Excess Child Mortality after Discharge from Hospital in Kilifi, Kenya: A Retrospective Cohort analysis/Surmortalite Infantile Apres la Sortie De L'hopital De Kilifi, Au Kenya: Une Analyse De Cohorte retrospective/Sobremortalidad Infantil Tras El Alta De Un Hospital En Kilifi, Kenia: Analisis Retrospectivo De Cohortes

Introduction The Integrated Management of Childhood Illness (IMCI) programme and inpatient guidelines of the World Health Organization (WHO) aim to standardize and improve the care of critically ill children at health facilities across Africa. (1-4) While the IMCI may reduce in-hospital child mortality, (5) its recommendations for the prevention and management of illness following discharge are based on limited evidence from the field and are rarely implemented. Several studies from developing countries have shown that children admitted to hospital and discharged alive are at increased risk of death for 12 months following discharge when compared with similar children in the community. Furthermore, malnutrition, anaemia, hypoxaemia, longer hospitalization and discharge against medical advice exacerbate this risk. (6-12) Additional data are needed to guide the development of strategies for effective follow-up care that will reduce post-discharge mortality. In Kilifi district, Kenya, infant and child mortality have dropped sharply in recent years, yet only one third of child deaths occur in hospital and access to hospital care for severely ill children is poor. (13) Previous data suggest that children who are discharged from hospital have a higher risk of dying during the 12-month period following discharge than comparable children in the community and that diarrhoea is a significant predictor of excess mortality. (6) In this study we sought to determine whether hospital admission could be characterized as an acute event with an impact on short-term mortality or as a marker of chronic frailty associated with an increased risk of dying over the longer term. We analysed 5 years of linked demographic and paediatric hospital surveillance data in a rolling cohort of approximately 111000 children aged less than 15 years at any one time, with detailed clinical and laboratory information available for all admissions. To guide hospital discharge policies and focus outpatient follow-up on high-risk groups, we estimated the burden and duration of excess mortality associated with hospital discharge and identified demographic and clinical risk factors for death in the post-discharge period. Methods This study was conducted in Kilifi district, a poor, rural area on the Indian Ocean coast of Kenya. The KEMRI/Wellcome Trust Research Programme has conducted laboratory, clinical and epidemiologic research in Kilifi for two decades. Kilifi District Hospital (KDH) in Kilifi town provides primary care and inpatient referral services for the entire district, following national and WHO management guidelines. The Kilifi Health and Demographic Surveillance Study (KHDSS) collects information on births, deaths and migrations in a population of 240 000 people residing in an 891 [km.sup.2] area around KDH. Beginning in April 2002, all patients hospitalized in the paediatric ward or paediatric high-dependency unit at the KDH had their hospital records, including standard clinical and laboratory data, linked to their demographic records with a unique personal identifier. The linked hospital and demographic databases enable us to monitor life events after hospital discharge for residents of the Health and Demographic Surveillance Study (HDSS) area. This analysis included all children