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Bourdon C, Diallo AH, Mohammad Sayeem Bin Shahid AS, Khan MA, Saleem AF, Singa BO, Gnoumou BS, Tigoi C, Otieno CA, Oduol CO, Lancioni CL, Manyasi C, McGrath CJ, Maronga C, Lwanga C, Brals D, Ahmed D, Mondal D, Denno DM, Mangale DI, Chimwezi E, Mbale E, Mupere E, Salauddin Mamun GM, Ouédraogo I, Berkley JA, Njunge JM, 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. Childhood growth during recovery from acute illness in Africa and South Asia: a secondary analysis of the childhood acute illness and nutrition (CHAIN) prospective cohort. EClinicalMedicine 2024; 70:102530. [PMID: 38510373 PMCID: PMC10950691 DOI: 10.1016/j.eclinm.2024.102530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Revised: 02/20/2024] [Accepted: 02/21/2024] [Indexed: 03/22/2024] Open
Abstract
Background Growth faltering is well-recognized during acute childhood illness and growth acceleration during convalescence, with or without nutritional therapy, may occur. However, there are limited recent data on growth after hospitalization in low- and middle-income countries. Methods We evaluated growth following hospitalization among children aged 2-23 months in sub-Saharan Africa and South Asia. Between November 2016 and January 2019, children were recruited at hospital admission and classified as: not-wasted (NW), moderately-wasted (MW), severely-wasted (SW), or having nutritional oedema (NO). We describe earlier (discharge to 45-days) and later (45- to 180-days) changes in length-for-age [LAZ], weight-for-age [WAZ], mid-upper arm circumference [MUACZ], weight-for-length [WLZ] z-scores, and clinical, nutritional, and socioeconomic correlates. Findings We included 2472 children who survived to 180-days post-discharge: NW, 960 (39%); MW, 572 (23%); SW, 682 (28%); and NO, 258 (10%). During 180-days, LAZ decreased in NW (-0.27 [-0.36, -0.19]) and MW (-0.23 [-0.34, -0.11]). However, all groups increased WAZ (NW, 0.21 [95% CI: 0.11, 0.32]; MW, 0.57 [0.44, 0.71]; SW, 1.0 [0.88, 1.1] and NO, 1.3 [1.1, 1.5]) with greatest gains in the first 45-days. Of children underweight (<-2 WAZ) at discharge, 66% remained underweight at 180-days. Lower WAZ post-discharge was associated with age-inappropriate nutrition, adverse caregiver characteristics, small size at birth, severe or moderate anaemia, and chronic conditions, while lower LAZ was additionally associated with household-level exposures but not with chronic medical conditions. Interpretation Underweight and poor linear growth mostly persisted after an acute illness. Beyond short-term nutritional supplementation, improving linear growth post-discharge may require broader individual and family support. Funding Bill & Melinda Gates FoundationOPP1131320; National Institute for Health ResearchNIHR201813.
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Affiliation(s)
- Celine Bourdon
- Translational Medicine, Hospital for Sick Children, Toronto, ON, Canada
| | - Abdoulaye Hama Diallo
- Department of Public Health, University Joseph Ki-Zerbo, Ouagadougou, Burkina Faso
- Department of Public Health, Centre Muraz Research Institute, Bobo-Dioulasso, Burkina Faso
| | | | - Md Alfazal Khan
- Health System and Population Studies Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Ali Faisal Saleem
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | | | | | - Caroline Tigoi
- Clinical Research Department, KEMRI–Wellcome Trust Research Programme, Kilifi, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | | | | | | | | | - Christine J. McGrath
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Christopher Maronga
- Clinical Research Department, KEMRI–Wellcome Trust Research Programme, Kilifi, Kenya
| | - Christopher Lwanga
- Uganda-Case Western Reserve University Research Collaboration, Kampala, Uganda
| | - Daniella Brals
- Department of Global Health, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Dilruba Ahmed
- Clinical Microbiology and Immunology Laboratory, Office of Executive Director, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Dinesh Mondal
- Nutrition Research Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Donna M. Denno
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Pediatrics, University of Washington, Seattle, WA, USA
| | | | - Emmanuel Chimwezi
- Department of Paediatrics and Child Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Emmie Mbale
- Department of Paediatrics and Child Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Ezekiel Mupere
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Gazi Md Salauddin Mamun
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Issaka Ouédraogo
- Department of Pediatrics, Banfora Referral Regional Hospital, Banfora, Burkina Faso
| | - James A. Berkley
- Clinical Research Department, KEMRI–Wellcome Trust Research Programme, Kilifi, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - James M. Njunge
- Clinical Research Department, KEMRI–Wellcome Trust Research Programme, Kilifi, Kenya
| | - Jenala Njirammadzi
- Department of Paediatrics and Child Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - John Mukisa
- Department of Immunology and Department of Molecular Biology Makerere University College of Health Sciences, Kampala, Uganda
| | - Johnstone Thitiri
- Clinical Research Department, KEMRI–Wellcome Trust Research Programme, Kilifi, Kenya
| | - Judd L. Walson
- Departments of International Health and Medicine, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Julie Jemutai
- Clinical Research Department, KEMRI–Wellcome Trust Research Programme, Kilifi, Kenya
| | - Kirkby D. Tickell
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Lubaba Shahrin
- Hospitals, Office of Executive Director, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Macpherson Mallewa
- Department of Paediatrics and Child Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Md Iqbal Hossain
- Nutrition Research Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Mohammod Jobayer Chisti
- Nutrition Research Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Molline Timbwa
- Clinical Research Department, KEMRI–Wellcome Trust Research Programme, Kilifi, Kenya
| | - Moses Mburu
- Clinical Research Department, KEMRI–Wellcome Trust Research Programme, Kilifi, Kenya
| | - Moses M. Ngari
- Clinical Research Department, KEMRI–Wellcome Trust Research Programme, Kilifi, Kenya
| | - Narshion Ngao
- Clinical Research Department, KEMRI–Wellcome Trust Research Programme, Kilifi, Kenya
| | - Peace Aber
- Uganda-Case Western Reserve University Research Collaboration, Kampala, Uganda
| | - Philliness Prisca Harawa
- Department of Paediatrics and Child Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Priya Sukhtankar
- Clinical Research Department, KEMRI–Wellcome Trust Research Programme, Kilifi, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Robert H.J. Bandsma
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | | | - Sassy Molyneux
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Health Systems and Research Ethics Department, KEMRI–Wellcome Trust Research Programme, Kilifi, Kenya
| | - Shalton Mwaringa
- Clinical Research Department, KEMRI–Wellcome Trust Research Programme, Kilifi, Kenya
| | - Shamsun Nahar Shaima
- Nutrition Research Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Syed Asad Ali
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Syeda Momena Afsana
- Clinical Biochemistry Laboratory, Office of Executive Director, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Sayera Banu
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Tahmeed Ahmed
- Nutrition Research Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
- Office of Executive Director, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Wieger P. Voskuijl
- Department of Paediatrics and Child Health, Kamuzu University of Health Sciences, Blantyre, Malawi
- Amsterdam UMC, Location University of Amsterdam, Amsterdam Institute for Global Child Health, Emma Children’s Hospital, Meibergdreef 9, Amsterdam, the Netherlands
- Amsterdam UMC, Location University of Amsterdam, Department of Global Health, Amsterdam Institute for Global Health and Development, Meibergdreef 9, Amsterdam, the Netherlands
| | - Zaubina Kazi
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
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Atim SA, Niebel M, Ashraf S, Vudriko P, Odongo S, Balinandi S, Aber P, Bameka R, Ademun AR, Masembe C, Tweyongyere R, Thomson EC. Prevalence of Crimean-Congo haemorrhagic fever in livestock following a confirmed human case in Lyantonde district, Uganda. Parasit Vectors 2023; 16:7. [PMID: 36611216 PMCID: PMC9824997 DOI: 10.1186/s13071-022-05588-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 11/13/2022] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Crimean-Congo haemorrhagic fever (CCHF) is a tick-borne viral infection, characterized by haemorrhagic fever in humans and transient asymptomatic infection in animals. It is an emerging human health threat causing sporadic outbreaks in Uganda. We conducted a detailed outbreak investigation in the animal population following the death from CCHF of a 42-year-old male cattle trader in Lyantonde district, Uganda. This was to ascertain the extent of CCHF virus (CCHFV) circulation among cattle and goats and to identify affected farms and ongoing increased environmental risk for future human infections. METHODS We collected blood and tick samples from 117 cattle and 93 goats, and tested these for anti-CCHFV antibodies and antigen using an enzyme-linked immunosorbent assay (ELISA), quantitative reverse transcriptase polymerase chain reaction (qRT-PCR) and target enrichment next generation sequencing. RESULTS CCHFV-specific IgG antibodies were detected in 110/117 (94.0%) cattle and 83/93 (89.3%) goats. Animal seropositivity was independently associated with female animals (AOR = 9.42, P = 0.002), and animals reared under a pastoral animal production system (AOR = 6.02, P = 0.019] were more likely to be seropositive than tethered or communally grazed animals. CCHFV was detected by sequencing in Rhipicephalus appendiculatus ticks but not in domestic animals. CONCLUSION This investigation demonstrated very high seroprevalence of CCHFV antibodies in both cattle and goats in farms associated with a human case of CCHF in Lyantonde. Therefore, building surveillance programs for CCHF around farms in this area and the Ugandan cattle corridor is indicated, in order to identify opportunities for case prevention and control.
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Affiliation(s)
- Stella A Atim
- College of Veterinary Medicine, Animal Resources and Biosecurity (CoVAB), Makerere University, Kampala, Uganda
- Centre of Virus Research (CVR), University of Glasgow, Glasgow, UK
- Ministry of Agriculture, Animal Industry and Fisheries, Entebbe, Uganda
| | - Marc Niebel
- Centre of Virus Research (CVR), University of Glasgow, Glasgow, UK
| | - Shirin Ashraf
- Centre of Virus Research (CVR), University of Glasgow, Glasgow, UK
| | - Patrick Vudriko
- College of Veterinary Medicine, Animal Resources and Biosecurity (CoVAB), Makerere University, Kampala, Uganda
| | - Steven Odongo
- College of Veterinary Medicine, Animal Resources and Biosecurity (CoVAB), Makerere University, Kampala, Uganda
| | - Stephen Balinandi
- Department of Emerging, Re-Emerging and Arbovirus Infections, Uganda Virus Research Institute, Entebbe, Uganda
| | - Peace Aber
- Case Western Research Collaboration, Makerere University, Kampala, Uganda
| | - Ronald Bameka
- Lyantonde District Local Government, Lyantonde, Uganda
| | - Anna R Ademun
- Ministry of Agriculture, Animal Industry and Fisheries, Entebbe, Uganda
| | - Charles Masembe
- College of Natural Resources (CoNAS), Makerere University, Kampala, Uganda
| | - Robert Tweyongyere
- College of Veterinary Medicine, Animal Resources and Biosecurity (CoVAB), Makerere University, Kampala, Uganda
| | - Emma C Thomson
- Centre of Virus Research (CVR), University of Glasgow, Glasgow, UK.
- MRC-University of Glasgow Centre for Virus Research, Stoker Building, 464 Bearsden Road, Glasgow, G61 1QH, UK.
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Babikako HM, Bourdon C, Mbale E, Aber P, Birabwa A, Chimoyo J, Voskuijl W, Kazi Z, Massara P, Mukisa J, Mupere E, Nampijja M, Saleem AF, Uebelhoer LS, Bandsma R, Walson JL, Berkley JA, Lancioni C, Gladstone M, van den Heuvel M. Neurodevelopment and Recovery From Wasting. Pediatrics 2022; 150:189663. [PMID: 36193695 DOI: 10.1542/peds.2021-055615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/29/2022] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Acute illness with malnutrition is a common indication for hospitalization among children in low- and middle-income countries. We investigated the association between wasting recovery trajectories and neurodevelopmental outcomes in young children 6 months after hospitalization for an acute illness. METHODS Children aged 2 to 23 months were enrolled in a prospective observational cohort of the Childhood Acute Illness & Nutrition Network, in Uganda, Malawi, and Pakistan between January 2017 and January 2019. We grouped children on the basis of their wasting recovery trajectories using change in mid-upper arm circumference for age z-score. Neurodevelopment was assessed with the Malawi Developmental Assessment Tool (MDAT development-for-age z-score [DAZ]) at hospital discharge and after 6 months. RESULTS We included 645 children at hospital discharge (mean age 12.3 months ± 5.5; 55% male); 262 (41%) with severe wasting, 134 (21%) with moderate wasting, and 249 (39%) without wasting. Four recovery trajectories were identified: high-stable, n = 112; wasted-improved, n = 404; severely wasted-greatly improved, n = 48; and severely wasted-not improved, n = 28. The children in the severely wasted-greatly improved group demonstrated a steep positive MDAT-DAZ recovery slope. This effect was most evident in children with both wasting and stunting (interaction wasted-improved × time × stunting: P < .001). After 6 months, the MDAT DAZ in children with wasting recovery did not differ from community children. In children who never recovered from wasting, there remained a significant delay in MDAT DAZ scores. CONCLUSIONS Neurodevelopment recovery occurred in parallel with wasting recovery in children convalescing from acute illness and was influenced by stunting.
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Affiliation(s)
| | - Celine Bourdon
- Childhood Acute Illness and Nutrition Network, Nairobi, Kenya.,Translational Medicine
| | - Emmie Mbale
- Childhood Acute Illness and Nutrition Network, Nairobi, Kenya.,Department of Paediatrics and Child Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Peace Aber
- Childhood Acute Illness and Nutrition Network, Nairobi, Kenya.,Makerere University, Uganda Case Western Reserve University Research Collaboration, Kampala, Uganda
| | - Annet Birabwa
- Childhood Acute Illness and Nutrition Network, Nairobi, Kenya.,Makerere University, Uganda Case Western Reserve University Research Collaboration, Kampala, Uganda
| | - Josephine Chimoyo
- Childhood Acute Illness and Nutrition Network, Nairobi, Kenya.,Department of Paediatrics and Child Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Wieger Voskuijl
- Childhood Acute Illness and Nutrition Network, Nairobi, Kenya.,Child Health and Development Center School of Medicine College of Health Sciences, Makerere University, Kampala, Uganda.,Centre for Global Health.,Amsterdam Center for Global health, Emma Children's Hospital, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | | | - Paraskevi Massara
- Translational Medicine.,Department of Nutritional Sciences, Faculty of Medicine
| | - John Mukisa
- Childhood Acute Illness and Nutrition Network, Nairobi, Kenya.,Departments of Immunology and Molecular Biology, Pathology.,Baylor College of Medicine, Houston, Texas
| | - Ezekiel Mupere
- Childhood Acute Illness and Nutrition Network, Nairobi, Kenya.,Makerere University, Uganda Case Western Reserve University Research Collaboration, Kampala, Uganda.,Paediatrics and Child Health, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Margaret Nampijja
- Childhood Acute Illness and Nutrition Network, Nairobi, Kenya.,MRC/UVRI & London School of Hygiene and Tropical Medicine, Uganda Research Unit, Entebbe, Uganda.,African Population and Health Research Center, Nairobi, Kenya
| | - Ali Faisal Saleem
- Childhood Acute Illness and Nutrition Network, Nairobi, Kenya.,Department of Pediatrics, Aga Khan University Hospital, Karachi, Pakistan
| | - Luke S Uebelhoer
- Childhood Acute Illness and Nutrition Network, Nairobi, Kenya.,Department of Pediatrics, Oregon Health & Science University, Portland, Oregon
| | - Robert Bandsma
- Childhood Acute Illness and Nutrition Network, Nairobi, Kenya.,Translational Medicine.,Centre for Global Health.,Department of Paediatrics and Child Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Judd L Walson
- Childhood Acute Illness and Nutrition Network, Nairobi, Kenya.,Departments of Global Health, Medicine, Pediatrics, and Epidemiology, University of Washington, Seattle, Washington
| | - James A Berkley
- Childhood Acute Illness and Nutrition Network, Nairobi, Kenya.,KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya.,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
| | - Christina Lancioni
- Childhood Acute Illness and Nutrition Network, Nairobi, Kenya.,Department of Pediatrics, Oregon Health & Science University, Portland, Oregon
| | - Melissa Gladstone
- Childhood Acute Illness and Nutrition Network, Nairobi, Kenya.,Department of Women and Children's Health, Institute of Life Course and Clinical Sciences, University of Liverpool, Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom
| | - Meta van den Heuvel
- Childhood Acute Illness and Nutrition Network, Nairobi, Kenya.,Centre for Global Health.,Division of Pediatrics, Hospital for Sick Children, Toronto, Canada.,Department of Pediatrics, University of Toronto, Canada
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Diallo AH, Sayeem Bin Shahid ASM, Khan AF, Saleem AF, Singa BO, Gnoumou BS, Tigoi C, Otieno CA, Bourdon C, Oduol CO, 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, Mamun GMS, Ouedraogo I, Berkley JA, Njirammadzi J, Mukisa J, Thitiri J, Carreon JD, 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 RHJ, Bamouni RM, Molyneux S, Mwaringa S, Shaima SN, Ali SA, Afsana SM, Banu S, Ahmed T, Voskuijl WP, Kazi Z. Childhood mortality during and after acute illness in Africa and south Asia: a prospective cohort study. Lancet Glob Health 2022; 10:e673-e684. [PMID: 35427524 PMCID: PMC9023747 DOI: 10.1016/s2214-109x(22)00118-8] [Citation(s) in RCA: 43] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 01/29/2022] [Accepted: 03/04/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Mortality among children with acute illness in low-income and middle-income settings remains unacceptably high and the importance of post-discharge mortality is increasingly recognised. We aimed to explore the epidemiology of deaths among young children with acute illness across sub-Saharan Africa and south Asia to inform the development of interventions and improved guidelines. METHODS In this prospective cohort study, we enrolled children aged 2-23 months with acute illness, stratified by nutritional status defined by anthropometry (ie, no wasting, moderate wasting, or severe wasting or kwashiorkor), who were admitted to one of nine hospitals in six countries across sub-Saharan Africa and south Asia between Nov 20, 2016, and Jan 31, 2019. We assisted sites to comply with national guidelines. Co-primary outcomes were mortality within 30 days of hospital admission and post-discharge mortality within 180 days of hospital discharge. A priori exposure domains, including demographic, clinical, and anthropometric characteristics at hospital admission and discharge, as well as child, caregiver, and household-level characteristics, were examined in regression and survival structural equation models. FINDINGS Of 3101 children (median age 11 months [IQR 7-16]), 1120 (36·1%) had no wasting, 763 (24·6%) had moderate wasting, and 1218 (39·3%) had severe wasting or kwashiorkor. Of 350 (11·3%) deaths overall, 234 (66·9%) occurred within 30 days of hospital admission and 168 (48·0%) within 180 days of hospital discharge. 90 (53·6%) post-discharge deaths occurred at home. The proportion of children who died following discharge was relatively preserved across nutritional strata. Numerically large high-risk and low-risk groups could be disaggregated for early mortality and post-discharge mortality. Structural equation models identified direct pathways to mortality and multiple socioeconomic, clinical, and nutritional domains acting indirectly through anthropometric status. INTERPRETATION Among diverse sites in Africa and south Asia, almost half of mortality occurs following hospital discharge. Despite being highly predictable, these deaths are not addressed in current guidelines. A fundamental shift to a child-centred, risk-based approach to inpatient and post-discharge management is needed to further reduce childhood mortality, and clinical trials of these approaches with outcomes of mortality, readmission, and cost are warranted. FUNDING The Bill & Melinda Gates Foundation.
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