Background

Severe anaemia is associated with high in-hospital mortality among young children. In malaria-endemic areas, surviving children also remain at increased risk of mortality for several months after hospital discharge. We aimed to compare the risks of morbidity and mortality among children discharged from hospital after recovery from severe anaemia versus other health conditions in malaria-endemic settings in Africa.

Methods

Following PRISMA guidelines, we searched PubMed, Scopus, Web of Science, and Cochrane Central from inception to Nov 30, 2021, without language restrictions, for prospective or retrospective cohort studies and randomised controlled trials that followed up children younger than 15 years for defined periods after hospital discharge in malaria-endemic countries in Africa. We excluded the intervention groups in trials and studies or subgroups involving children with sickle cell anaemia, malignancies, or surgery or trauma, or those reporting follow-up data that were combined with the in-hospital period. Two independent reviewers extracted the data and assessed the quality and risk of bias using the Newcastle Ottawa Scale or the Cochrane Collaboration's tool. The coprimary outcomes were all-cause death and all-cause readmissions 6 months after discharge. This study is registered with PROSPERO, CRD42017079282.

Findings

Of 2930 articles identified in our search, 27 studies were included. For children who were recently discharged following hospital admission with severe anaemia, all-cause mortality by 6 months was higher than during the in-hospital period (n=5 studies; Mantel-Haenszel odds ratio 1·72, 95% CI 1·22–2·44; p=0·0020; I²=51·5%) and more than two times higher than children previously admitted without severe anaemia (n=4 studies; relative risk [RR] 2·69, 95% CI 1·59–4·53; p<0·0001; I²=69·2%). Readmissions within 6 months of discharge were also more common in children admitted with severe anaemia than in children admitted with other conditions (n=1 study; RR 3·05, 1·12–8·35; p<0·0001). Children admitted with severe acute malnutrition (regardless of severe anaemia) also had a higher 6-month mortality after discharge than those admitted for other reasons (n=2 studies; RR=3·12, 2·02–4·68; p<0·0001; I²=54·7%). Other predictors of mortality after discharge included discharge against medical advice, HIV, bacteraemia, and hypoxia.

Interpretation

In malaria-endemic settings in Africa, children admitted to hospital with severe anaemia and severe acute malnutrition are at increased risk of mortality in the first 6 months after discharge compared with children admitted with other health conditions. Improved strategies are needed for the management of these high-risk groups during the period after discharge.

Funding

Research Council of Norway and US Centers for Disease Control and Prevention.

中文翻译：

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非洲疟疾流行地区因严重贫血和其他健康问题入院的儿童出院后发病率和死亡率：一项系统回顾和荟萃分析

背景

严重贫血与幼儿的高院内死亡率有关。在疟疾流行地区，幸存的儿童在出院后的几个月内死亡风险仍然增加。我们的目的是比较非洲疟疾流行环境中严重贫血康复出院儿童与其他健康状况儿童的发病率和死亡率风险。

方法

遵循 PRISMA 指南，我们在 PubMed、Scopus、Web of Science 和 Cochrane Central 中搜索了从开始到 2021 年 11 月 30 日的前瞻性或回顾性队列研究和随机对照试验，这些研究从开始到 2021 年 11 月 30 日对 15 岁以下的儿童进行了特定时期的随访在非洲疟疾流行国家出院后。我们排除了试验和研究中的干预组或涉及患有镰状细胞性贫血、恶性肿瘤、手术或创伤的儿童的亚组，或那些报告与住院期间相结合的随访数据的干预组。两名独立审查员提取数据并使用纽卡斯尔渥太华量表或 Cochrane 协作网的工具评估质量和偏倚风险。共同主要结局是出院后 6 个月的全因死亡和全因再入院。本研究已在 PROSPERO 注册，CRD42017079282。

发现

在我们检索到的 2930 篇文章中，有 27 项研究被纳入。对于因严重贫血入院后最近出院的儿童，6 个月时的全因死亡率高于住院期间（n=5 项研究；Mantel-Haenszel 比值比 1·72，95% CI 1·22 –2·44；p=0·0020；I ² =51·5%），比之前没有严重贫血的儿童高两倍以上（n=4 研究；相对风险 [RR] 2·69，95% CI 1·59–4·53；p<0·0001；I ²=69·2%）。出院后 6 个月内再入院在因严重贫血入院的儿童中也比在因其他疾病入院的儿童中更常见（n=1 研究；RR 3·05、1·12–8·35；p<0·0001）。因严重急性营养不良（无论是否患有严重贫血）入院的儿童出院后 6 个月死亡率也高于因其他原因入院的儿童（n=2 项研究；RR=3·12、2·02–4·68；p< 0·0001；I ² =54·7%）。出院后死亡率的其他预测因素包括不遵医嘱出院、HIV、菌血症和缺氧。

解释

在非洲疟疾流行的环境中，与因其他健康问题入院的儿童相比，因严重贫血和严重急性营养不良入院的儿童在出院后的头 6 个月内死亡的风险更高。在出院后的这段时间里，需要改进策略来管理这些高危人群。

资金

挪威研究委员会和美国疾病控制与预防中心。