Background: The Integrated Management of Childhood Illness (IMCI) guidelines guide the healthcare workers (HCW) referral decision of under-5 children at primary health centres (PHCs). The AIRE project has implemented the routine Pulse Oximeter (PO) use into IMCI consultations at PHCs in West Africa (Burkina Faso, Guinea, Mali and Niger) to improve the diagnosis and referral of severe cases. We analysed the frequency and correlates of missed opportunities for hospitalisation (MOH) of IMCI severe pneumonia cases. Methods: All the children aged 2-59 months attending IMCI consultations, classified as severe cases using IMCI+PO were enrolled with parental consent in a prospective cohort of 14-day in 16 research PHCs (4/country). HCW referral decision, and MOHR for severe pneumonia were described. Correlates of MOH were investigated using a generalized linear mixed regression model with a random effect on country. Results: From June 2021 to June 2022, among the 1,786 children aged 2-59 months classified as severe cases by IMCI+PO, 682 (38.2%) were severe pneumonia: among those, 35 (5.1%) had also a severe anaemia, 47 (6.9%) a severe hypoxemia (SpO2<90%) and 602 (88.3%) a severe malaria. Overall, HCW made the referral decision for 125 (18.3%) children, refused by three (2.4%) families; thus, 560 (82.1%) were MOH. Severe anaemia reduced the adjusted odds ratio [aOR] of MOH (aOR: 0.02; 95% confidence interval [95%CI]: 0.01-0.07) while having an SpO2 between 90 to 93% (aOR: 12.16, 95%CI: 3.47-42.61), or greater than 94% (aOR: 11.81; 95%CI: 3.98-35.02), or a severe malaria (aOR: 2.55; 95%CI: 1.04-6.26) significantly increased it. Conclusion: MOH for severe pneumonia were extremely high at PHC level in these settings, mainly explained by HCW decisions. The absence of severe hypoxemia was an expected decision factor but co-morbidity with severe malaria is a concern. Supporting HCW and hospital referral remain essential to improve the management of severe pneumonia.

The authors have declared no competing interest.

PACTR202206525204526

The AIRE project was funded by UNITAID, with in-kind support from Inserm and IRD.

I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.

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The details of the IRB/oversight body that provided approval or exemption for the research described are given below:

- The WHO Ethics Review Committee (WHO-ERC) gave ethical approval for this work (ERC.0003364) - The Inserm Institutional Evaluation Ethics Committee (IEEC) gave ethical approval for this work (Inserm IEEC 20-720). - The "Comite d Ethique pour la Recherche en Sante (CERS), of Burkina Faso gave ethical approval for this work (2020-4-070). - The "Comite National d Ethique pour la Recherche en Sante (CNERS)", of Guinea gave ethical approval for this work (169/CNERS/21). - The "Comite National d Ethique pour la Sante et les Sciences de la vie (CNESS)", of Mali gave ethical approval for this work (127/MSDS-CNESS). - The "Comite National d Ethique pour la Recherche en Sante (CNERS)", of Niger gave ethical approval for this work (67/2020/CNERS).

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