Missed opportunities for hospitalisation of severe pneumonia identified using Integrated Management of Childhood Illness and pulse oximetry at primary care among children aged 2 to 59 months: the AIRE research cohort, 2021 - 2022
Authors: Lucien Dahourou Désiré , Désiré Néboua , Boris Hedible Gildas , Zineb Zair , Sarah Louart , Yassa Guilavogui Jean Paul , Guaniyi Sawadogo Abdoul , Bertrand Meda , Solange Ouédraogo Yugbaré , Sory Diallo Ibrahima , Aziz Diakité Abdoul , Hannatou Abarry Souleymane , Valéry Ridde , Valériane Leroy ,   the AIRE Research Study Group
Published: February 2025

Background

The Integrated Management of Childhood Illness (IMCI) guidelines guide the healthcare workers (HCW) referral decision of under-5 children at primary health centres (PHCs). The AIRE project has implemented the routine Pulse Oximeter (PO) use into IMCI consultations at PHCs in West Africa (Burkina Faso, Guinea, Mali and Niger) to improve the diagnosis and referral of severe cases. We analysed the frequency and correlates of missed opportunities for hospitalisation (MOH) of IMCI severe pneumonia cases.

Methods

All the children aged 2-59 months attending IMCI consultations, classified as severe cases using IMCI+PO were enrolled with parental consent in a prospective cohort of 14-day in 16 research PHCs (4/country). HCW referral decision, and MOH for severe pneumonia were described. Correlates of MOH were investigated using a generalized linear mixed regression model with a random effect on country.

Results

From June 2021 to June 2022, among the 1,786 children aged 2-59 months classified as severe cases by IMCI+PO, 682 (38.2%) were severe pneumonia: among those, 35 (5.1%) had also a severe anaemia, 47 (6.9%) a severe hypoxemia (SpO2<90%) and 602 (88.3%) a severe malaria. Overall, HCW made the referral decision for 125 (18.3%) children, refused by three (2.4%) families; thus, 560 (82.1%) were MOH. Severe anaemia reduced the adjusted odds ratio [aOR] of MOH (aOR: 0.02; 95% confidence interval [95%CI]: 0.01-0.07) while having an SpO2between 90 to 93% (aOR: 12.16, 95%CI: 3.47-42.61), or greater than 94% (aOR: 11.81; 95%CI: 3.98-35.02), or a severe malaria (aOR: 2.55; 95%CI: 1.04-6.26) significantly increased it.

Conclusion

MOH for severe pneumonia were extremely high at PHC level in these settings, mainly explained by HCW’ decisions. The absence of severe hypoxemia was an expected decision factor but co-morbidity with severe malaria is a concern. Supporting HCW and hospital referral remain essential to improve the management of severe pneumonia.

What is already known on this topic

Pneumonia remains the leading cause of under-5 children mortality in sub-Saharan Africa.

The implementation of standardized guidelines, such as the World Health Organization’s (WHO’s) Integrated Management of Childhood Illnesses (IMCI) has reduced mortality from pneumonia but remain insufficient.

Introduction of Pulse Oximetry at primary care should improve the diagnosis of severe hypoxemia associated with severe pneumonia requiring urgent referral.

Little is known about the referral to hospital and hospitalisations of severe pneumonia cases identified in primary care in West African settings.

What this study adds

This study, carried out in 16 primary health care centres in four West African countries (Burkina Faso, Guinea, Mali, Niger) showed a high rate of severe pneumonia among severe IMCI cases (38%) and a high rate of missed opportunities for hospitalisation of these severe pneumonia (82.1%). This latter was mainly attributed to the lack of referral decision made by healthcare workers (HCW).

It is notifiable that co-morbidity with severe malaria was also frequent, 88%.

The absence of severe hypoxemia (SpO2<90%) and of severe anaemia reduced the risk of missed opportunity of hospital referral but severe malaria co-morbidity increased it.

How this study might affect research, practice or policy

The use of PO was associated with a more appropriate HCW’ referral decision for severe pneumonia with severe hypoxemia, but the management of co-morbidity with severe malaria should be strengthen to improve optimal care.

Decision makers should be sensitized on the importance of missed opportunities for hospital referral of severe pneumonia, which remains the leading killer of under-5 children, and mobilised to improve their hospital referral system with appropriate management to improve under-5 children quality of care.