br> <br><strong>Ethics Declaration:</strong> Institutional review boards at the University of British Columbia (H21-02795), the University of California San Francisco (21-34663), the University Teaching Hospital of Kigali (EC/CHUK/1/005/2022), and the University of Uganda (No 573/CMHS IRB/2022) approved the study.</p> <br /><strong>NOTE for restricted files:</strong> If you are not yet a CoLab member, please complete our <a href = "https://rc.bcchr.ca/redcap/surveys/?s=EDCYL7AC79">membership application survey</a> to gain access to restricted files within 2 business days. <br />Some files may remain restricted to CoLab members. These files are deemed more sensitive by the file owner and are meant to be shared on a case-by-case basis. Please contact the CoLab coordinator at <a href = mailto:sepsiscolab@bccchr.ca>sepsiscolab@bcchr.ca</a> or visit our <a href = "https://wfpiccs.org/pediatric-sepsis-colab/">website</a>.

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(Source Repository: UBC Dataverse) AND (Author: Uwiragiye, Emmanuel)

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