Missed opportunities for hospital referral of young children with severe pneumonia identified at primary care using pulse oximetry: an analysis from the AIRE study in West Africa

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Résumé

Childhood Illness (IMCI) guidelines, healthcare workers
(HCWs) should refer all severe pneumonia among children
under 5 seen in primary care in resource-limited
settings.
We investigated the frequency and correlates of missed
opportunities for hospital referral (MOHR) of clinical severe
pneumonia. Our study was embedded within the Améliorer
l'Identification des détresses Respiratoires chez l'Enfant
project, which involved the routine implementation of
pulse oximetry (PO) within IMCI consultations at primary
healthcare centres (PHCs) in West Africa: Burkina Faso,
Guinea, Mali and Niger.
Methods All children aged 2–59 months attending IMCI
consultations in 16 PHCs and classified as severe cases
using IMCI+PO were enrolled into a prospective cohort
for 14 days, with parental consent. We estimated the
rate of MOHR for IMCI-defined
severe pneumonia, which
was either not referred, or referred but did not make it to
hospital. Correlates of MOHR at day 14 were investigated
using logistic mixed regression with random effect for
PHCs.
Results From June 2021 to June 2022, among the 1786
children aged 2–59 months classified as severe cases by
IMCI+PO, 682 (38.2%) were severe pneumonia. Of these,
35 (5.1%) also had severe anaemia, 47 (6.9%) severe
hypoxaemia (SpO2 <90%) and 602 (88.3%) severe malaria.
HCW made the referral decision for 125 (18.3%) children,
refused by three (2.4%) families; 560 (82.1%) were MOHR.
Severe anaemia reduced the odds of MOHR (adjusted
OR (aOR): 0.02; 95% CI 0.01 to 0.07) whereas having an
SpO2 between 90% and 93% (aOR: 12.16; 95% CI 3.47 to
42.61) or greater than 94% (aOR: 11.81; 95% CI 3.98 to
35.02) or severe malaria (aOR:2.55; 95% CI 1.04 to 6.26)
significantly increased it.
Conclusion MOHR for severe pneumonia was extremely
high at PHC level in these settings, mainly explained
by HCW’s decisions. Strengthening the referral system
and training HCW to reinforce their adherence to IMCIguidelines remains essential to improve the management
of severe pneumonia.
Trial registration number PACTR202206525204526; Pan
African Clinical Trials Registry on 15 June 2022

Mots-clés

Trial registration number PACTR202206525204526; Pan African Clinical Trials Registry on 15 June 2022.