Oxygen therapy for children: A key tool in reducing deaths from pneumonia

Predicting the potential impact of scaling up four pneumonia interventions on under-five pneumonia mortality: A prospective Lives Saved Tool (LiST) analysis for Bangladesh, Chad, and Ethiopia

Background

Pneumonia remains the leading cause of mortality in under-five children outside the neonatal period. Progress has slowed down in the last decade, necessitating increased efforts to scale up effective pneumonia interventions.

Methods

We used the Lives Saved Tool (LiST), a modelling software for child mortality in low- and middle-income settings, to prospectively analyse the potential impact of upscaling pneumonia interventions in Bangladesh, Chad, and Ethiopia from 2023 to 2030. We included Haemophilus influenzae type B (Hib) vaccination, pneumococcal conjugate vaccine (PCV), oral antibiotics, pulse oximetry, and oxygen as pneumonia interventions in our analysis. Outcomes of interest were the number of pneumonia deaths averted, the proportion of deaths averted by intervention, and changes in the under-five mortality rate.

Findings

We found that 19 775 lives of children under-five could be saved in Bangladesh, 76 470 in Chad, and 97 343 in Ethiopia by scaling intervention coverages to ≥90% by 2030. Our estimated reductions in pneumonia deaths among children under five range from 44.61% to 57.91% in the respective countries. Increased coverage of oral antibiotics, pulse oximetry, and oxygen show similar effects in all three countries, averting between 18.80% and 23.65% of expected pneumonia deaths. Scaling-up PCV has a prominent effect, especially in Chad, where it could avert 14.04% of expected pneumonia deaths. Under-five mortality could be reduced by 1.42 per 1000 live births in Bangladesh, 22.52 per 1000 live births in Chad, and 5.48 per 1000 live births in Ethiopia.

Conclusions

This analysis shows the high impact of upscaling pneumonia interventions. The lack of data regarding coverage indicators is a barrier for further research, policy, and implementation, all requiring increased attention.

Pneumonia knowledge and care seeking behavior for children under-five years in Jigawa, Northwest Nigeria: a cross-sectional study

Background

Between 2013 and 2022, Nigeria did not meet globally defined targets for pneumonia control, despite some scale-up of vaccinations, oxygen and antibiotics. A deliberate focus on community-based programs is needed to improve coverage of protective, preventive and treatment interventions. We therefore aimed to describe caregiver knowledge and care seeking behaviour for childhood pneumonia, in a high child mortality setting in Nigeria, to inform the development of effective community-based interventions for pneumonia control.

Methods

We conducted a cross-sectional household survey in Kiyawa Local Government Area, Jigawa State, Nigeria between December 2019 and March 2020. We asked caregivers about their knowledge of pneumonia symptoms, prevention, risks, and treatment. A score of 1 was assigned for each correct response. We showed them videos of pneumonia specific symptoms and asked (1) if their child had any respiratory symptoms in the 2-weeks prior; (2) their subsequent care-seeking behaviour. Multivariate regressions explored socio-demographic and clinical factors associated with care seeking.

Results

We surveyed 1,661 eligible women, with 2,828 children under-five. Only 4.9% of women could name both cough and difficulty/fast breathing as pneumonia symptoms, and the composite knowledge scores for pneumonia prevention, risks and treatment were low. Overall, 19.0% (536/2828) of children had a report of pneumonia specific symptoms in the prior two-weeks, and of these 32.3% (176/536) were taken for care. The odds of care seeking was higher among children: with fever (AOR:2:45 [95% CI: 1.38-4.34]); from wealthiest homes (AOR: 2:13 [95% CI: 1.03-4.38]) and whose mother first married at 20-26 years compared to 15-19 years (AOR: 5.15 [95% CI: 1.38-19.26]). Notably, the caregiver's knowledge of pneumonia was not associated with care seeking.

Conclusion

While some socio-demographic factors were associated with care seeking for children with symptoms of Acute Respiratory Infection (ARI), caregiver's knowledge of the disease was not. Therefore, when designing public health interventions to address child mortality, information-giving alone is likely to be insufficient.

Effect of an Educational Program on Nurses' Knowledge and Practice of Oxygen Therapy

INTRODUCTION

Past studies have shown that healthcare professionals may lack awareness and knowledge regarding oxygen therapy, and its implementation often has several obstacles. This study was carried out to investigate the effect of an educational program about oxygen therapy on nurses' knowledge and practices.

METHODS

This cross-sectional, quasi-experimental study was conducted in 2022 at the pediatric department of Nishtar Hospital, Multan, where 160 nurses from primary and secondary health centers attended an educational program delivered in the pediatric department. The pre-test-post-test approach was used to evaluate the effectiveness of the structured educational program. The independent variable was the educational program, and the dependent variable was the nurses' knowledge and practice about oxygen toxicity. Data analysis was performed using SPSS version 23 (IBM Corp., New York, USA). The data were tabulated as means and standard deviations for numerical values and frequency percentages for categorical values. The student's t-test and the chi-square test were applied to investigate any associations among variables.

RESULTS

The average test scores before and after the implementation of the educational program were 10.75±2.65 and 17.52±2.04, respectively. The average post-test score was greater than that of the pre-test, and the difference was statistically significant (p<0.001).

CONCLUSION

The study found that after the implementation of the educational program, the knowledge and practices of nurses regarding oxygen therapy improved significantly, with the majority showing a positive attitude toward the program.

Pulse oximetry: why oxygen saturation is still not a part of standard pediatric guidelines in low-and-middle-income countries (LMICs)

BACKGROUND

With the high frequency of acute respiratory infections in children worldwide, particularly so in low-resource countries, the development of effective diagnostic support is crucial. While pulse oximetry has been found to be an acceptable method of hypoxemia detection, improving clinical decision making and efficient referral, many healthcare set ups in low- and middle-income countries have not been able to implement pulse oximetry into their practice.

MAIN BODY

A review of past pulse oximetry implementation attempts in low- and middle-income countries proposes the barriers and potential solutions for complete integration in the healthcare systems. The addition of pulse oximetry into WHO health guidelines would prove to improve detection of respiratory distress and ensuing therapeutic measures. Incorporation is limited by the cost and unavailability of pulse oximeters, and subsequent oxygen accessibility. This restriction is compounded by the lack of trained personnel, and healthcare provider misconceptions. These hurdles can be combated by focus on low-cost devices, and cooperation at national levels for development in healthcare infrastructure, resource transport, and oxygen delivery systems.

CONCLUSION

The implementation of pulse oximetry shows promise to improve child morbidity and mortality from pneumonia in low- and middle-income countries. Steady measures taken to improve access to pulse oximeters and oxygen supplies, along with enhanced medical provider training are encouraging steps to thorough pulse oximetry integration.

Slow progress towards pneumonia control for children in low-and-middle income countries as measured by pneumonia indicators: A systematic review of the literature

Background

The integrated Global Action Plan for Prevention and Control of Pneumonia and Diarrhoea (GAPPD) has the goal of ending preventable childhood deaths from pneumonia and diarrhoea by 2025 with targets and indicators to monitor progress. The aim of this systematic review is to summarise how low-and-middle income countries (LMICs) reported pneumonia-specific GAPPD indicators at national and subnational levels and whether GAPPD targets have been achieved.

Methods

We searched MEDLINE, Embase, PubMed and Global Health Databases, and the World Health Organization (WHO) website. Publications/reports between 2015 and 2020 reporting on two or more GAPPD-pneumonia indicators from LMICs were included. Data prior to 2015 were included if available in the same report series. Quality of publications was assessed with the Quality Assessment Tool for Quantitative Studies. A narrative synthesis of the literature was performed to describe which countries and WHO regions were reporting on GAPPD indicators and progress in GAPPD coverage targets.

Results

Our search identified 17 publications/reports meeting inclusion criteria, with six from peer-reviewed publications. Data were available from 139 LMICs between 2010 and 2020, predominantly from Africa. Immunisation coverage rates were the indicators most commonly reported, followed by exclusive breastfeeding rates and pneumonia case management. Most GAPPD indicators were reported at the national level with minimal reporting at the subnational level. Immunisation coverage (Haemophilus influenzae, measles, diphtheria-tetanus-pertussis vaccines) in the WHO Europe, Americas and South-East Asia regions were meeting 90% coverage targets, while pneumococcal conjugate vaccine coverage lagged globally. The remaining GAPPD indicators (breastfeeding, pneumonia case management, antiretroviral prophylaxis, household air pollution) were not meeting GAPPD targets in LMICs. There was a strong negative correlation between pneumonia specific GAPPD coverage rates and under-five mortality (Pearson correlation coefficient range = -0.74, -0.79).

Conclusion

There is still substantial progress to be made in LMICs to achieve the 2025 GAPPD targets. Current GAPPD indicators along with country reporting mechanisms should be reviewed with consideration of adding undernutrition and access to oxygen therapy as important indicators which impact pneumonia outcomes. Further research on GAPPD indicators over longer time periods and at subnational levels can help identify high-risk populations for targeted pneumonia interventions.

Pulse oximetry and oxygen services for the care of children with pneumonia attending frontline health facilities in Lagos, Nigeria (INSPIRING-Lagos): study protocol for a mixed-methods evaluation

INTRODUCTION

The aim of this evaluation is to understand whether introducing stabilisation rooms equipped with pulse oximetry and oxygen systems to frontline health facilities in Ikorodu, Lagos State, alongside healthcare worker (HCW) training improves the quality of care for children with pneumonia aged 0-59 months. We will explore to what extent, how, for whom and in what contexts the intervention works.

METHODS AND ANALYSIS

Quasi-experimental time-series impact evaluation with embedded mixed-methods process and economic evaluation.

SETTING

seven government primary care facilities, seven private health facilities, two government secondary care facilities.

TARGET POPULATION

children aged 0-59 months with clinically diagnosed pneumonia and/or suspected or confirmed COVID-19.

INTERVENTION

'stabilisation rooms' within participating primary care facilities in Ikorodu local government area, designed to allow for short-term oxygen delivery for children with hypoxaemia prior to transfer to hospital, alongside HCW training on integrated management of childhood illness, pulse oximetry and oxygen therapy, immunisation and nutrition. Secondary facilities will also receive training and equipment for oxygen and pulse oximetry to ensure minimum standard of care is available for referred children.

PRIMARY OUTCOME

correct management of hypoxaemic pneumonia including administration of oxygen therapy, referral and presentation to hospital.

SECONDARY OUTCOME

14-day pneumonia case fatality rate. Evaluation period: August 2020 to September 2022.

ETHICS AND DISSEMINATION

Ethical approval from University of Ibadan, Lagos State and University College London. Ongoing engagement with government and other key stakeholders during the project. Local dissemination events will be held with the State Ministry of Health at the end of the project (December 2022). We will publish the main impact results, process evaluation and economic evaluation results as open-access academic publications in international journals.

TRIAL REGISTRATION NUMBER

ACTRN12621001071819; Registered on the Australian and New Zealand Clinical Trials Registry.

Quality of care for children with acute respiratory infections in health facilities: a comparative analysis of assessment tools

Background

Severe childhood pneumonia requires treatment in hospital by trained health care workers. It is therefore important to determine if health facilities provide quality health services for children with acute respiratory infections (ARI), including pneumonia. Using established indicators from WHO to measure quality of care (QoC) as a reference standard, this review aims to evaluate how well existing tools assess QoC for children presenting to health facilities with ARI.

Methods

Existing assessment tools identified from a published systematic literature review that evaluated QoC assessment tools for children (<15 years) in health facilities for all health conditions were included in this ARI-specific review. 27 ARI-specific indicators or “quality measures” from the WHO “Standards for improving quality of care for children and young adolescents in health facilities” were selected for use as a reference standard to assess QoC for children presenting to health facilities with ARI symptoms. Each included assessment tool was evaluated independently by two paediatricians to determine how many of the WHO ARI quality measures were assessable by the tool. The assessment tools were then ranked in order of percentage of ARI quality measures assessable.

Results

Nine assessment tools that assessed QoC for children attending health facilities were included. Two hospital care tools developed by WHO had the most consistency with ARI-specific indicators, assessing 22/27 (81.5%) and 20/27 (74.1%) of the quality measures. The remaining tools were less consistent with the ARI-specific indicators, including between zero to 16 of the 27 quality measures. The most common indicators absent from the tools were assessment of appropriate use of pulse oximetry and administration of oxygen, how often oxygen supply was unavailable, and mortality rates.

Conclusions

The existing WHO hospital-based QoC assessment tools are comprehensive but could be enhanced by improved data quality around oxygen availability and appropriate use of pulse oximetry and oxygen administration. Any tools, however, should be considered within broader assessments of QoC, rather than utilised in isolation. Further adaptation to local settings will improve feasibility and facilitate progress in the delivery of quality health care for children with ARI.

Registration

The protocol of the original systematic review was registered in PROSPERO ID: CRD42020175652.

Factors associated with serious outcomes of pneumonia among children in a birth cohort in South Africa

BACKGROUND

Child hospitalization for pneumonia remains common, and pneumonia is a major cause of child mortality. Early identification of clinical factors associated with serious outcomes may help target risk-mitigation strategies.

METHODS

Pneumonia cases occurring in the Drakenstein Child Health Study, a prospective birth cohort outside Cape Town, South Africa were analysed, and factors associated with serious outcomes of pneumonia were identified. Pregnant women were enrolled antenatally, followed through pregnancy, and mother-child pairs from birth to 2 years. Active surveillance for pneumonia was done. Children hospitalized with pneumonia had chest radiography and blood drawn for inflammatory markers; course, outcome and duration of hospitalization were investigated. Serious outcomes were defined as in-hospital mortality or admission to intensive care unit (ICU). Prolonged hospitalization was also explored as a proxy for severity. Features associated with serious outcomes or prolonged hospitalization were analysed using modified Poisson regression.

RESULTS

Among 1143 live born infants, there were 174 hospitalized pneumonia events in 133 children under 2 years. Three children (1.7%) died, 14 (8%) required ICU admission for respiratory support. In modified Poisson regression, age < 2 months, preterm birth, or hypoxia (oxygen saturation <92%) were significantly associated with serious outcomes. Preterm birth, low birth weight, HIV exposure, stunting, or underweight-for-age (UWFA) were associated with prolonged hospitalization. Chest radiography, elevated C reactive protein, white blood cell and neutrophil counts were not useful to predict death or ICU admission in children hospitalized with pneumonia.

CONCLUSIONS

In this cohort, death from pneumonia was rare, but clinical features associated with serious outcomes and prolonged hospitalization were identified. These may help with risk stratification, to identify children who may benefit from enhanced monitoring or earlier escalation to respiratory support.

Measuring oxygen access: lessons from health facility assessments in Lagos, Nigeria

The COVID-19 pandemic has highlighted global oxygen system deficiencies and revealed gaps in how we understand and measure 'oxygen access'. We present a case study on oxygen access from 58 health facilities in Lagos state, Nigeria. We found large differences in oxygen access between facilities (primary vs secondary, government vs private) and describe three key domains to consider when measuring oxygen access: availability, cost, use. Of 58 facilities surveyed, 8 (14%) of facilities had a functional pulse oximeter. Oximeters (N=27) were typically located in outpatient clinics (12/27, 44%), paediatric ward (6/27, 22%) or operating theatre (4/27, 15%). 34/58 (59%) facilities had a functional source of oxygen available on the day of inspection, of which 31 (91%) facilities had it available in a single ward area, typically the operating theatre or maternity ward. Oxygen services were free to patients at primary health centres, when available, but expensive in hospitals and private facilities, with the median cost for 2 days oxygen 13 000 (US$36) and 27 500 (US$77) Naira, respectively. We obtained limited data on the cost of oxygen services to facilities. Pulse oximetry use was low in secondary care facilities (32%, 21/65 patients had SpO₂ documented) and negligible in private facilities (2%, 3/177) and primary health centres (<1%, 2/608). We were unable to determine the proportion of hypoxaemic patients who received oxygen therapy with available data. However, triangulation of existing data suggested that no facilities were equipped to meet minimum oxygen demands. We highlight the importance of a multifaceted approach to measuring oxygen access that assesses access at the point-of-care and ideally at the patient-level. We propose standard metrics to report oxygen access and describe how these can be integrated into routine health information systems and existing health facility assessment tools.

Improving Hospital Oxygen Systems for COVID-19 in Low-Resource Settings: Lessons From the Field

Oxygen therapy is an essential medicine and core component of effective hospital systems. However, many hospitals in low- and middle-income countries lack reliable oxygen access-a deficiency highlighted and exacerbated by the coronavirus disease (COVID-19) pandemic. Oxygen access can be challenged by equipment that is low quality and poorly maintained, lack of clinical and technical training and protocols, and deficiencies in local infrastructure and policy environment. We share learnings from 2 decades of oxygen systems work with hospitals in Africa and the Asia-Pacific regions, highlighting practical actions that hospitals can take to immediately expand oxygen access. These include strategies to: (1) improve pulse oximetry and oxygen use, (2) support biomedical engineers to optimize existing oxygen supplies, and (3) expand on existing oxygen systems with robust equipment and smart design. We make all our resources freely available for use and local adaptation.

Improving Hospital Oxygen Systems for COVID-19 in Low-Resource Settings: Lessons From the Field

Oxygen therapy is an essential medicine and core component of effective hospital systems. However, many hospitals in low- and middle-income countries lack reliable oxygen access-a deficiency highlighted and exacerbated by the coronavirus disease (COVID-19) pandemic. Oxygen access can be challenged by equipment that is low quality and poorly maintained, lack of clinical and technical training and protocols, and deficiencies in local infrastructure and policy environment. We share learnings from 2 decades of oxygen systems work with hospitals in Africa and the Asia-Pacific regions, highlighting practical actions that hospitals can take to immediately expand oxygen access. These include strategies to: (1) improve pulse oximetry and oxygen use, (2) support biomedical engineers to optimize existing oxygen supplies, and (3) expand on existing oxygen systems with robust equipment and smart design. We make all our resources freely available for use and local adaptation.

Response to oxygen therapy using oxygen concentrators run off solar power in children with respiratory distress in remote primary health facilities in Papua New Guinea

Oxygen therapy reduces mortality and morbidity from hypoxaemia in children. There are no published studies assessing individual patient responses to oxygen when delivered by oxygen concentrators in primary healthcare facilities.Ours was a prospective observational study in remote health facilities over three years. A data recording form was used for children who required oxygen. Oxygen saturation (SpO₂) was recorded before administration of oxygen, at 30 min and then daily. We assessed the primary diagnosis and the outcome.The common primary diagnoses needing oxygen were pneumonia: moderate (39%) and severe (37%). The median SpO₂ before administration of oxygen in 913 patients was 80% (interquartile range [IQR] 66%-88%), and by five days, for the 121 patients who were recorded, SpO₂ was 97% (IQR 93%-98%). Of the 745 patients with a recorded outcome, 99% had an uneventful recovery.We conclude that oxygen concentrators are effective in treating children in rural health facilities in Papua New Guinea.