Epidemiology, pathways, patterns of care and Day-14 mortality of severe cases according to hypoxemia among IMCI children using routine Pulse Oximeter decentralized at Primary Healthcare in West Africa: the AIRE cohort study in Burkina Faso, Guinea, Mali and Niger, 2021 - 2022
Authors: Gildas Boris Hedible , Guaniyi Sawadogo Abdoul , Zineb Zair , Désiré Kargougou G , Bertrand Méda , Lucie Peters-Bokol , Jacques S Kolié , Sarah Louart , Solange Ouédraogo Yugbaré , Aziz Diakite Abdoul , Sory Diallo Ibrahima , Hannatou Abarry Souleymane , Sandrine Busière , Franck Lamontagne , Susan Shepherd , Valéry Ridde , Valériane Leroy ,   the AIRE Research Study Group
Published: October 2024

Background

The AIRE project has implemented routine Pulse Oximeter (PO) use in Integrated Management of Childhood Illness (IMCI) consultations to improve the diagnosis and care management of severe illnesses in primary health centre (PHC) in Burkina Faso, Guinea, Mali and Niger. We analysed care management of severe cases according to hypoxemia, and the determinants of their Day-14 mortality.

Methods

All children under-5 attending IMCI consultations using PO and classified as severe cases (severe IMCI cases or with severe hypoxemia: SpO2<90%) were enrolled at 16 research PHCs (four/country) in a 14-Day prospective cohort with parental consent. Care management according to hypoxemia severity and determinants of Day-14 mortality were analysed.

Results

From June 2021 to June 2022, 1,998 severe cases, including 212 (10.6%) aged <2 months were enrolled. Severe hypoxemia was common (7.1%), affecting both respiratory cases (9.9%) and non-respiratory cases (3.7%); 10.5% had moderate hypoxemia (90%≤SpO2≤93%). Overall, 463 (23.2%) have been hospitalised. At Day-14, 95 (4.8%) have died, and 27 (1.4%) were lost-to-follow-up. The proportions of referral decision, hospitalisation and oxygen therapy were significantly higher for severe hypoxemic cases (83.8%, 82.3%, 34.5%, respectively) than for those with moderate hypoxemia (32.7%, 26.5%, 7.1%, respectively) or without hypoxemia (26.3%, 17.5%, 1.4%, respectively). Similarly, Day-14 mortality rates were 26.1%, 7.5% and 2.3% respectively (p<0.001). Death occurred within a median delay of one day for severe hypoxemia. In an adjusted mixed-effect Cox model, age <2 months, severe and moderate hypoxemia, severe malaria, and place of case management elsewhere than at PHC independently increased mortality at Day-14.

Conclusion

Both severe and moderate hypoxemia were frequent among outpatient critically ill children diagnosed using PO, and associated with a high mortality. Although, the diagnosis of hypoxemia prompted their care management, hospital referral and access to oxygen remain sub-optimal and crucial levers for reducing under-5 mortality in West Africa.

Study registration number

PACTR202206525204526 Registered on 06/15/2022

What is already known on this topic?

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Under-5 mortality is high and severe hypoxemia is a strong predictor of death reported in East African studies conducted in primary care level among severely ill children

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Hypoxemia is underdiagnosed clinically leading to delayed referral and access to oxygen therapy.

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Pulse Oximetry is a simple, low cost and reliable tool to diagnose hypoxemia at a decentralized level.

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Few studies have explored the pathways and patterns of care of severe cases identified at primary care level using Pulse Oximetry, but none conducted in West Africa.

What this study adds?

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Hypoxemia is frequent among children under-5 with serious illnesses in Burkina Faso, Guinea, Mali and Niger: 17.6% overall (severe: 7.1% SpO2<90% and moderate: 10.5% SpO2[90-93%]), higher in neonates, and affecting both respiratory and non-respiratory cases.

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Implementing systematic PO use into Integrated Management of Childhood Illness consultations has improved clinicians’ decision in case management of severe cases. It showed an increasing gradient of care management indicators according to hypoxemia: referral decision, effective hospitalization and oxygen therapy rates were significantly higher for severe hypoxemic cases compared to those with moderate hypoxemia, and those without hypoxemia.

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Nevertheless, hospitalisation and access to oxygen remain sub-optimal.

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Day-14 mortality rate was high, occurred mainly during hospital transfer or at hospital admission, and was correlated with the level of hypoxemia.

How this study might affect research, practice or policy?

This study supports the need to:

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Reconsider the place of place of pulse oximetry and the oxygen saturation thresholds in primary care

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Update IMCI guidelines with the routine introduction of PO use at primary care to improve the diagnosis and case management of children based on risk-stratification according to severe and moderate hypoxemia

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Strengthen the hospital referral system in West Africa to ensure that all severe cases with severe hypoxemia identified at primary care will have a chance to access to oxygen available at hospital level, or consider access to mobile oxygen at PHC.