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BackgroundThe Amélioration de l'Identification des détresses Respiratoires de l'Enfant (AIRE) project introduced the routine use of pulse oximetry (PO) into Integrated Management of Childhood Illness (IMCI) consultations within primary health centres (PHCs) in Burkina Faso, Guinea, Mali and Niger. We analysed how severe cases were managed and 14-day mortality by hypoxaemia severity.MethodsAll children aged under 5 years attending IMCI consultations integrating PO use at 16 research PHCs and classified as severe cases (severe IMCI cases or severe hypoxemia: SpO2 <90%) were eligible for referral and enrolled in a 14-day prospective cohort with parental consent. Referral decisions, admissions, access to oxygen therapy and Kaplan-Meier probability of death were compared by hypoxaemia severity. An adjusted mixed-effects Cox regression model with a random effect for PHC estimated adjusted ORs (aORs) and 95% CIs of mortality by day 14.ResultsFrom July 2021 to July 2022, 1998 severe cases were enrolled, including 10.6% aged <2 months; 7.1% had severe hypoxaemia, and 10.5% had moderate hypoxaemia (90%≤oxygen saturation≤93%). By day 14, 625 (31.3%) were referred, 463 (23.2%) hospitalised, and 95 children (4.8%) had died. Referral decisions, hospitalisations and oxygen therapy rates were significantly higher for severe hypoxaemic cases (83.8%, 82.3% and 34.5%, respectively) than for moderate hypoxaemic cases (32.7%, 26.5% and 7.1%, respectively) and cases without hypoxaemia (26.3%, 17.5% and 1.4%, respectively). Similarly, day 14 mortality rates were 26.1%, 7.5% and 2.3%, respectively. The aORs for mortality were severe hypoxaemia (9.34, 95% CI 5.08 to 17.16), moderate hypoxaemia (2.32, 95% CI 1.16 to 4.64), age <2 months (3.68, 95% CI 1.67 to 8.13), severe malaria (2.02, 95% CI 1.03 to 3.97) and living in Niger (4.06, 95% CI 1.41 to 11.67).ConclusionRegardless of severity, hypoxaemia was common among outpatients screened using PO and meeting criteria for severity. Its presence was associated with mortality risk. Incorporating PO within IMCI prompted care management of severely hypoxaemic cases, but hospital referrals and access to oxygen remain sub-optimal and are crucial levers for reducing under-five mortality.Study registration numberPACTR202206525204526 registered retrospectively on 15 June 2022.

Background The AIRE operational project will evaluate the implementation of the routine Pulse Oximeter (PO) use in the integrated management of childhood illness (IMCI) strategy for children under-5 in primary health care centers (PHC) in West Africa. The introduction of PO should promote the accurate identification of hypoxemia (pulse blood oxygen saturation Sp02 < 90%) among all severe IMCI cases (respiratory and non-respiratory) to prompt their effective case management (oxygen, antibiotics and other required treatments) at hospital. We seek to understand how the routine use of PO integrated in IMCI outpatients works (or not), for whom, in what contexts and with what outcomes. Methods The AIRE project is being implemented from 03/2020 to 12/2022 in 202 PHCs in four West African countries (Burkina Faso, Guinea, Mali, Niger) including 16 research PHCs (four per country). The research protocol will assess three complementary components using mixed quantitative and qualitative methods: a) context based on repeated cross-sectional surveys: baseline and aggregated monthly data from all PHCs on infrastructure, staffing, accessibility, equipment, PO use, severe cases and care; b) the process across PHCs by assessing acceptability, fidelity, implementation challenges and realistic evaluation, and c) individual outcomes in the research PHCs: all children under-5 attending IMCI clinics, eligible for PO use will be included with parental consent in a cross-sectional study. Among them, severe IMCI cases will be followed in a prospective cohort to assess their health status at 14 days. We will analyze pathways, patterns of care, and costs of care. Discussion This research will identify challenges to the systematic implementation of PO in IMCI consultations, such as health workers practices, frequent turnover, quality of care, etc. Further research will be needed to fully address key questions such as the best time to introduce PO into the IMCI process, the best SpO2 threshold for deciding on hospital referral, and assessing the cost-effectiveness of PO use. The AIRE research will provide health policy makers in West Africa with sufficient evidence on the context, process and outcomes of using PO integrated into IMCI to promote scale-up in all PHCs. Trial registration Trial registration number: PACTR202206525204526 retrospectively registered on 06/15/2022.