Evaluating the impact of pulse oximetry on childhood pneumonia mortality in resource-poor settings

Abstract

D espite interventions being available, it is estimated that pneumonia is responsible for 15% of childhood deaths worldwide 1 . Reductions in annual mortality remain modest, with nearly 950,000 under-5 year olds dying of pneumonia in 2013 (ref. 2). Despite the unprecedented rate of Haemophilus influenzae type B (Hib) and pneumococcal vaccine (PCV) introduction, achieving high levels of coverage in developing countries is still challenging 3 . Therefore, in regions where vaccine introduction and scale-up lags behind other countries, improved access to diagnosis and treatment is crucial. This includes interventions at multiple points in the continuum of care -improving care-seeking practices, increasing the availability of suitable diagnostics, and guiding both formal and informal care providers in appropriate disease management. Unfortunately, current treatment coverage remains low, and, more importantly, most childhood pneumonia deaths result from a lack of, or delay in, accurate diagnosis 4 .A crucial component of improving pneumonia outcomes is the early identification of patients at risk of treatment failure and the timely provision of supportive care. However, in the absence of appropriate prognostic tools at the frontline, currently recommended World Health Organization (WHO) guidelines for integrated management of childhood illness (IMCI) often lead to an overuse of antibiotics and the under-referral of patients with severe pneumonia who require hospital care 5 . The most recent 2015 technical update of IMCI guidelines defines non-severe pneumonia as the presence of fast breathing or chest in-drawing or both, which is treatable with oral antibiotics.Severe pneumonia is defined as cough or difficulty breathing in the presence of danger signs, and requires referral to a hospital or health facility for injectable antibiotics or other supportive care such as oxygen therapy 6 . Currently, identification of these IMCI symptoms remains inconsistent and unreliable among community health-care workers or carers without clinical training 7 . Therefore, improved prognostic and diagnostic tools for case-management are necessary to substantially reduce pneumonia-associated morbidity and mortality.Hypoxaemia and malnutrition are strong predictors of mortality in children who are hospitalized for pneumonia 8,9 . This has led to increasing support for the use of oxygen therapy and monitoring oxygen saturation in the management of severe cases. It is estimated that 15% of children who are hospitalized for pneumonia have hypoxaemia (oxygen saturation, or SpO2, of <90% (ref. 10) and that around 1.5 million children with severe pneumonia require oxygen treatment each year 11 . The use of pulse-oximetry devices (used to measure the oxygen level in the blood) in community health-care settings has been proposed as a method to identify hypoxic children at risk of treatment failure. These devices may be particularly beneficial at the frontline given that they require little training and reduce the reliance on clinical symptoms. The...

Pulse oximetry for children with pneumonia treated as outpatients in rural Malawi

“…In rural areas in low-income countries, there is interest in training community and health-centre-based health workers in oximetry – and making oximetry more widely available – so that more hypoxaemic children at risk of death can be referred to hospitals 8 . Oximetry requires negligible infrastructure, is portable, non-invasive and user-friendly and offers a more accurate and objective way to identify hypoxaemia in children than clinical signs alone 3 , 8 , 9 .…”

“…Oximetry requires negligible infrastructure, is portable, non-invasive and user-friendly and offers a more accurate and objective way to identify hypoxaemia in children than clinical signs alone 3 , 8 , 9 . Among practitioners and caregivers faced with decisions on the care of a child with severe pneumonia, the results of oximetry may be more persuasive than a clinical assessment alone 10 …”

Identification of miRNA biomarkers of pneumonia using RNA-sequencing and bioinformatics analysis

“…Viral infection is a primary factor for the mortality of patients with severe pneumonia (6) and a number of viruses, such as the respiratory syncytial virus, have been identified in infants and children with severe pneumonia (7). Although vaccines against viruses, including Haemophilus influenzae type b and Streptococcus pneumoniae, have been introduced in numerous locations, achieving sufficient coverage in developed countries remains a challenge (5). Therefore, it is important to develop novel and improved methods of diagnosing and treating patients with pneumonia.…”

“…Although the occurrence of childhood pneumonia has been reduced, the decline has been small. Reportedly, ~950,000 individuals <5 years old succumbed to pneumonia in 2013 (5).…”

Pulse oximetry: an important first step in improving health outcomes, but is of little use if there is no oxygen

“…Floyd et al 6 recently developed a model to evaluate the benefit of pulse oximetry in reducing childhood pneumonia mortality in resource-poor settings. According to their analysis, combining pulse oximetry with implementation of WHO (integrated management of childhood illness) treatment guidelines would prevent 148 000 pneumonia-related deaths annually in the 15 highest-burden countries, at a cost of less than US$53 per disability-adjusted life year.…”