Predicting hospitalised paediatric pneumonia mortality risk: An external validation of RISC and mRISC, and local tool development (RISC-Malawi) from Malawi

Shubhada Hooli, Tim Colbourn, Norman Lufesi, Anthony Costello, Bejoy Nambiar, Satid Thammasitboon, Charles Makwenda, Charles Mwansambo, Eric D. McCollum, Carina King

Research output: Contribution to journalArticlepeer-review

27 Scopus citations


Background: Pneumonia is the leading infectious cause of under-5 mortality in sub-Saharan Africa. Clinical prediction tools may aide case classification, triage, and allocation of hospital resources. We performed an external validation of two published prediction tools and compared this to a locally developed tool to identify children admitted with pneumonia at increased risk for inhospital mortality in Malawi. Methods: We retrospectively analyzed the performance of the Respiratory Index of Severity in Children (RISC) and modified RISC (mRISC) scores in a child pneumonia dataset prospectively collected during routine care at seven hospitals in Malawi between 2011±2014. RISC has both an HIV-infected and HIV-uninfected tool. A local score (RISC-Malawi) was developed using multivariable logistic regression with missing data multiply imputed using chained equations. Score performances were assessed using c-statistics, sensitivity, specificity, positive predictive value, negative predictive value, and likelihood statistics. Results: 16,475 in-patient pneumonia episodes were recorded (case-fatality rate (CFR): 3.2%), 9,533 with complete data (CFR: 2.0%). The c-statistic for the RISC (HIV-uninfected) score, used to assess its ability to differentiate between children who survived to discharge and those that died, was 0.72. The RISC-Malawi score, using mid-upper arm circumference as an indicator of malnutrition severity, had a c-statistic of 0.79. We were unable to perform a comprehensive external validation of RISC (HIV-infected) and mRISC as both scores include parameters that were not routinely documented variables in our dataset. Conclusion: In our population of Malawian children with WHO-defined pneumonia, the RISC (HIV-uninfected) score identified those at high risk for in-hospital mortality. However the refinement of parameters and resultant creation of RISC-Malawi improved performance. Next steps include prospectively studying both scores to determine if incorporation into routine care delivery can have a meaningful impact on in-hospital CFRs of children with WHO-defined pneumonia.

Original languageEnglish (US)
Article numbere0168126
JournalPloS one
Issue number12
StatePublished - Dec 2016

ASJC Scopus subject areas

  • General Biochemistry, Genetics and Molecular Biology
  • General Agricultural and Biological Sciences
  • General


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