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Hama Diallo A, Shahid ASMSB, Khan AF, Saleem AF, Singa BO, Gnoumou BS, Tigoi C, Achieng C, Bourdon C, Oduol C, Lancioni CL, Manyasi C, McGrath CJ, Maronga C, Lwanga C, Brals D, Ahmed D, Mondal D, Denno DM, Mangale DI, Chimezi E, Mbale E, Mupere E, Salauddin Mamun GM, Ouédraogo I, Berkley JA, Njirammadzi J, Mukisa J, Thitiri J, Walson JL, Jemutai J, Tickell KD, Shahrin L, Mallewa M, Hossain MI, Chisti MJ, Timbwa M, Mburu M, Ngari MM, Ngao N, Aber P, Harawa PP, Sukhtankar P, Bandsma RH, Bamouni RM, Molyneux S, Mwaringa S, Shaima SN, Ali SA, Afsana SM, Banu S, Ahmed T, Voskuijl WP, Kazi Z. Hospital readmission following acute illness among children 2-23 months old in sub-Saharan Africa and South Asia: a secondary analysis of CHAIN cohort. EClinicalMedicine 2024; 73:102676. [PMID: 38933099 PMCID: PMC11200276 DOI: 10.1016/j.eclinm.2024.102676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 05/13/2024] [Accepted: 05/20/2024] [Indexed: 06/28/2024] Open
Abstract
Background Children in low and middle-income countries remain vulnerable following hospital-discharge. We estimated the incidence and correlates of hospital readmission among young children admitted to nine hospitals in sub-Saharan Africa and South Asia. Methods This was a secondary analysis of the CHAIN Network prospective cohort enrolled between 20th November 2016 and 31st January 2019. Children aged 2-23 months were eligible for enrolment, if admitted for an acute illness to one of the study hospitals. Exclusions were requiring immediate resuscitation, inability to tolerate oral feeds in their normal state of health, had suspected terminal illness, suspected chromosomal abnormality, trauma, admission for surgery, or their parent/caregiver was unwilling to participate and attend follow-up visits. Data from children discharged alive from the index admission were analysed for hospital readmission within 180-days from discharge. We examined ratios of readmission to post-discharge mortality rates. Using models with death as the competing event, we evaluated demographic, nutritional, clinical, and socioeconomic associations with readmission. Findings Of 2874 children (1239 (43%) girls, median (IQR) age 10.8 (6.8-15.6) months), 655 readmission episodes occurred among 506 (18%) children (198 (39%) girls): 391 (14%) with one, and 115 (4%) with multiple readmissions, with a rate of: 41.0 (95% CI 38.0-44.3) readmissions/1000 child-months. Median time to readmission was 42 (IQR 15-93) days. 460/655 (70%) and 195/655 (30%) readmissions occurred at index study hospital and non-study hospitals respectively. One-third (N = 213/655, 33%) of readmissions occurred within 30 days of index discharge. Sites with fewest readmissions had the highest post-discharge mortality. Most readmissions to study hospitals (371/450, 81%) were for the same illness as the index admission. Age, prior hospitalisation, chronic conditions, illness severity, and maternal mental health score, but not sex, nutritional status, or physical access to healthcare, were associated with readmission. Interpretation Readmissions may be appropriate and necessary to reduce post-discharge mortality in high mortality settings. Social and financial support, training on recognition of serious illness for caregivers, and improving discharge procedures, continuity of care and facilitation of readmission need to be tested in intervention studies. We propose the ratio of readmission to post-discharge mortality rates as a marker of overall post-discharge access and care. Funding The Bill & Melinda Gates Foundation (OPP1131320).
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Rees CA, Kisenge R, Godfrey E, Ideh RC, Kamara J, Coleman-Nekar YJ, Samma A, Manji HK, Sudfeld CR, Westbrook A, Niescierenko M, Morris CR, Whitney CG, Breiman RF, Duggan CP, Manji KP. Derivation and Internal Validation of a Novel Risk Assessment Tool to Identify Infants and Young Children at Risk for Post-Discharge Mortality in Dar es Salaam, Tanzania and Monrovia, Liberia. J Pediatr 2024; 273:114147. [PMID: 38878962 DOI: 10.1016/j.jpeds.2024.114147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 05/23/2024] [Accepted: 06/11/2024] [Indexed: 07/18/2024]
Abstract
OBJECTIVE To derive and validate internally a novel risk assessment tool to identify young children at risk for all-cause mortality ≤60 days of discharge from hospitals in sub-Saharan Africa. STUDY DESIGN We performed a prospective observational cohort study of children aged 1-59 months discharged from Muhimbili National Hospital in Dar es Salaam, Tanzania and John F. Kennedy Medical Center in Monrovia, Liberia (2019-2022). Caregivers received telephone calls up to 60 days after discharge to ascertain participant vital status. We collected socioeconomic, demographic, clinical, and anthropometric data during hospitalization. Candidate variables with P < .20 in bivariate analyses were included in a multivariable logistic regression model with best subset selection to identify risk factors for the outcome. We internally validated our tool using bootstrapping with 500 repetitions. RESULTS There were 1933 young children enrolled in the study. The median (IQR) age was 11 (4, 23) months and 58.7% were males. In total, 67 (3.5%) died during follow-up. Ten variables contributed to our tool (total possible score 82). Cancer (aOR 10.6, 95% CI 2.58, 34.6), pedal edema (aOR 6.94, 95% CI 1.69, 22.6), and leaving against medical advice (aOR 6.46, 95% CI 2.46, 15.3) were most predictive of post-discharge mortality. Our risk assessment tool demonstrated good discriminatory value (optimism corrected area under the receiver operating characteristic curve 0.77), high precision, and sufficient calibration. CONCLUSIONS After validation, this tool may be used to identify young children at risk for post-discharge mortality to direct resources for follow-up of high-risk children.
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Affiliation(s)
- Chris A Rees
- Division of Pediatric Emergency Medicine, Emory University School of Medicine, Atlanta, GA; Department of Emergency Medicine, Children's Healthcare of Atlanta, Atlanta, GA.
| | - Rodrick Kisenge
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Evance Godfrey
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Readon C Ideh
- Department of Pediatrics, John F. Kennedy Medical Center, Monrovia, Liberia
| | - Julia Kamara
- Department of Pediatrics, John F. Kennedy Medical Center, Monrovia, Liberia
| | | | - Abraham Samma
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Hussein K Manji
- Department of Emergency Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania; Accident and Emergency Department, The Aga Khan Health Services, Dar es Salaam, Tanzania
| | - Christopher R Sudfeld
- Departments of Nutrition and Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Adrianna Westbrook
- Pediatric Biostatistics Core, Department of Pediatrics, Emory University, Atlanta, GA
| | - Michelle Niescierenko
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA; Department of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, MA
| | - Claudia R Morris
- Division of Pediatric Emergency Medicine, Emory University School of Medicine, Atlanta, GA; Department of Emergency Medicine, Children's Healthcare of Atlanta, Atlanta, GA
| | | | - Robert F Breiman
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Christopher P Duggan
- Departments of Nutrition and Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA; Division of Gastroenterology, Hepatology, and Nutrition, Center for Nutrition, Boston Children's Hospital, Boston, MA
| | - Karim P Manji
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
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Wiens MO, Nguyen V, Bone JN, Kumbakumba E, Businge S, Tagoola A, Sherine SO, Byaruhanga E, Ssemwanga E, Barigye C, Nsungwa J, Olaro C, Ansermino JM, Kissoon N, Singer J, Larson CP, Lavoie PM, Dunsmuir D, Moschovis PP, Novakowski S, Komugisha C, Tayebwa M, Mwesigwa D, Knappett M, West N, Mugisha NK, Kabakyenga J. Prediction models for post-discharge mortality among under-five children with suspected sepsis in Uganda: A multicohort analysis. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0003050. [PMID: 38683787 PMCID: PMC11057737 DOI: 10.1371/journal.pgph.0003050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 04/04/2024] [Indexed: 05/02/2024]
Abstract
In many low-income countries, over five percent of hospitalized children die following hospital discharge. The lack of available tools to identify those at risk of post-discharge mortality has limited the ability to make progress towards improving outcomes. We aimed to develop algorithms designed to predict post-discharge mortality among children admitted with suspected sepsis. Four prospective cohort studies of children in two age groups (0-6 and 6-60 months) were conducted between 2012-2021 in six Ugandan hospitals. Prediction models were derived for six-months post-discharge mortality, based on candidate predictors collected at admission, each with a maximum of eight variables, and internally validated using 10-fold cross-validation. 8,810 children were enrolled: 470 (5.3%) died in hospital; 257 (7.7%) and 233 (4.8%) post-discharge deaths occurred in the 0-6-month and 6-60-month age groups, respectively. The primary models had an area under the receiver operating characteristic curve (AUROC) of 0.77 (95%CI 0.74-0.80) for 0-6-month-olds and 0.75 (95%CI 0.72-0.79) for 6-60-month-olds; mean AUROCs among the 10 cross-validation folds were 0.75 and 0.73, respectively. Calibration across risk strata was good: Brier scores were 0.07 and 0.04, respectively. The most important variables included anthropometry and oxygen saturation. Additional variables included: illness duration, jaundice-age interaction, and a bulging fontanelle among 0-6-month-olds; and prior admissions, coma score, temperature, age-respiratory rate interaction, and HIV status among 6-60-month-olds. Simple prediction models at admission with suspected sepsis can identify children at risk of post-discharge mortality. Further external validation is recommended for different contexts. Models can be digitally integrated into existing processes to improve peri-discharge care as children transition from the hospital to the community.
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Affiliation(s)
- Matthew O. Wiens
- Institute for Global Health at BC Children’s and Women’s Hospital, Vancouver, Canada
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, Canada
- BC Children’s Hospital Research Institute, Vancouver, Canada
- Walimu, Kampala, Uganda
| | - Vuong Nguyen
- Institute for Global Health at BC Children’s and Women’s Hospital, Vancouver, Canada
| | - Jeffrey N. Bone
- BC Children’s Hospital Research Institute, Vancouver, Canada
| | - Elias Kumbakumba
- Department of Paediatrics and Child Health, Mbarara University of Science and Technology, Mbarara, Uganda
| | | | - Abner Tagoola
- Jinja Regional Referral Hospital, Jinja City, Uganda
| | | | | | | | | | - Jesca Nsungwa
- Ministry of Health for the Republic of Uganda, Kampala, Uganda
| | - Charles Olaro
- Ministry of Health for the Republic of Uganda, Kampala, Uganda
| | - J. Mark Ansermino
- Institute for Global Health at BC Children’s and Women’s Hospital, Vancouver, Canada
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, Canada
- BC Children’s Hospital Research Institute, Vancouver, Canada
| | - Niranjan Kissoon
- BC Children’s Hospital Research Institute, Vancouver, Canada
- Department of Pediatrics, University of British Columbia, Vancouver, Canada
| | - Joel Singer
- School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - Charles P. Larson
- School of Population and Global Health, McGill University, Montréal, Canada
| | - Pascal M. Lavoie
- BC Children’s Hospital Research Institute, Vancouver, Canada
- Department of Pediatrics, University of British Columbia, Vancouver, Canada
| | - Dustin Dunsmuir
- Institute for Global Health at BC Children’s and Women’s Hospital, Vancouver, Canada
- BC Children’s Hospital Research Institute, Vancouver, Canada
| | - Peter P. Moschovis
- Division of Global Health, Massachusetts General Hospital, Boston, MA, United States of America
| | - Stefanie Novakowski
- Institute for Global Health at BC Children’s and Women’s Hospital, Vancouver, Canada
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, Canada
| | | | | | | | - Martina Knappett
- Institute for Global Health at BC Children’s and Women’s Hospital, Vancouver, Canada
| | - Nicholas West
- BC Children’s Hospital Research Institute, Vancouver, Canada
| | | | - Jerome Kabakyenga
- Maternal Newborn & Child Health Institute, Mbarara University of Science and Technology, Mbarara, Uganda
- Faculty of Medicine, Department of Community Health, Mbarara University of Science and Technology, Mbarara, Uganda
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Rees CA, Ideh RC, Kisenge R, Kamara J, Coleman-Nekar YJG, Samma A, Godfrey E, Manji HK, Sudfeld CR, Westbrook AL, Niescierenko M, Morris CR, Whitney CG, Breiman RF, Duggan CP, Manji KP. Identifying neonates at risk for post-discharge mortality in Dar es Salaam, Tanzania, and Monrovia, Liberia: Derivation and internal validation of a novel risk assessment tool. BMJ Open 2024; 14:e079389. [PMID: 38365298 PMCID: PMC10875550 DOI: 10.1136/bmjopen-2023-079389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 02/06/2024] [Indexed: 02/18/2024] Open
Abstract
INTRODUCTION The immediate period after hospital discharge carries a large burden of childhood mortality in sub-Saharan Africa. Our objective was to derive and internally validate a risk assessment tool to identify neonates discharged from the neonatal ward at risk for 60-day post-discharge mortality. METHODS We conducted a prospective observational cohort study of neonates discharged from Muhimbili National Hospital in Dar es Salaam, Tanzania, and John F Kennedy Medical Centre in Monrovia, Liberia. Research staff called caregivers to ascertain vital status up to 60 days after discharge. We conducted multivariable logistic regression analyses with best subset selection to identify socioeconomic, demographic, clinical, and anthropometric factors associated with post-discharge mortality. We used adjusted log coefficients to assign points to each variable and internally validated our tool with bootstrap validation with 500 repetitions. RESULTS There were 2344 neonates discharged and 2310 (98.5%) had post-discharge outcomes available. The median (IQR) age at discharge was 8 (4, 15) days; 1238 (53.6%) were male. In total, 71 (3.1%) died during follow-up (26.8% within 7 days of discharge). Leaving against medical advice (adjusted OR [aOR] 5.62, 95% CI 2.40 to 12.10) and diagnosis of meconium aspiration (aOR 6.98, 95% CI 1.69 to 21.70) conferred the greatest risk for post-discharge mortality. The risk assessment tool included nine variables (total possible score=63) and had an optimism corrected area under the receiver operating characteristic curve of 0.77 (95% CI 0.75 to 0.80). A score of ≥6 was most optimal (sensitivity 68.3% [95% CI 64.8% to 71.5%], specificity 72.1% [95% CI 71.5% to 72.7%]). CONCLUSIONS A small number of factors predicted all-cause, 60-day mortality after discharge from neonatal wards in Tanzania and Liberia. After external validation, this risk assessment tool may facilitate clinical decision making for eligibility for discharge and the direction of resources to follow-up high risk neonates.
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Affiliation(s)
- Chris A Rees
- Division of Pediatric Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Emergency Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Readon C Ideh
- Department of Pediatrics, John F Kennedy Medical Center, Monrovia, Liberia
| | - Rodrick Kisenge
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
| | - Julia Kamara
- Department of Pediatrics, John F Kennedy Medical Center, Monrovia, Liberia
| | | | - Abraham Samma
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
| | - Evance Godfrey
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
| | - Hussein K Manji
- Department of Emergency Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Dar es Salaam, United Republic of Tanzania
- Accident and Emergency Department, The Aga Khan Health Services, Dar es Salaam, Dar es Salaam, United Republic of Tanzania
| | - Christopher R Sudfeld
- Departments of Nutrition and Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Boston, USA
| | - Adrianna L Westbrook
- Pediatric Biostatistics Core, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Michelle Niescierenko
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Claudia R Morris
- Division of Pediatric Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Emergency Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Cynthia G Whitney
- Emory Global Health Institute, Emory University, Atlanta, Georgia, USA
| | - Robert F Breiman
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Infectious Diseases and Oncology Research Institute, University of the Witwatersrand, Johannesburg, South Africa
| | - Christopher P Duggan
- Departments of Nutrition and Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Boston, USA
- Center for Nutrition, Children's Hospital Boston, Boston, Massachusetts, USA
| | - Karim P Manji
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
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Rees CA, Kisenge R, Ideh RC, Kamara J, Coleman YJ, Samma A, Godfrey E, Manji HK, Sudfeld CR, Westbrook AL, Niescierenko M, Morris CR, Whitney CG, Breiman RF, Manji KP, Duggan CP. Predictive value of clinician impression for readmission and postdischarge mortality among neonates and young children in Dar es Salaam, Tanzania and Monrovia, Liberia. BMJ Paediatr Open 2023; 7:e001972. [PMID: 37385735 PMCID: PMC10314694 DOI: 10.1136/bmjpo-2023-001972] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 06/11/2023] [Indexed: 07/01/2023] Open
Abstract
BACKGROUND There are no validated clinical decision aids to identify neonates and young children at risk of hospital readmission or postdischarge mortality in sub-Saharan Africa, leaving the decision to discharge a child to a clinician's impression. Our objective was to determine the precision of clinician impression to identify neonates and young children at risk for readmission and postdischarge mortality. METHODS We conducted a survey study nested in a prospective observational cohort of neonates and children aged 1-59 months followed 60 days after hospital discharge from Muhimbili National Hospital in Dar es Salaam, Tanzania or John F. Kennedy Medical Center in Monrovia, Liberia. Clinicians who discharged each enrolled patient were surveyed to determine their perceived probability of the patient's risk of 60-day hospital readmission or postdischarge mortality. We calculated the area under the precision-recall curve (AUPRC) to determine the precision of clinician impression for both outcomes. RESULTS Of 4247 discharged patients, 3896 (91.7%) had available clinician surveys and 3847 (98.7%) had 60-day outcomes available: 187 (4.8%) were readmitted and 120 (3.1%) died within 60 days of hospital discharge. Clinician impression had poor precision in identifying neonates and young children at risk of hospital readmission (AUPRC: 0.06, 95% CI: 0.04 to 0.08) and postdischarge mortality (AUPRC: 0.05, 95% CI: 0.03 to 0.08). Patients for whom clinicians attributed inability to pay for future medical treatment as the reason for risk for unplanned hospital readmission had 4.76 times the odds hospital readmission (95% CI: 1.31 to 17.25, p=0.02). CONCLUSIONS Given the poor precision of clinician impression alone to identify neonates and young children at risk of hospital readmission and postdischarge mortality, validated clinical decision aids are needed to aid in the identification of young children at risk for these outcomes.
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Affiliation(s)
- Chris A Rees
- Division of Pediatric Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
- Emergency Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Rodrick Kisenge
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
| | - Readon C Ideh
- Department of Pediatrics, John F. Kennedy Medical Center, Monrovia, Liberia
| | - Julia Kamara
- Department of Pediatrics, John F. Kennedy Medical Center, Monrovia, Liberia
| | - Ye-Jeung Coleman
- Department of Pediatrics, John F. Kennedy Medical Center, Monrovia, Liberia
| | - Abraham Samma
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
| | - Evance Godfrey
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
| | - Hussein K Manji
- Department of Emergency Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
- Accident and Emergency Department, The Aga Khan Health Services, Dar es Salaam, United Republic of Tanzania
| | - Christopher R Sudfeld
- Departments of Nutrition and Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Adrianna L Westbrook
- Pediatric Biostatistics Core, Department of Pediatrics, Emory University, Atlanta, Georgia, USA
| | - Michelle Niescierenko
- Division of Emergency Medicine, Boston Children s Hospital, Boston, Massachusetts, USA
- Departments of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, MA, USA
| | - Claudia R Morris
- Division of Pediatric Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
- Emergency Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Cynthia G Whitney
- Emory Global Health Institute, Emory University, Atlanta, Georgia, USA
| | - Robert F Breiman
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Karim P Manji
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
| | - Christopher P Duggan
- Departments of Nutrition and Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
- Center for Nutrition, Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Boston, MA, USA
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