Identification of severe cases with routine Pulse Oximetry use into the Integrated Management of Childhood Illness at Primary Health Centres level in West Africa: A cross-sectional study within the AIRE project in Burkina Faso, Guinea, Mali and Niger, 2021 - 2022

Background

The Integrated Management of Childhood Illness (IMCI) guidelines is a symptom-based algorithm guiding healthcare workers in resource-limited countries to identify critically ill children under-5 in primary healthcare centre (PHC). Hypoxemia, a life-threatening event, is often clinically underdiagnosed. The AIRE project has implemented the routine use of Pulse Oximeter (PO) in IMCI consultations to improve the diagnosis of severe hypoxemia (SpO ₂ < 90%) and the management of severe cases at PHC level in Burkina Faso, Guinea, Mali and Niger. We measured the prevalence of IMCI+PO severe cases, and their associated social and structural factors among IMCI outpatients.

Methods

In 16 AIRE research PHC (4/country), all the children under-5 attending IMCI consultations, except those aged 2-59 months classified as simple case without cough or breathing difficulties, were eligible for PO use and enrolled in a cross-sectional study with parental consent. Severe IMCI+PO cases were defined as IMCI severe cases or those with severe hypoxemia.

Results

From June 2021 to June 2022, 968 neonates (0-59 days) and 14,868 children (2-59 months) were included. Prevalence of severe IMCI+PO cases was heterogeneous between countries: 5.0% in Burkina Faso, 6.1% in Niger, 18.9% in Mali and 44.6% in Guinea. Among neonates, 21.9% (95%CI: 19.3-24.6) were classified as IMCI+PO severe cases versus 12.0% (95%CI: 11.4-12.5) in older children. Severe hypoxemia was identified in 3.3% of neonates versus 0.8% in older children (p<0.001). The adjusted social and structural factors associated with disease severity commons to all four countries were: age <2 months or >2 years, IMCI-consultation delay >2 days, home to PHC travel time >30 minutes.

Conclusion

Despite between-country heterogeneity, the prevalence of seriously ill children under-5 including severe hypoxemia was high, particularly in neonates, and those without accessibility to PHC. Improving earlier access to primary healthcare and management of severe cases remains needed in West Africa.

• What is already known on this topic

  • A few studies have reported the prevalence and correlates of severe illnesses with the IMCI guidelines using routine integration of pulse oximetry (PO) among all children under-5 at primary healthcare Centres (PHC) level in low-middle income countries (LMICs), and to our knowledge none has been done in West Africa.

• What this study adds

  This study:

  • reports a high prevalence of severe cases using IMCI including PO among outpatient children under-5 attending IMCI consultation, and heterogeneous between countries (Burkina Faso, Guinea, Mali, Niger)

  • shows that overall prevalence of severe cases was significantly twice higher in neonates (21.9%) than in children aged 2-59 months (12.0%). Similarly, the prevalence of severe hypoxemia was higher in neonates (3.3%) than in older children (0.8%).

  • highlights the accessibility challenges to primary healthcare for children with serious illnesses, and inadequate decision about their specific care management.

• How this study might affect research, practice or policy

  • This study provides original and reliable estimates for policy-makers to invest in earlier access to primary healthcare and better referral decision of severe IMCI cases to improve child health in West Africa.

  • These indicators will be useful in assessing the added-value of PO integration into IMCI in LMICs and support scaling-up of PO into both national and international IMCI guidelines.