Verbal Autopsy to Assess Postdischarge Mortality in Children With Suspected Sepsis in Uganda

Abstract

Background: Reducing child mortality in low-income countries is constrained by a lack of vital statistics. In the absence of such data, verbal autopsies provide an acceptable method to determining attributable causes of death. The objective was to assess potential causes of pediatric postdischarge mortality in children younger than age 5 years (under-5) originally admitted for suspected sepsis using verbal autopsies.

Methods: Secondary analysis of verbal autopsy data from children admitted to 6 hospitals across Uganda from July 2017 to March 2020. Structured verbal autopsy interviews were conducted for all deaths within 6 months after discharge. Two physicians independently classified a primary cause of death, up to 4 alternative causes, and up to 5 contributing conditions using the Start-Up Mortality List, with discordance resolved by consensus.

Results: Verbal autopsies were completed for 361 (98.6%) of the 366 (5.9%) children who died among 6191 discharges (median admission age: 5.4 months [interquartile range, 1.8-16.7]; median time to mortality: 28 days [interquartile range, 9-74]). Most deaths (62.3%) occurred in the community. Leading primary causes of death, assigned in 356 (98.6%) of cases, were pneumonia (26.2%), sepsis (22.1%), malaria (8.5%), and diarrhea (7.9%). Common contributors to death were malnutrition (50.5%) and anemia (25.7%). Reviewers were less confident in their causes of death for neonates than older children (P < .05).

Conclusions: Postdischarge mortality frequently occurred in the community in children admitted for suspected sepsis in Uganda. Analyses of the probable causes for these deaths using verbal autopsies suggest potential areas for interventions, focused on early detection of infections, as well as prevention and treatment of underlying contributors such as malnutrition and anemia.

FIGURE 1

Flow diagram of children under-5 admitted with suspected sepsis enrolled in the prospective cohort study from July 2017 to March 2020 and outcomes 6 months after discharge.

FIGURE 2

Causes of death proportions (ICD-10-SMoL Causes of Death Code) and physician certainty level for children aged <28 days at death, N = 19. Abbreviation: ICD-10-SMoL, Start-Up Mortality List. Note: Other and unspecified congenital malformations (5–94) includes other congenital malformations of the digestive system, congenital malformations of the respiratory system, cleft lip and cleft palate, etc. Other and unspecified perinatal conditions (5–90) includes hemorrhagic and hematological disorders of fetus and newborn, transitory endocrine and metabolic disorders specific to fetus and newborn, respiratory and cardiovascular disorders specific to the perinatal period, etc.

FIGURE 3

Causes of death proportions (ICD-10-SMoL Causes of Death Code) and physician certainty level for children 28 days to 5 years, N = 347. Abbreviations: ICD-10-SMoL, Start-Up Mortality List; TB, tuberculosis; VA, verbal autopsy. *Other: Other and unspecified diseases of the respiratory system (5–70), 3 (0.9%); Other and unspecified congenital malformations (5–94), 2 (0.6%); Other diseases of the digestive system (5–74), 2 (0.6%); Chronic lower respiratory diseases (5–69), 2 (0.6%); Other and unspecified malignant neoplasms (5–45), 2 (0.6%); Leukemia (5–44), 2 (0.6%); Intrauterine hypoxia and birth asphyxia (5–89), 1 (0.3%); Other and unspecified diseases of the genitourinary system (5–78), 1 (0.3%); Renal failure (5–77), 1 (0.3%); Acute rheumatic fever and chronic rheumatic heart diseases (5–60), 1 (0.3%); Other and unspecified endocrine, nutritional and metabolic diseases (5–51), 1 (0.3%).

FIGURE 4

Causes of death proportions (ICD-10 SMoL Causes of Death Code) <1 month and >1 month after discharge among children aged 0 to 5 years, N = 364^a. Abbreviations: ICD-10-SMoL, Start-Up Mortality List; TB, tuberculosis. ^aTwo children missing an exact death date and were excluded from this analysis.