Comment
World Pneumonia Day 2016: pulse oximetry and oxygen
Pneumonia persists as the leading infectious killer
of children worldwide. Hypoxaemia is a predictor
of mortality from childhood pneumonia, and
approximately 1·5 million children with severe
pneumonia require oxygen treatment each year.1 Pulse
oximetry and oxygen are key interventions for treating
pneumonia and preventing death. Pulse oximetry, the
standard for detecting hypoxaemia, is cost-effective
and can identify 20–30% more cases than using clinical
signs alone.2 In addition to averting deaths, oximetry
helps identify children requiring referral, increases the
number of correctly treated severe pneumonia cases,
and reduces the incidence of incorrect treatment with
antibiotics.3 Early identification of hypoxaemia with
oximetry and appropriate treatment with oxygen are
lifesaving; yet availability and access to both services
remain inadequate in low-resource settings.
There is an urgent need to increase access to oxygen
and pulse oximetry in low-resource settings. Recent
WHO guidance comprising a publication of technical
specifications for oxygen concentrators intended for
use in low-resource settings,4 an expansive manual on
the management of hypoxaemia,5 and identification
of oxygen as a critical service in the care of newborns6
has strengthened the call for improving access to
these essential tools. Further consideration is being
given to including hypoxaemia as a general danger
sign in the integrated management of acutely ill
children. Engagements with suppliers and interested
governments have established that safe and reliable
provision of oxygen requires a systems approach with
wrap-around services including maintenance, training,
and supervision, plus strong linkages between different
health system levels. This approach necessitates
thinking of oxygen and oximeters as a service requiring
careful planning, rather than simply as commodities
which require procurement and distribution.
In Ethiopia, Nigeria, and Papua New Guinea work is
underway to better understand how health systems
can include safe and reliable identification of severe
illness and treatment of hypoxaemic patients. Ethiopia
has been a leader in planning for such an effort.
Ethiopia has experienced significant improvements
in its health system and the health status of its
population, reducing its under-5 mortality by two-thirds
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between 1990 and 2012, and successfully meeting Published Online
November 9, 2016
Millennium Development Goal 4 on child survival.7 http://dx.doi.org/10.1016/
However, pneumonia remains a leading cause of S2214-109X(16)30296-0
under-5 deaths.8 The complexity and comorbidity of
the residual mortality will require greater focus on
referral linkages and supportive care systems in order
to maintain the significant pace of mortality decline
observed between 2000 and 2015. Currently, many
Ethiopian health centres do not have fully functional
oxygen cylinders, concentrators, or oximeters available.
Standard operating procedures or job aids for safe and
effective oxygen therapy or identification of children
with hypoxaemia or severe disease are not common,
and often no staff are trained in providing oxygen
therapy. Additionally, there are no policies and adapted
guidelines for the use of oxygen and oximetry. This lack
of access to oxygen and pulse oximetry is not unique to
Ethiopia. It is a familiar situation throughout much of
the world, particularly in rural areas with limited access
to care services.
However, Ethiopia is addressing this situation head-
on. To increase access to oxygen and pulse oximetry,
the Ethiopian Ministry of Health (MOH) has responded
by undertaking a comprehensive strategic planning
process captured as a roadmap for oxygen and pulse
oximetry scale-up.9 A national technical working
group has been formed to support the coordination,
planning, and implementation of the roadmap. This is
a formidable commitment benefiting from the strong
coordination of the Ethiopian MOH and setting the
stage for ongoing improvement to the quality of care
within the primary health care unit—a core pillar of the
country’s national Health Sector Transformation Plan.
To support the Ethiopian MOH, international and local
partners are planning activities focused on establishing
a supply chain of oxygen and oximetry commodities
as well as appropriate policies and guidelines, training,
and behaviour change programmes, accompanied
by monitoring, learning and evaluation plans, and
advocacy efforts. Even when oxygen and oximetry
are available, reported therapeutic use for childhood
pneumonia can be low, with common barriers including
insufficient supply; competition for use; lack of policies,
guidelines, and training; and perceived high cost.10
A broadly engaged effort is therefore required to ensure
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appropriate and safe use of oxygen services at each
suitable facility level commensurate with the proper
systems in place, including trained staff, adequate
electricity, and demand for services across multiple
indications.
While efforts are being made to address hypoxaemia
and its associated mortality, more needs to be done.
Children with pneumonia will continue to die without
access to pulse oximeters and oxygen. Increased global
awareness and action are necessary. Despite pneumonia
being a leading cause of death among children—more
than HIV, malaria, and tuberculosis combined—necessary
resources are not being invested to the same degree, and
children with pneumonia do not receive the care they
deserve. Ethiopia is demonstrating that a coordinated
and strategic approach can help reverse this tide.
*Amy Sarah Ginsburg, Rasa Izadnegahdar, Keith P Klugman
Save the Children, Fairfield, CT 06825, USA (ASG); and Bill and
Melinda Gates Foundation, Seattle, WA, USA (RI, KPK)
aginsburg@savechildren.org
We declare no competing interests.
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Copyright © The Author(s). Published by Elsevier Ltd. This is an Open Access
article under the CC BY license.
1 Nair H, Simoes EA, Rudan I, et al. Global and regional burden of hospital
admissions for severe acute lower respiratory infections in young children
in 2010: a systematic analysis. Lancet 2013; 381: 1380–90.
2 Duke T, Subhi R, Peel D, Frey B. Pulse oximetry: technology to reduce child
mortality in developing countries. Ann Trop Paediatr 2009; 29: 165–75.
3 Floyd J, Wu L, Hay Burgess D, Izadnegahdar R, Mukanga D, Ghani AC.
Evaluating the impact of pulse oximetry on childhood pneumonia
mortality in resource-poor settings. Nature 2015; 528: S53–59.
4 World Health Organization. Technical specifications for oxygen
concentrators. http://apps.who.int/medicinedocs/en/d/Js22194en/
(accessed Oct 27, 2016).
5 World Health Organization. Oxygen therapy for children: a manual for
health workers. http://www.who.int/maternal_child_adolescent/
documents/child-oxygen-therapy/en/ (accessed Oct 26, 2016).
6 World Health Organization. WHO technical specifications of neonatal
resuscitation devices. http://apps.who.int/medicinedocs/en/m/abstract/
Js22389en/ (accessed Oct 26, 2016).
7 World Health Organization. Ethiopia: child health. http://www.afro.who.
int/en/ethiopia/country-programmes/topics/4475-child-health.html
(accessed Sept 18, 2016).
8 Walker CL, Rudan I, Liu L, et al. Global burden of childhood pneumonia and
diarrhoea. Lancet 2013; 381: 1405–16.
9 Federal Ministry of Health, Ethiopia. Medical oxygen and pulse oximetry
scale up road map in Ethiopia (2016–2021). Addid Ababa: Federal Ministry
of Health, 2016.
10 Ginsburg AS, Van Cleve WC, Thompson MI, English M. Oxygen and pulse
oximetry in childhood pneumonia: a survey of healthcare providers in
resource-limited settings. J Trop Pediatr 2012; 58: 389–93.
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