World Pneumonia Day 2016: pulse oximetry and oxygen
Authors: Amy Sarah Ginsburg, Rasa Izadnegahdar, Keith P Klugman
Journal: The Lancet Global Health (2016)

Pneumonia persists as the leading infectious killer of children worldwide. Hypoxaemia is a predictor of mortality from childhood pneumonia, and approximately 1·5 million children with severe pneumonia require oxygen treatment each year.1Nair H Simoes EA Rudan I et al.Global and regional burden of hospital admissions for severe acute lower respiratory infections in young children in 2010: a systematic analysis.Lancet. 2013; 381: 1380-1390Summary Full Text Full Text PDF PubMed Scopus (487) Google Scholar Pulse oximetry and oxygen are key interventions for treating pneumonia and preventing death. Pulse oximetry, the standard for detecting hypoxaemia, is cost-effective and can identify 20–30% more cases than using clinical signs alone.2Duke T Subhi R Peel D Frey B Pulse oximetry: technology to reduce child mortality in developing countries.Ann Trop Paediatr. 2009; 29: 165-175Crossref PubMed Scopus (63) Google Scholar In addition to averting deaths, oximetry helps identify children requiring referral, increases the number of correctly treated severe pneumonia cases, and reduces the incidence of incorrect treatment with antibiotics.3Floyd J Wu L Hay Burgess D Izadnegahdar R Mukanga D Ghani AC Evaluating the impact of pulse oximetry on childhood pneumonia mortality in resource-poor settings.Nature. 2015; 528: S53-S59Crossref PubMed Scopus (51) Google Scholar Early identification of hypoxaemia with oximetry and appropriate treatment with oxygen are lifesaving; yet availability and access to both services remain inadequate in low-resource settings. There is an urgent need to increase access to oxygen and pulse oximetry in low-resource settings. Recent WHO guidance comprising a publication of technical specifications for oxygen concentrators intended for use in low-resource settings,4World Health OrganizationTechnical specifications for oxygen concentrators.http://apps.who.int/medicinedocs/en/d/Js22194en/Google Scholar an expansive manual on the management of hypoxaemia,5World Health OrganizationOxygen therapy for children: a manual for health workers.http://www.who.int/maternal_child_adolescent/documents/child-oxygen-therapy/en/Google Scholar and identification of oxygen as a critical service in the care of newborns6World Health OrganizationWHO technical specifications of neonatal resuscitation devices.http://apps.who.int/medicinedocs/en/m/abstract/Js22389en/Google Scholar has strengthened the call for improving access to these essential tools. Further consideration is being given to including hypoxaemia as a general danger sign in the integrated management of acutely ill children. Engagements with suppliers and interested governments have established that safe and reliable provision of oxygen requires a systems approach with wrap-around services including maintenance, training, and supervision, plus strong linkages between different health system levels. This approach necessitates thinking of oxygen and oximeters as a service requiring careful planning, rather than simply as commodities which require procurement and distribution. In Ethiopia, Nigeria, and Papua New Guinea work is underway to better understand how health systems can include safe and reliable identification of severe illness and treatment of hypoxaemic patients. Ethiopia has been a leader in planning for such an effort. Ethiopia has experienced significant improvements in its health system and the health status of its population, reducing its under-5 mortality by two-thirds between 1990 and 2012, and successfully meeting Millennium Development Goal 4 on child survival.7World Health OrganizationEthiopia: child health.http://www.afro.who.int/en/ethiopia/country-programmes/topics/4475-child-health.htmlGoogle Scholar However, pneumonia remains a leading cause of under-5 deaths.8Walker CL Rudan I Liu L et al.Global burden of childhood pneumonia and diarrhoea.Lancet. 2013; 381: 1405-1416Summary Full Text Full Text PDF PubMed Scopus (1440) Google Scholar The complexity and comorbidity of the residual mortality will require greater focus on referral linkages and supportive care systems in order to maintain the significant pace of mortality decline observed between 2000 and 2015. Currently, many Ethiopian health centres do not have fully functional oxygen cylinders, concentrators, or oximeters available. Standard operating procedures or job aids for safe and effective oxygen therapy or identification of children with hypoxaemia or severe disease are not common, and often no staff are trained in providing oxygen therapy. Additionally, there are no policies and adapted guidelines for the use of oxygen and oximetry. This lack of access to oxygen and pulse oximetry is not unique to Ethiopia. It is a familiar situation throughout much of the world, particularly in rural areas with limited access to care services. However, Ethiopia is addressing this situation head-on. To increase access to oxygen and pulse oximetry, the Ethiopian Ministry of Health (MOH) has responded by undertaking a comprehensive strategic planning process captured as a roadmap for oxygen and pulse oximetry scale-up.9Federal Ministry of HealthEthiopiaMedical oxygen and pulse oximetry scale up road map in Ethiopia (2016–2021). Federal Ministry of Health, Addid Ababa2016Google Scholar A national technical working group has been formed to support the coordination, planning, and implementation of the roadmap. This is a formidable commitment benefiting from the strong coordination of the Ethiopian MOH and setting the stage for ongoing improvement to the quality of care within the primary health care unit—a core pillar of the country's national Health Sector Transformation Plan. To support the Ethiopian MOH, international and local partners are planning activities focused on establishing a supply chain of oxygen and oximetry commodities as well as appropriate policies and guidelines, training, and behaviour change programmes, accompanied by monitoring, learning and evaluation plans, and advocacy efforts. Even when oxygen and oximetry are available, reported therapeutic use for childhood pneumonia can be low, with common barriers including insufficient supply; competition for use; lack of policies, guidelines, and training; and perceived high cost.10Ginsburg AS Van Cleve WC Thompson MI English M Oxygen and pulse oximetry in childhood pneumonia: a survey of healthcare providers in resource-limited settings.J Trop Pediatr. 2012; 58: 389-393Crossref PubMed Scopus (51) Google Scholar A broadly engaged effort is therefore required to ensure appropriate and safe use of oxygen services at each suitable facility level commensurate with the proper systems in place, including trained staff, adequate electricity, and demand for services across multiple indications. While efforts are being made to address hypoxaemia and its associated mortality, more needs to be done. Children with pneumonia will continue to die without access to pulse oximeters and oxygen. Increased global awareness and action are necessary. Despite pneumonia being a leading cause of death among children—more than HIV, malaria, and tuberculosis combined—necessary resources are not being invested to the same degree, and children with pneumonia do not receive the care they deserve. Ethiopia is demonstrating that a coordinated and strategic approach can help reverse this tide. We declare no competing interests.