Background: The AIRE project has implemented routine Pulse Oximeter (PO) use in Integrated
Management of Childhood Illness (IMCI) consultations to improve the diagnosis and care management
of severe illnesses in primary health centre (PHC) in Burkina Faso, Guinea, Mali and Niger. We analysed
care management of severe cases according to hypoxemia, and the determinants of their Day-14
mortality.
Methods: All children under-5 attending IMCI consultations using PO and classified as severe cases
(severe IMCI cases or with severe hypoxemia: SpO2<90%) were enrolled at 16 research PHCs
(four/country) in a 14-Day prospective cohort with parental consent. Care management according to
hypoxemia severity and determinants of Day-14 mortality were analysed.
Results: From June 2021 to June 2022, 1,998 severe cases, including 212 (10.6%) aged <2 months were
enrolled. Severe hypoxemia was common (7.1%), affecting both respiratory cases (9.9%) and non
respiratory cases (3.7%); 10.5% had moderate hypoxemia (90%≤SpO2≤93%). Overall, 463 (23.2%) have
been hospitalised. At Day-14, 95 (4.8%) have died, and 27 (1.4%) were lost-to-follow-up. The
proportions of referral decision, hospitalisation and oxygen therapy were significantly higher for severe
hypoxemic cases (83.8%, 82.3%, 34.5%, respectively) than for those with moderate hypoxemia (32.7%,
26.5%, 7.1%, respectively) or without hypoxemia (26.3%, 17.5%, 1.4%, respectively). Similarly, Day-14
mortality rates were 26.1%, 7.5% and 2.3% respectively (p<0.001). Death occurred within a median
delay of one day for severe hypoxemia. In an adjusted mixed-effect Cox model, age <2 months, severe
and moderate hypoxemia, severe malaria, and place of case management elsewhere than at PHC
independently increased mortality at Day-14.
Conclusion: Both severe and moderate hypoxemia were frequent among outpatient critically ill
children diagnosed using PO, and associated with a high mortality. Although, the diagnosis of
hypoxemia prompted their care management, hospital referral and access to oxygen remain sub
optimal and crucial levers for reducing under-5 mortality in West Africa.

Children, IMCI Severe illness, Pulse Oximeter, Primary Health Centres, Mortality, West Africa