Predictive value of pulse oximetry for mortality in infants and children presenting to primary care with clinical pneumonia in rural Malawi: A data linkage study

English version

Autoři: Tim Colbourn ^aff001; Carina King ^aff001; James Beard ^aff001; Tambosi Phiri ^aff003; Malizani Mdala ^aff003; Beatiwel Zadutsa ^aff003; Charles Makwenda ^aff003; Anthony Costello ^aff001; Norman Lufesi ^aff004; Charles Mwansambo ^aff004; Bejoy Nambiar ^aff005; Shubhada Hooli ^aff006; Neil French ^aff007; Naor Bar Zeev ^aff007; Shamim Ahmad Qazi ^aff010; Yasir Bin Nisar ^aff011; Eric D. McCollum ^aff009
Působiště autorů: Institute for Global Health, University College London, London, United Kingdom ^aff001; Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden ^aff002; Parent and Child Health Initiative, Lilongwe, Malawi ^aff003; Ministry of Health, Lilongwe, Malawi ^aff004; UNICEF, Lilongwe, Malawi ^aff005; Department of Pediatrics, Section of Emergency Medicine, Baylor College of Medicine, Houston, Texas, United States of America ^aff006; Institute of Infection & Global Health, University of Liverpool, Liverpool, United Kingdom ^aff007; Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi ^aff008; Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America ^aff009; Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland ^aff010; Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland ^aff011; Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America ^aff012
Vyšlo v časopise: Predictive value of pulse oximetry for mortality in infants and children presenting to primary care with clinical pneumonia in rural Malawi: A data linkage study. PLoS Med 17(10): e32767. doi:10.1371/journal.pmed.1003300
Kategorie: Research Article
doi: https://doi.org/10.1371/journal.pmed.1003300

Souhrn

Background

The mortality impact of pulse oximetry use during infant and childhood pneumonia management at the primary healthcare level in low-income countries is unknown. We sought to determine mortality outcomes of infants and children diagnosed and referred using clinical guidelines with or without pulse oximetry in Malawi.

Methods and findings

We conducted a data linkage study of prospective health facility and community case and mortality data. We matched prospectively collected community health worker (CHW) and health centre (HC) outpatient data to prospectively collected hospital and community-based mortality surveillance outcome data, including episodes followed up to and deaths within 30 days of pneumonia diagnosis amongst children 0–59 months old. All data were collected in Lilongwe and Mchinji districts, Malawi, from January 2012 to June 2014. We determined differences in mortality rates using <90% and <93% oxygen saturation (SpO₂) thresholds and World Health Organization (WHO) and Malawi clinical guidelines for referral. We used unadjusted and adjusted (for age, sex, respiratory rate, and, in analyses of HC data only, Weight for Age Z-score [WAZ]) regression to account for interaction between SpO₂ threshold (pulse oximetry) and clinical guidelines, clustering by child, and CHW or HC catchment area. We matched CHW and HC outpatient data to hospital inpatient records to explore roles of pulse oximetry and clinical guidelines on hospital attendance after referral. From 7,358 CHW and 6,546 HC pneumonia episodes, we linked 417 CHW and 695 HC pneumonia episodes to 30-day mortality outcomes: 16 (3.8%) CHW and 13 (1.9%) HC patients died. SpO₂ thresholds of <90% and <93% identified 1 (6%) of the 16 CHW deaths that were unidentified by integrated community case management (iCCM) WHO referral protocol and 3 (23%) and 4 (31%) of the 13 HC deaths, respectively, that were unidentified by the integrated management of childhood illness (IMCI) WHO protocol. Malawi IMCI referral protocol, which differs from WHO protocol at the HC level and includes chest indrawing, identified all but one of these deaths. SpO₂ < 90% predicted death independently of WHO danger signs compared with SpO₂ ≥ 90%: HC Risk Ratio (RR), 9.37 (95% CI: 2.17–40.4, p = 0.003); CHW RR, 6.85 (1.15–40.9, p = 0.035). SpO₂ < 93% was also predictive versus SpO₂ ≥ 93% at HC level: RR, 6.68 (1.52–29.4, p = 0.012). Hospital referrals and outpatient episodes with referral decision indications were associated with mortality. A substantial proportion of those referred were not found admitted in the inpatients within 7 days of referral advice. All 12 deaths in 73 hospitalised children occurred within 24 hours of arrival in the hospital, which highlights delay in appropriate care seeking. The main limitation of our study was our ability to only match 6% of CHW episodes and 11% of HC episodes to mortality outcome data.

Conclusions

Pulse oximetry identified fatal pneumonia episodes at HCs in Malawi that would otherwise have been missed by WHO referral guidelines alone. Our findings suggest that pulse oximetry could be beneficial in supplementing clinical signs to identify children with pneumonia at high risk of mortality in the outpatient setting in health centres for referral to a hospital for appropriate management.

Klíčová slova:

Death rates – Global health – Inpatients – Malawi – Medical risk factors – Outpatients – Oxygen – Pneumonia

Zdroje

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