PROJECT SUMMARY
In high income countries, SUDI, and its sub-categories (1) Sudden Infant Death Syndrome (SIDS) and (2)
Accidental Suffocation Deaths (ASD), are the leading preventable causes of infant mortality. The ensuing ‘back
to sleep’ campaigns have since proven among the most effective public health strategies ever identified for
reducing infant mortality. Yet, in low and middle-income countries (LMICs) almost nothing is known about the
burden of SUDI or its modifiable risk factors, and very few African countries have policies targeting SUDI. In our
recent systematic review, we documented a near absence of research on SUDI in Africa, excepting several well-
conducted investigations from South Africa. Our focus on SUDI emerged during a multi-year postmortem infant
surveillance project to establish the fatal burden of Respiratory Syncytial Virus. Over 3 years, we enrolled ~80%
of all infant deaths in Lusaka, Zambia, nearly 2,300 infants. Ultimately, SUDI was implicated in 7.4% of those
community deaths. Far from being rare, SUDI appeared to be a very common cause of infant demise, with
modifiable risk factors that were ubiquitous yet wholly unaddressed by existing policies in Zambia. If confirmed,
SUDI constitutes a major unmet opportunity to reduce infant mortality in Africa that has largely been ignored by
the global health community. Yet, our early data fall short of the gold standard for evaluating SUDI deaths.
Robust local prevalence data will be essential to support policy initiatives targeting SUDI and as a baseline from
which to judge the impact of such policies. Therefore, we are proposing Project Chisoni, a rigorous 5-year study
to precisely define the burden of SUDI and its modifiable risk factors in Zambia.
To achieve those broader goals, we have convened a multinational multidisciplinary team with expertise in
pediatrics, cause of death analysis, SUDI, pathology, molecular biology, and SUDI epidemiology. Our aims are:
SA1 will create a ‘gold standard’ evaluation of community infant deaths to demonstrate the burden of SUDI in
an African setting, which will include in-depth post-mortem evaluations, multiplex PCR to identify unanticipated
infectious causes of death and detailed death scene investigations to understand the context in which each death
occurred. This will generate the proportion of deaths that are due to SUDI and SUDI deaths/1000 live births.
SA2 includes three sub-aims. SA2.1 will be a matched case-control study examining the association of risk
factors with SUDI among the cases in SA1 vs. a group of contemporaneously enrolled healthy control infants;
SA2.2 takes the ORs and prevalence data from SA1 and S2.1 to calculate the population attributable fraction
(PAF) for risk factors alone or in combination, and therefore the theoretical number of lives that could be saved
through mitigation; and SA2.3 seeks to expand the generalizability of this project by conducting additional risk
factor prevalence surveys in different urban and rural settings in Zambia and several other African nations.
