Abstract
BackgroundPneumonia is the leading infectious cause of under-5 mortality in sub-Saharan Africa. Clinical prediction tools may aide case classification, triage, and allocation of hospital resources. We performed an external validation of two published prediction tools and compared this to a locally developed tool to identify children admitted with pneumonia at increased risk for in-hospital mortality in Malawi.MethodsWe retrospectively analyzed the performance of the Respiratory Index of Severity in Children (RISC) and modified RISC (mRISC) scores in a child pneumonia dataset prospectively collected during routine care at seven hospitals in Malawi between 2011–2014. RISC has both an HIV-infected and HIV-uninfected tool. A local score (RISC-Malawi) was developed using multivariable logistic regression with missing data multiply imputed using chained equations. Score performances were assessed using c-statistics, sensitivity, specificity, positive predictive value, negative predictive value, and likelihood statistics.Results16,475 in-patient pneumonia episodes were recorded (case-fatality rate (CFR): 3.2%), 9,533 with complete data (CFR: 2.0%). The c-statistic for the RISC (HIV-uninfected) score, used to assess its ability to differentiate between children who survived to discharge and those that died, was 0.72. The RISC-Malawi score, using mid-upper arm circumference as an indicator of malnutrition severity, had a c-statistic of 0.79. We were unable to perform a comprehensive external validation of RISC (HIV-infected) and mRISC as both scores include parameters that were not routinely documented variables in our dataset.ConclusionIn our population of Malawian children with WHO-defined pneumonia, the RISC (HIV-uninfected) score identified those at high risk for in-hospital mortality. However the refinement of parameters and resultant creation of RISC-Malawi improved performance. Next steps include prospectively studying both scores to determine if incorporation into routine care delivery can have a meaningful impact on in-hospital CFRs of children with WHO-defined pneumonia.
Highlights
Pneumonia is the number one cause of infectious under-5 child mortality in sub-Saharan Africa, attributed to 935,000 child deaths (14.9% of total) annually [1]
We retrospectively analyzed the performance of the Respiratory Index of Severity in Children (RISC) and modified RISC scores in a child pneumonia dataset prospectively collected during routine care at seven hospitals in Malawi between 2011–2014
In our population of Malawian children with WHO-defined pneumonia, the RISC (HIV-uninfected) score identified those at high risk for in-hospital mortality
Summary
Pneumonia is the number one cause of infectious under-5 child mortality in sub-Saharan Africa, attributed to 935,000 child deaths (14.9% of total) annually [1]. 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]. 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].
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