Abstract
Severity scores are used to improve triage of hospitalized patients in high-income settings, but the scores may not translate well to low- and middle-income settings such as sub-Saharan Africa. To assess the performance of the Universal Vital Assessment (UVA) score, derived in 2017, compared with other illness severity scores for predicting in-hospital mortality among adults with febrile illness in northern Tanzania. This prognostic study used clinical data collected for the duration of hospitalization among patients with febrile illness admitted to Kilimanjaro Christian Medical Centre or Mawenzi Regional Referral Hospital in Moshi, Tanzania, from September 2016 through May 2019. All adult and pediatric patients with a history of fever within 72 hours or a tympanic temperature of 38.0 °C or higher at screening were eligible for enrollment. Of 3761 eligible participants, 1132 (30.1%) were enrolled in the parent study; of those, 597 adults 18 years or older were included in this analysis. Data were analyzed from December 2019 to September 2021. Modified Early Warning Score (MEWS), National Early Warning Score (NEWS), quick Sequential Organ Failure Assessment (qSOFA), Systemic Inflammatory Response Syndrome (SIRS) assessment, and UVA. The main outcome was in-hospital mortality during the same hospitalization as the participant's enrollment. Crude risk ratios and 95% CIs for in-hospital death were calculated using log-binomial risk regression for proposed score cutoffs for each of the illness severity scores. The area under the receiver operating characteristic curve (AUROC) for estimating the risk of in-hospital death was calculated for each score. Among 597 participants, the median age was 43 years (IQR, 31-56 years); 300 participants (50.3%) were female, 198 (33.2%) were HIV-infected, and in-hospital death occurred in 55 (9.2%). By higher risk score strata for each score, compared with lower risk strata, risk ratios for in-hospital death were 3.7 (95% CI, 2.2-6.2) for a MEWS of 5 or higher; 2.7 (95% CI, 0.9-7.8) for a NEWS of 5 or 6; 9.6 (95% CI, 4.2-22.2) for a NEWS of 7 or higher; 4.8 (95% CI, 1.2-20.2) for a qSOFA score of 1; 15.4 (95% CI, 3.8-63.1) for a qSOFA score of 2 or higher; 2.5 (95% CI, 1.2-5.2) for a SIRS score of 2 or higher; 9.1 (95% CI, 2.7-30.3) for a UVA score of 2 to 4; and 30.6 (95% CI, 9.6-97.8) for a UVA score of 5 or higher. The AUROCs, using all ordinal values, were 0.85 (95% CI, 0.80-0.90) for the UVA score, 0.81 (95% CI, 0.75-0.87) for the NEWS, 0.75 (95% CI, 0.69-0.82) for the MEWS, 0.73 (95% CI, 0.67-0.79) for the qSOFA score, and 0.63 (95% CI, 0.56-0.71) for the SIRS score. The AUROC for the UVA score was significantly greater than that for all other scores (P < .05 for all comparisons) except for NEWS (P = .08). This prognostic study found that the NEWS and the UVA score performed favorably compared with other illness severity scores in predicting in-hospital mortality among a hospitalized cohort of adults with febrile illness in northern Tanzania. Given its reliance on readily available clinical data, the UVA score may have utility in the triage and prognostication of patients admitted to the hospital with febrile illness in low- to middle-income settings such as sub-Saharan Africa.
Highlights
Infectious diseases are a leading cause of acute illness, disability, and death worldwide.[1,2] Despite efforts to improve scientific knowledge of febrile illness in low- and middle-income countries (LMICs),[3,4,5,6,7] the tools available to improve management of such acute illness remain inadequate.A major component of research on the management of acute febrile illness focuses on the appropriate identification and triage of severely ill patients once they reach the health care system
By higher risk score strata for each score, compared with lower risk strata, risk ratios for in-hospital death were 3.7 for a Modified Early Warning Score (MEWS) of 5 or higher; 2.7 for a National Early Warning Score (NEWS) of 5 or 6; 9.6 for a NEWS of 7 or higher; 4.8 for a quick Sequential Organ Failure Assessment (qSOFA) score of 1; 15.4 for a qSOFA score of 2 or higher; 2.5 for a Systemic Inflammatory Response Syndrome (SIRS) score of 2 or higher; 9.1 for a Universal Vital Assessment (UVA) score of 2 to 4; and 30.6 for a UVA score of 5 or higher
The area under the receiver operating characteristic curve (AUROC), using all ordinal values, were 0.85 for the UVA score, 0.81 for the NEWS, 0.75 for the MEWS, 0.73 for the qSOFA score, and 0.63 for the SIRS score
Summary
Infectious diseases are a leading cause of acute illness, disability, and death worldwide.[1,2] Despite efforts to improve scientific knowledge of febrile illness in low- and middle-income countries (LMICs),[3,4,5,6,7] the tools available to improve management of such acute illness remain inadequate.A major component of research on the management of acute febrile illness focuses on the appropriate identification and triage of severely ill patients once they reach the health care system. Infectious diseases are a leading cause of acute illness, disability, and death worldwide.[1,2] Despite efforts to improve scientific knowledge of febrile illness in low- and middle-income countries (LMICs),[3,4,5,6,7] the tools available to improve management of such acute illness remain inadequate. In high-income countries, several illness severity scores have been developed for patients with severe illness, including patients with febrile illness.[8,9,10] most such models were developed entirely within high-income settings. It is unsurprising that studies of existing illness severity scores derived in high-income countries have shown mixed results for predictive performance for adverse outcomes in LMICs.[12,13,14,15,16]
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