“Unlocking the door to oxygen access – pulse oximetry as part of a holistic approach”

Pneumonia is the world’s single biggest infectious killer of adults and children, claiming the lives of 2.5 million people every year – the equivalent of the entire population of Chicago.

The COVID-19 pandemic has shone the spotlight on this neglected killer, with figures from the Every Breath Counts coalition revealing that the pandemic could add a further 1.9 million pneumonia deaths this year alone.

The world’s first Global Forum on Childhood Pneumonia was held earlier this year in Barcelona. Organisations including Save the Children, Unicef, Unitaid and many others came together to commit to the implementation of targeted pneumonia strategies, the prioritisation of vulnerable populations and the acceleration of breakthrough innovations.

Now in a time of COVID-19, the importance of access to oxygen and diagnostic tools as vital components to improving global health is increasingly being recognised – while the challenges around provision in low-income countries have never been greater.

The problem is complex: tools to diagnose respiratory distress are often not well-embedded in health systems, and oxygen therapies are expensive, designed to be implemented in high-resource healthcare settings.

The challenges are immense, but Unitaid and partners are working on end-to-end solutions that leverage the power of innovation to save lives.

Pulse oximetry – great things come in small packages

Pulse oximeters are tools found in most healthcare settings in high-income countries and even in the latest generation of the Apple Watch.

These simple devices use light to measure oxygen levels in the blood and have played a critical role in the COVID-19 pandemic, flagging up patients who are deteriorating before their condition becomes critical.

In low and middle-income countries, pulse oximetry has the potential to save the lives of thousands of people and lower the number of preventable deaths from childhood pneumonia in particular.

Before the COVID-19 pandemic struck, two Unitaid partners – PATH and ALIMA – were due to roll out the Tools for Integrated Management of Childhood Illness (TIMCI) and Améliorer l'Identification des détresses Respiratoires chez l’Enfant (AIRE) projects in nine countries in Africa and Asia.

The Unitaid-funded projects aim to improve access to affordable and appropriate technologies - notably pulse oximetry and clinical decision support tools - to help better identify critically-ill children and refer them for treatment without delay.

TIMCI project director Michael Ruffo says: “By expanding access to these tools, and collecting data on their implementation and impact, we’re taking an important step toward ending preventable child deaths from devastating diseases like pneumonia, and realising more integrated health systems.”

Innovation is at the core of these projects – with both organisations working to expand access to pulse oximeters that are more robust and suited to low-resource environments, as well as tools that assist in making diagnosis and treatment decisions, at nearly 560 public health facilities across nine countries.

“Pulse oximeters are not available in many health centres because they are not integrated in a systematic way in country protocols”, says Marine Vignon from ALIMA, who is heading up the AIRE project.

Rapid redeployment to help the fight against COVID-19

Although the pandemic delayed the roll-out of AIRE and TIMCI, a rapid reaction by Unitaid and partners saw a donation of pulse oximeters made to several African countries to help with their pandemic response.

In Burkina Faso, Mali, Guinea, Senegal and Niger, ALIMA arranged the distribution of pulse oximeters to triage centres for COVID-19, helping doctors identify potential cases and the need for oxygen therapy. Training on effective triage systems and PPE was also provided to health workers.

Kebe is a triage nurse at Pikine Health Center near Dakar in Senegal, who has been on the frontline working against both pneumonia and COVID-19.

She says: “The pulse oximeters help me a lot in my work. We use them with suspected COVID-19 cases, children and older people. When we take the oxygen saturation readings, we know whether they need oxygen or not.”

Her emergency nurse colleague in the same facility agrees, emphasising that pulse oximeters help him “do a better job for patients in respiratory distress” and in the context of COVID-19, have helped him and colleagues spot oxygen desaturation – a key sign of the virus.

PATH has facilitated donations in Kenya and Senegal. 90 pulse oximeters have been donated to health facilities in Senegal, while 89 pulse oximeters have been donated to 65 health facilities across six counties in Kenya, supported by training on their use and maintenance for the facility managers.

Dr. David Mukabi is the County Director of Health for Busia County, a province near the border with Uganda. He said: “The support has come to the county to channel COVID 19 support. We are very grateful because it is difficult to diagnose children and we appreciate the value of the pulse oximeter and its ability to support health workers in diagnosis of children.”

The TIMCI project also created an online catalogue of COVID-19 training resources for health care workers, and is supporting medical device repairs and training for biomedical engineers in Kenya, Myanmar and Tanzania.

Implementation in the field of the AIRE and TIMCI projects is due to start in the first three months of 2021, with preparatory work and training already going on behind the scenes.

From diagnosis to treatment – developing end-to-end solutions

Diagnosing respiratory conditions is just one piece of the jigsaw of solutions needed to combat pneumonia, particularly in young children.

Once patients in respiratory distress have been identified as requiring treatment, access to medical oxygen is often needed – and fast.

Timely access to oxygen therapy can make the difference between life and death when treating patients with moderate to severe disease, other complications and now COVID-19.

Oxygen therapy is often not available in low-resource settings due to poor infrastructure, lack of fit-for-purpose oxygen delivery systems, and human resource and funding constraints.

Liquid oxygen in the form of cylinders and tanks can be expensive and difficult to transport, while oxygen concentrators suffer from high rates of mechanical failure.

Unitaid partner PATH, as part of their work on the COVID-19 Respiratory Care Response Coordination project, has launched a COVID-19 Oxygen Needs Tracker, revealing the enormous daily need for oxygen in many low- and middle-income countries, to meet the demand of the pandemic as it continues.

This lack of medical oxygen is arguably one of the defining health equity issues of our age that has been laid bare by the pandemic.

“Despite the challenges that come with pandemic response, there are also opportunities,” says Jeff Bernson, Chief Programs and Innovation Officer at PATH. “If we act together across sectors to prioritise oxygen now, not only can we facilitate a rapid response to the pandemic, but close wide gaps in access that too many countries continue to face. This is the time to build sustainable oxygen therapy platforms that save lives for generations to come.”

Innovation - the key to bridging the oxygen gap

Innovative ideas are needed to solve this oxygen deficit – and Unitaid is addressing this through the first awards for its new agility mechanism, UnitaidExplore.

Launched earlier in 2020, the initial two awards have now been given to Vayu Health and The EssentialTech Centre respectively, to help kick-start the scale-up of two potentially ground-breaking devices in widening paediatric access to oxygen.

Vayu Global Health Innovations - a Boston-based ‘bench top to bedside’ entity - will use the funding to take forward development of its bCPAP and oxygen blender devices, which enable babies to access oxygen therapy without the need for an electricity supply or a compressed air tank.

Listen below to an interview with Vayu Managing Director Dr Thomas Burke, who explains the background to their work and their plans for the future.

Interview: Dr Thomas Burke of Vayu Global Health Innovations talks about receiving funding from UnitaidExplore

Meanwhile, The EssentialTech Centre, part of the Swiss Federal Institute of Technology (EPFL) in Lausanne, aims to develop a new, affordable oxygen concentrator designed for use in remote health centres, as well as an integrated oxygen delivery service.

Their core mission is to overcome oxygen concentrator mechanical failure, by improving individual components of the technology to better resist hot, humid conditions where power is intermittent and of poor quality. The concentrator will also have the ability to store both oxygen and electricity, when power is unavailable.

Leader of the EssentialTech Centre’s GlobalO2 Program Gene Saxon said: “We believe that oxygen should be available to every child that needs it, no matter where they are born. This holistic approach will allow health-care workers to spend more time focusing on their patients, rather than their equipment.”

Where to next?

It’s clear that COVID-19 will be with us for some time, and what is also increasingly evident is that the pandemic presents an opportunity to ‘build back better’, investing in pneumonia control now to help countries fight both COVID-19 and other respiratory illnesses.

Looking towards the aims set out by the 2030 Sustainable Development Goals, there can be no end to preventable deaths for under-fives and no chance at healthy lives for everyone without reducing deaths from pneumonia.

Reflecting on the challenges ahead, Unitaid’s Executive Director Philippe Duneton says: “The COVID-19 pandemic has shone a spotlight on a longstanding problem: poor access to pulse oximetry and medical oxygen in LMICs.

“This has significantly hindered our ability to adequately manage children with pneumonia and other illnesses contributing to unacceptably high levels of child deaths.

“We now need to ensure that efforts to improve access to these tools for COVID patients are sustainable and also consider the ongoing needs of key populations including children under five.”

Related publication: Leveraging the COVID-19 response to end preventable child deaths from pneumonia, The Lancet, 12.11.2020