ABSTRACT

The PhD study was initiated during employment at the Bandim Health Project in Guinea Bissau during 1995 to 1997. Linking longitudinal community data to prospectively registered hospital information we have examined the use of hospital services, risk factors for case fatality, hospital mortality and post-discharge mortality both prior to and during a civil war in Guinea Bissau. Furthermore, we examined the effects of routine vaccinations on in-hospital mortality and post-discharge survival.

Results. Almost 45% of all children in the area were hospitalised at least once before the age of five years and every fourth death occurred at the hospital. In-hospital mortality was 12.2, and adding 12-month post-discharge mortality the over-all mortality was 20%. Post-discharge mortality compared with community mortality, was 12 times higher during the first two weeks after discharge and remained significantly higher in the period 3-6 months after hospitalisation. Risk factor analyses were performed for hospitalisation, for community and hospital mortality as well as for post-discharge mortality. The risk factors for hospitalisation did not reflect the risk factors for in-hospital mortality, whereas good consistency was found between risk factors for community and hospital-related mortality. During a 12-month war period, the hospital CFR and post-hospital mortality were significantly reduced (0.68 and 0.57, respectively). The decline could not be explained by changes in recruitment, discharge policy or general changes in mortality. Immunisations had effects on in-hospital mortality which cannot be explained by the expected disease specific effects of vaccines; a strong protective effect of measles vaccine on overall in-hospital mortality (MR = 0.51 (CI95% 0.27-0.98)), being strongest for girls, and a significantly higher CFR for DTP vaccinated girls than for DTP vaccinated males (MR=1.63 (CI95% 1.03-2.59))

Future perspectives. Hospital registration is an important tool for monitoring quality of care and to evaluate the impact of clinical interventions and consequences of cost recovery systems. Main targets for interventions should be a prioritised management of severely ill children at arrival and of high-risk children at discharge, as well as improvements in staff dedication and morale. Emergency treatment should be kept free of charge to avoid further inequity by increased mortality among children of poor families. The changes in hospital case fatality rates associated with different vaccines were consistent with community findings and warrant further research to understand and control the immune stimulatory effects of routine vaccines.