Performance of five risk stratification tools for paediatric pneumonia against WHO scores using data from the PediCAP trial in sub-Saharan Africa
- 1Innovative Clinical Trials Unit at UCL
Abstract
ObjectivesRisk stratification tools for childhood pneumonia may improve identification of children at highest risk of death in low-resource settings. However, their added value over the WHO Integrated Management of Childhood Illness (IMCI) criteria and danger signs remains uncertain. We compared the performance of published paediatric pneumonia risk scores with WHO-IMCI criteria and WHO danger signs using data from a multi-country African clinical trial.
DesignSecondary analysis of a multi-country randomised controlled trial
SettingThirteen hospitals in Mozambique, South Africa, Uganda, Zambia, and Zimbabwe.
ParticipantsChildren aged 2-59 months without HIV hospitalised with WHO-defined severe community-acquired pneumonia in the PediCAP trial.
Primary and secondary outcome measuresThe primary outcome was in-hospital mortality. Secondary outcomes were mortality during hospitalisation or within 7 days of discharge, and the exploratory outcome of readmission or death by day 28. Discrimination was assessed using area under the receiver operating characteristic curve (ROC-AUC).
ResultsAmong 1052 children, 18 (1.7%) died in hospital and 22 (2.1%) died in hospital or within 7 days of discharge. Among 1010 children with day-28 follow-up, 63 (6.2%) died or were readmitted by day 28. ROC-AUC point estimates for in-hospital mortality ranged from approximately 0.73 to 0.87. WHO danger signs had lower point estimate than the other scores, although confidence intervals overlapped substantially and no score demonstrated clear superiority. Similar findings were observed for mortality during hospitalisation or within 7 days of discharge. In contrast, all approaches showed limited discrimination for the exploratory outcome of 28-day readmission or death (ROC-AUC approximately 0.54-0.57).
ConclusionsIn this multi-country cohort of children hospitalised with severe pneumonia, no score demonstrated clear superiority for mortality prediction, although modest differences cannot be excluded. Published risk scores and WHO-IMCI criteria showed broadly similar performance. These findings suggest that strengthening implementation of WHO clinical criteria may be at least as important as introducing additional risk stratification tools in low-resource settings.
Trial RegistrationISRCTN63115131
What is already known on this topicSeveral clinical risk scores have been developed to predict mortality in childhood pneumonia, with some validation studies in low-resource settings, although direct comparisons across multiple risk stratification tools within the same population are limited.
WHO IMCI criteria are widely used in many low-resource settings, but performance relative to published risk stratification tools remains uncertain.
What this study addsIn a multi-country African cohort of children hospitalised with severe pneumonia, published paediatric pneumonia risk scores and WHO IMCI criteria showed broadly similar point estimates for mortality prediction, with no score demonstrating clear superiority.
WHO danger signs generally had lower point estimates than the published risk scores and WHO IMCI criteria, although confidence intervals overlapped substantially.
How this study might affect research, practice, or policyThese findings suggest that strengthening implementation of existing WHO IMCI-based assessment may be at least as important as introducing additional risk stratification tools in low-resource settings.
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BibTeX
@misc{nalwanga2026performance,
title = {{Performance of five risk stratification tools for paediatric pneumonia against WHO scores using data from the PediCAP trial in sub-Saharan Africa}},
author = {D. Nalwanga and M. Clements and V. Musiime and V. Mulenga and H. A. Mujuru and M. Sidat and W. C. Buck and S. Madhi and J. A. Bielicki and D. P. Moore and A. S. Walker and M. Sharland and PediCAP trial team},
howpublished = {medRxiv},
year = {2026},
month = jun,
doi = {10.64898/2026.06.02.26353886},
url = {https://www.medrxiv.org/content/10.64898/2026.06.02.26353886v2},
note = {CC BY},
}
RIS
TY - UNPB
TI - Performance of five risk stratification tools for paediatric pneumonia against WHO scores using data from the PediCAP trial in sub-Saharan Africa
AU - D. Nalwanga
AU - M. Clements
AU - V. Musiime
AU - V. Mulenga
AU - H. A. Mujuru
AU - M. Sidat
AU - W. C. Buck
AU - S. Madhi
AU - J. A. Bielicki
AU - D. P. Moore
AU - A. S. Walker
AU - M. Sharland
AU - PediCAP trial team
PY - 2026
DA - 2026/06/02
PB - medRxiv
DO - 10.64898/2026.06.02.26353886
UR - https://www.medrxiv.org/content/10.64898/2026.06.02.26353886v2
AB - ObjectivesRisk stratification tools for childhood pneumonia may improve identification of children at highest risk of death in low-resource settings. However, their added value over the WHO Integrated Management of Childhood Illness (IMCI) criteria and danger signs remains uncertain. We compared the performance of published paediatric pneumonia risk scores with WHO-IMCI criteria and WHO danger signs using data from a multi-country African clinical trial. DesignSecondary analysis of a multi-country randomised controlled trial SettingThirteen hospitals in Mozambique, South Africa, Uganda, Zambia, and Zimbabwe. ParticipantsChildren aged 2-59 months without HIV hospitalised with WHO-defined severe community-acquired pneumonia in the PediCAP trial. Primary and secondary outcome measuresThe primary outcome was in-hospital mortality. Secondary outcomes were mortality during hospitalisation or within 7 days of discharge, and the exploratory outcome of readmission or death by day 28. Discrimination was assessed using area under the receiver operating characteristic curve (ROC-AUC). ResultsAmong 1052 children, 18 (1.7%) died in hospital and 22 (2.1%) died in hospital or within 7 days of discharge. Among 1010 children with day-28 follow-up, 63 (6.2%) died or were readmitted by day 28. ROC-AUC point estimates for in-hospital mortality ranged from approximately 0.73 to 0.87. WHO danger signs had lower point estimate than the other scores, although confidence intervals overlapped substantially and no score demonstrated clear superiority. Similar findings were observed for mortality during hospitalisation or within 7 days of discharge. In contrast, all approaches showed limited discrimination for the exploratory outcome of 28-day readmission or death (ROC-AUC approximately 0.54-0.57). ConclusionsIn this multi-country cohort of children hospitalised with severe pneumonia, no score demonstrated clear superiority for mortality prediction, although modest differences cannot be excluded. Published risk scores and WHO-IMCI criteria showed broadly similar performance. These findings suggest that strengthening implementation of WHO clinical criteria may be at least as important as introducing additional risk stratification tools in low-resource settings. Trial RegistrationISRCTN63115131 What is already known on this topicSeveral clinical risk scores have been developed to predict mortality in childhood pneumonia, with some validation studies in low-resource settings, although direct comparisons across multiple risk stratification tools within the same population are limited. WHO IMCI criteria are widely used in many low-resource settings, but performance relative to published risk stratification tools remains uncertain. What this study addsIn a multi-country African cohort of children hospitalised with severe pneumonia, published paediatric pneumonia risk scores and WHO IMCI criteria showed broadly similar point estimates for mortality prediction, with no score demonstrating clear superiority. WHO danger signs generally had lower point estimates than the published risk scores and WHO IMCI criteria, although confidence intervals overlapped substantially. How this study might affect research, practice, or policyThese findings suggest that strengthening implementation of existing WHO IMCI-based assessment may be at least as important as introducing additional risk stratification tools in low-resource settings.
ER -