Improved oxygen systems for childhood pneumonia: a multihospital effectiveness study in Papua New Guinea

Background In rural hospitals of developing countries, oxygen supplies are poor and detection of hypoxaemia is difficult. Oxygen concentrators and pulse oximeters might help to manage the disease; however, use of such technology in developing countries needs comprehensive assessment. We studied the effect of an improved oxygen system on death rate in children with pneumonia in Papua New Guinea. Methods We installed an improved oxygen system in five hospitals in Papua New Guinea, and assessed its use in more than 11000 children with pneumonia (2001-07) and compared case-fatality rates. Admissions between January, 2001, and December, 2004, formed the pre-intervention group, and those between July, 2005, and October, 2007, formed the post-intervention group. Oxygen concentrators and pulse oximeters were introduced in the five hospitals, and a protocol for detection of hypoxaemia and clinical use of oxygen was supplied. All children admitted had their oxygen saturation measured; if it was less than 90%, oxygen was delivered via nasal prongs at a starting flow rate of 0.5-1 L/min. We recorded all costs associated with the establishment and maintenance of this system. The study was approved by the Medical Research Advisory Committee of Papua New Guinea, number MRAC 04.02. Findings Before the use of this system, 356 of 7161 children admitted in the five hospitals for pneumonia died (case-fatality rate 4.97% [95% CI 4.5-5.5]), whereas 133 of 4130 children died in the 27 months after the introduction of the system (3.22% [2.7-3.8]). After the improved system was introduced, the risk of death for a child with pneumonia was 35% lower than was that before the project began (risk ratio 0.65 [0.52-0.78], p<0.0001). Mortality rates varied between hospitals. The estimated costs of this system were US$51 per patient treated, US$1673 per life saved, and US$50 per disability-adjusted life-year (DALY) averted. Interpretation Pulse oximetry and oxygen concentrators can alleviate oxygen shortages, reduce mortality, and improve quality of care for children with pneumonia in developing countries. The cost-effectiveness of this system compared favourably with that of other public-health interventions. Funding The Papua New Guinea National Department of Health; WHO, Papua New Guinea and Western Pacific Regional Office; AirSep corporation, Buffalo, NY, USA; the Ross Trust, VIC, Australia; AusAID; Jacques Gostelli, Switzerland; and a grant from the University of Melbourne.