Over the ten-year study period, 698 (2,7%) of the 25 595 hospitalised children under five years old died in King Edward VIII Hospital. During this period, the total number of under-five hospitalisations remained relatively constant between 2507 (lowest) and 2724 (highest) each year. Despite this, the percentage of under-five deaths in these annual hospitalisations significantly decreased from 5,1% in 2009 to 1,8% in 2018 (p < 0.001). The trend of this decrease is illustrated in Fig. 1.
Of all hospitalised children, 2328 (9, 1%) were classified as having severe acute malnutrition (SAM). The change in the proportion of SAM admissions as a percentage of all under-five admissions also showed a decrease over this period. Figure 2 illustrates this decrease.
There were 285 SAM deaths during the study period. This constituted 12,2% of all 2328 under-five SAM admissions and 40,8% of all under-five deaths. From 2009 to 2018, there was no significant change in the proportion of SAM deaths, either as a percentage of SAM admissions (case fatality rate) or as a percentage of under-five deaths. For ten years, the mean case fatality rate was 12,2% (range 8,4% to 18,1%), placing it well above the WHO target of < 5%. Figure 3 illustrates these trends.
Upon analysis of SAM deaths, n = 285, the mean age of children was 16,9 months, which was significantly different from the mean age of children classified in other nutritional categories who had died. This was significantly different from the ages of children who died who were classified as nutritionally normal. The gender in both the SAM (n = 285) and NAM (n = 301) categories was also significantly different. More boys had died in the SAM category (62,7%) compared to NAM (49,5%).
Table 1 indicates the relationship between age and gender in the death of children in various WHO nutritional categories.
Table 1
HIV exposure and infection in under-five mortality
WHO
|
MAM
(N = 79)
|
NAM
(N = 301)
|
Obese
(N = 19)
|
SAM
(N = 285)
|
p-value
|
Overall
(N = 684)
|
Age (months)
|
|
|
|
|
p < 0.001
|
|
Means
|
8.10 ± 9.12
(112.6)
|
12.9 ± 13.0
(100.3)
|
16.9 ± 11.2
(65.8)
|
14.1 ± 12.9
(92.0)
|
13.0 ± 12.6
(97.6)
|
Median(Q1-Q3)
|
5.00(3.00–8.00)
|
7.00(3.00–19.0)
|
17.0(8.50–23.0)
|
10.0(5.00–18.0)
|
8.00
(4.00–18.0)
|
Min-Max
|
1.00–46.0
|
1.00–59.0
|
1.00–36.0
|
1.00–58.0
|
1.00–59.0
|
Gender
|
|
|
|
|
p = 0.006
|
|
Male
|
49 (62.0%)
|
147 (49.5%)
|
13 (68.4%)
|
178 (62.7%)
|
387
(57.0%)
|
Female
|
30 (38.0%)
|
150 (50.5%)
|
6 (31.6%)
|
106 (37.3%)
|
292
(43.0%)
|
Most under-five deaths, 60.7% (n = 415), occurred in HIV-exposed children. Of all the deaths, 49,4% (338) were HIV negative, and 36,8% (252) were HIV positive. In cases where the HIV status was known, most SAM deaths comprised HIV-positive children (46.7%), while the majority of deaths in children who were not classified as SAM were HIV-negative. Table 2 indicates the relationships between HIV exposure and HIV infection status in various WHO nutritional categories.
Table 2
The relationship between HIV exposure and HIV infection status in various WHO nutritional categories
WHO
|
MAM
(N = 79)
|
Normal
(N = 301)
|
Obese
(N = 19)
|
SAM
(N = 285)
|
p-value
|
Overall
(N = 684)
|
Exposed
|
|
|
|
|
p = 0.373
|
|
No
|
24 (30.4%)
|
123 (40.9%)
|
7 (36.8%)
|
115 (40.4%)
|
269 (39.3%)
|
Yes
|
55 (69.6%)
|
178 (59.1%)
|
12 (63.2%)
|
170 (59.6%)
|
415 (60.7%)
|
HIV status
|
|
|
|
|
p < 0.001
|
|
Negative
|
40 (50.6%)
|
172 (57.1%)
|
16 (84.2%)
|
110 (38.6%)
|
338 (49.4%)
|
Positive
|
30 (38.0%)
|
87 (28.9%)
|
2 (10.5%)
|
133 (46.7%)
|
252 (36.8%)
|
Unknown HIV
|
9 (11.4%)
|
42 (14.0%)
|
1 (5.3%)
|
42 (14.7%)
|
94 (13.7%)
|
There was a significant decrease in the percentage of HIV-exposed SAM deaths from 2009 (72%) to 2018 (35%). Figure 4 illustrates this change.
The proportion of HIV-positive, HIV-negative, and HIV unknown SAM deaths changed over the study period. This change was statistically significant. Figure 5 illustrates these trends. In 2009, most (70,2%) SAM deaths were HIV infected, compared with only 6,7% of SAM deaths in 2018. There was also a significant drop in HIV unknown results from 19,8% of all SAM deaths not having an HIV result documented in 2009 to no SAM deaths having no HIV result reported in 2018. In analysing the severely acutely malnourished children who died in relation to both age and HIV status, there was a significant association between being below six months and HIV positive. Figure 6 illustrates these relationships.
Cause of death
The top three primary causes of death were septicemia (33%, n = 223) and lower respiratory tract infections (27%, n = 182), followed by acute gastroenteritis (15%, 7%, n = 106). Significantly more children died from septicaemia as the primary cause of death 41, 6%, (n = 117) in SAM children who died compared with 25, 3% (n = 75) in children classified as NAM. Table 3 indicates the proportion of primary causes of death in each nutritional category. There were no significant changes in the proportions of the three most common causes of death in either the SAM or NAM groups over the study period. Figure 7 illustrates changes in these proportions over the ten years.
Table 3
Causes of death from 2009 until 2018 in all children who died
|
WHO nutritional classification categories
|
Primary cause of death
|
MAM
(N = 79)
|
NAM
(N = 301)
|
Obese
(N = 19)
|
SAM
(N = 285)
|
Overall
(N = 684)
|
|
Acute Gastroenteritis
(AGE)
|
9 (11.5%)
|
47 (15.8%)
|
7 (36.8%)
|
43 (15.3%)
|
106 (15.7%)
|
p-value = 0.044
|
Lower Respiratory Tract Infections (LRTI)
|
24 (30.8%)
|
94 (31.6%)
|
4 (21.1%)
|
60 (21.4%)
|
182 (27.0%)
|
Confirmed /Suspected
Septicaemia (Sepsis)
|
28 (35.9%)
|
75 (25.3%)
|
3 (15.8%)
|
117 (41.6%)
|
223 (33.0%)
|
Meningitis
|
5 (6.4%)
|
13 (4.4%)
|
0 (0.0%)
|
12 (4.3%)
|
30 (4.4%)
|
Cardiac failure
|
4 (5.1%)
|
23 (7.7%)
|
3 (15.8%)
|
15 (5.3%)
|
45 (6.7%)
|
Neurological causes
|
4 (5.1%)
|
22 (7.4%)
|
1 (5.3%)
|
13 (4.6%)
|
40 (5.9%)
|
Liver Failure /disease
|
2 (2.6%)
|
11 (3.7%)
|
1 (5.3%)
|
13 (4.6%)
|
27 (4.0%)
|
Renal Failure /disease
|
0 (0.0%)
|
3 (1.0%)
|
0 (0.0%)
|
3 (1.1%)
|
6 (0.9%)
|
Other causes
|
2 (2.6%)
|
9 (3.0%)
|
0 (0.0%)
|
5 (1.8%)
|
16 (2.4%)
|