Implication of the 2014 World Health Organization Integrated Management of Childhood Illness Pneumonia Guidelines with and without pulse oximetry use in Malawi: A retrospective cohort study

Background: Under-5 pneumonia mortality remains high in low-income countries. In 2014 the World Health Organization (WHO) advised that children with chest indrawing pneumonia, but without danger signs or peripheral oxygen saturation (SpO2) < 90% be treated community, rather than hospitalized. Malawi there is limited pulse oximetry availability. Methods: Secondary analysis of 13,413 under-5 cases Malawi. Pneumonia associated case fatality ratios (CFR) were calculated by disease severity under assumptions 2005 and WHO Integrated Management Childhood Illness (IMCI) guidelines, oximetry. We investigated if readings missing not at random (MNAR). Results: The CFR patients classified as having non-severe per IMCI guidelines doubled assumption was available (1.5% vs 0.7% oximetry, P<0.001). When applied a SpO2 threshold for referral and/or admission, number meeting hospitalization criteria decreased 70.3%. Unrecorded MNAR an adjusted odds 4.9 (3.8, 6.3), similar to 90%. Although fewer girls hospitalized, female sex independent risk factor. Conclusions: In Malawi, implementation will miss cases. Alternatively, may result large reduction rates significantly increasing inability obtain reading considered sign.