Mortality and its risk factors in Malawian children admitted to hospital with clinical pneumonia, 2001–12: a retrospective observational study

Abstract

Summary 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. Findings 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%). Interpretation 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.

Development of HIV drug resistance and therapeutic failure in children and adolescents in rural Tanzania

“…As mentioned above, the additional counselling in patients on protease inhibitor-based second-line treatment might have slightly biased this finding. Girls were more vulnerable to virologic failure and the development of HIV-DRM for reasons that could not be explained in the framework of this study, but indeed sex inequalities were also found in other recent studies from East Africa [42]. …”

Predicting Hospitalised Paediatric Pneumonia Mortality Risk: An External Validation of RISC and mRISC, and Local Tool Development (RISC-Malawi) from Malawi

“…Clinical data was collected as part of routine care by healthcare workers using the standard CLHP inpatient case report forms [6]. Variables collected included: demographics, immunization status, past medical history, history of present illness, vital signs, anthropometrics, clinical exam findings on admission, HIV and malaria status, chest radiograph findings, and treatment course.…”

“…Variables collected included: demographics, immunization status, past medical history, history of present illness, vital signs, anthropometrics, clinical exam findings on admission, HIV and malaria status, chest radiograph findings, and treatment course. HIV and malaria testing, while recommended, were inconsistently available [6–8]. …”

“…Pneumonia was defined by clinical findings as per the Malawi Ministry of Health Case Management Guidelines [6] (Table 1). Some children were receiving supplemental oxygen while their transcutaneous peripheral capillary hemoglobin oxygen saturation (SpO 2 ) was obtained by study staff.…”

“…The CLHP included the introduction of national clinical pneumonia diagnosis and management guidelines (adapted from the 2000 World Health Organization (WHO) guidelines) and a nationwide case report form for all children admitted to hospitals with pneumonia [5]. Although there has been an overall reduction in the pneumonia case fatality rate (CFR) since implementing the CLHP, minimal declines were seen in subpopulations of higher risk children with clinical danger signs and severe acute malnutrition [6]. Multiple factors may contribute to this lack of improvement, including case misclassification with resultant incorrect antibiotic usage [7], inconsistent adherence to guidelines [8], human resource constraints, medication stockouts [9] and lack of pulse oximetry and oxygen availability [10].…”