{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,23]],"date-time":"2026-06-23T17:51:20Z","timestamp":1782237080628,"version":"3.54.5"},"reference-count":33,"publisher":"Public Library of Science (PLoS)","issue":"6","license":[{"start":{"date-parts":[[2026,6,23]],"date-time":"2026-06-23T00:00:00Z","timestamp":1782172800000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS One"],"abstract":"\n Background<\/jats:title>\n Pneumonia is preventable and treatable, yet it remains the leading infectious cause of illness and death among under-five children. Bubble continuous positive airway pressure (bCPAP) offers a promising option for oxygen therapy combined with appropriate antibiotics and other supportive care. However, the cost-effectiveness of bCPAP in resource-limited settings such as Ethiopia is not documented. We aimed to evaluate the cost-effectiveness of bCPAP in treating severe pneumonia and hypoxaemia in under-five children in Ethiopia.<\/jats:p>\n <\/jats:sec>\n \n Methods<\/jats:title>\n We developed a decision-analytical model (decision tree) to determine the cost-effectiveness of a locally made bCPAP compared with the standard of care (WHO-recommended low-flow oxygen therapy) in general hospitals. Effectiveness was measured as the number of child deaths and disability adjusted life years (DALYs) averted. Cost data were extracted from published literature and local markets. The incremental cost-effectiveness ratio (ICER) was calculated and evaluated against the willingness-to-pay (WTP) thresholds set at multiples (0.34, 1, and 3) of Ethiopia\u2019s GDP per capita. Sensitivity analyses were performed to test the robustness of the results.<\/jats:p>\n <\/jats:sec>\n \n Results<\/jats:title>\n For every 10,000 children with severe pneumonia and hypoxaemia, providing oxygen using locally made bCPAP will save an additional 31 children compared to the standard of care. A locally made bCPAP has an ICER of 139.5 USD per DALY averted. These results were robust in the sensitivity analysis performed, showing a 100% probability of being cost-effective at one times the GDP per capita of Ethiopia.<\/jats:p>\n <\/jats:sec>\n \n Conclusion<\/jats:title>\n A locally made bCPAP is a highly cost-effective intervention for treating severe pneumonia and hypoxaemia in under-five children in Ethiopian general hospitals. These findings provide critical evidence for decision-makers to support and scale-up use of bCPAP in Ethiopia and other similar low and middle income countries.<\/jats:p>\n <\/jats:sec>","DOI":"10.1371\/journal.pone.0352122","type":"journal-article","created":{"date-parts":[[2026,6,23]],"date-time":"2026-06-23T17:29:14Z","timestamp":1782235754000},"page":"e0352122","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":0,"title":["Cost-effectiveness of bubble continuous positive airway pressure in treating severe pneumonia and hypoxaemia in under-five children in Ethiopia"],"prefix":"10.1371","volume":"21","author":[{"ORCID":"https:\/\/orcid.org\/0009-0009-1769-6984","authenticated-orcid":true,"given":"Abdi Gari","family":"Negasa","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Firew Tekle","family":"Bobo","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Meseret","family":"Gebre","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tsinuel","family":"Nigatu","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1777-0816","authenticated-orcid":true,"given":"Mirkuzie","family":"Woldie","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mideksa Adugna","family":"Koricho","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mohammod J.","family":"Chisti","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Peter","family":"Berman","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Girmaye","family":"Dinsa","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2026,6,23]]},"reference":[{"key":"pone.0352122.ref001","unstructured":"World Health Organization. Pneumonia in children. https:\/\/www.who.int\/news-room\/fact-sheets\/detail\/pneumonia. 2022. Accessed 2023 October 1."},{"key":"pone.0352122.ref002","unstructured":"World Health Organization. Pocket book of hospital care for children: guidelines for the management of common childhood illnesses. Geneva: World Health Organization. 2013."},{"issue":"9998","key":"pone.0352122.ref003","doi-asserted-by":"crossref","first-page":"1057","DOI":"10.1016\/S0140-6736(15)60249-5","article-title":"Bubble continuous positive airway pressure for children with severe pneumonia and hypoxaemia in Bangladesh: an open, randomised controlled trial","volume":"386","author":"MJ Chisti","year":"2015","journal-title":"Lancet"},{"issue":"5","key":"pone.0352122.ref004","doi-asserted-by":"crossref","DOI":"10.1016\/S2214-109X(24)00032-9","article-title":"Effectiveness of bubble continuous positive airway pressure for treatment of children aged 1-59 months with severe pneumonia and hypoxaemia in Ethiopia: a pragmatic cluster-randomised controlled trial","volume":"12","author":"M Gebre","year":"2024","journal-title":"Lancet Glob Health"},{"issue":"9","key":"pone.0352122.ref005","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0136166","article-title":"Hypoxaemia as a Mortality Risk Factor in Acute Lower Respiratory Infections in Children in Low and Middle-Income Countries: Systematic Review and Meta-Analysis","volume":"10","author":"M Lazzerini","year":"2015","journal-title":"PLoS One"},{"key":"pone.0352122.ref006","unstructured":"World Health Organization. Pneumonia. Geneva: World Health Organization. 2022. https:\/\/www.who.int\/news-room\/fact-sheets\/detail\/pneumonia"},{"key":"pone.0352122.ref007","doi-asserted-by":"crossref","first-page":"101441","DOI":"10.1016\/j.cegh.2023.101441","article-title":"Determinants of under-five pneumonia among children visited in nine public health Hospitals in Ethiopia","volume":"24","author":"F Girma","year":"2023","journal-title":"Clinical Epidemiology and Global Health"},{"key":"pone.0352122.ref008","doi-asserted-by":"crossref","first-page":"1606783","DOI":"10.1155\/2020\/1606783","article-title":"Magnitude and predictors of pneumonia among under-five children in Ethiopia: A systematic review and meta-analysis","volume":"2020","author":"YM Alamneh","year":"2020","journal-title":"J Environ Public Health"},{"key":"pone.0352122.ref009","doi-asserted-by":"crossref","first-page":"20503121221078445","DOI":"10.1177\/20503121221078445","article-title":"Severe pneumonia: Treatment outcome and its determinant factors among under-five patients, Jimma, Ethiopia","volume":"10","author":"K Tegenu","year":"2022","journal-title":"SAGE Open Med"},{"key":"pone.0352122.ref010","unstructured":"World Health Organization. Revised WHO classification and treatment of childhood pneumonia at health facilities. Geneva: WHO. 2021."},{"issue":"3","key":"pone.0352122.ref011","doi-asserted-by":"crossref","first-page":"204","DOI":"10.1016\/j.siny.2016.02.009","article-title":"Continuous positive airway pressure: Physiology and comparison of devices","volume":"21","author":"S Gupta","year":"2016","journal-title":"Semin Fetal Neonatal Med"},{"issue":"3","key":"pone.0352122.ref012","doi-asserted-by":"crossref","first-page":"339","DOI":"10.1093\/tropej\/fmz069","article-title":"To Bubble or Not? A Systematic Review of Bubble Continuous Positive Airway Pressure in Children in Low- and Middle-Income Countries","volume":"66","author":"M N\u00f8rgaard","year":"2020","journal-title":"J Trop Pediatr"},{"issue":"6","key":"pone.0352122.ref013","doi-asserted-by":"crossref","DOI":"10.1016\/S2214-109X(17)30145-6","article-title":"Continuous positive airway pressure for children with undifferentiated respiratory distress in Ghana: an open-label, cluster, crossover trial","volume":"5","author":"PT Wilson","year":"2017","journal-title":"Lancet Glob Health"},{"issue":"11","key":"pone.0352122.ref014","doi-asserted-by":"crossref","first-page":"964","DOI":"10.1016\/S2213-2600(19)30243-7","article-title":"Bubble continuous positive airway pressure for children with high-risk conditions and severe pneumonia in Malawi: an open label, randomised, controlled trial","volume":"7","author":"ED McCollum","year":"2019","journal-title":"Lancet Respir Med"},{"issue":"17","key":"pone.0352122.ref015","doi-asserted-by":"crossref","first-page":"4934","DOI":"10.3390\/jcm11174934","article-title":"Effectiveness of Bubble Continuous Positive Airway Pressure (BCPAP) for Treatment of Children Aged 1-59 Months with Severe Pneumonia and Hypoxemia in Ethiopia: A Pragmatic Cluster Randomized Controlled Clinical Trial","volume":"11","author":"M Gebre","year":"2022","journal-title":"J Clin Med"},{"issue":"6","key":"pone.0352122.ref016","doi-asserted-by":"crossref","first-page":"601","DOI":"10.1007\/s40273-021-01112-8","article-title":"Consolidated Health Economic Evaluation Reporting Standards 2022 (CHEERS 2022) Statement: Updated Reporting Guidance for Health Economic Evaluations","volume":"40","author":"D Husereau","year":"2022","journal-title":"Pharmacoeconomics"},{"key":"pone.0352122.ref017","unstructured":"Ministry of Health E. Administration and control authority standard treatment guidelines. 2014."},{"key":"pone.0352122.ref018","unstructured":"World Health Organization. Making fair choices on the path to universal health coverage: Final report of the WHO Consultative Group on Equity and Universal Health Coverage. 2014."},{"issue":"5","key":"pone.0352122.ref019","doi-asserted-by":"crossref","DOI":"10.1016\/j.heliyon.2021.e07063","article-title":"Factors associated with mortality in pediatric pneumonia patients supported with mechanical ventilation in developing country","volume":"7","author":"A Meliyanti","year":"2021","journal-title":"Heliyon"},{"issue":"1","key":"pone.0352122.ref020","doi-asserted-by":"crossref","first-page":"9","DOI":"10.1186\/s12931-023-02648-3","article-title":"Risk factors for prolonged mechanical ventilation in critically ill patients with influenza-related acute respiratory distress syndrome","volume":"25","author":"P-C Hsu","year":"2024","journal-title":"Respir Res"},{"key":"pone.0352122.ref021","unstructured":"Central Statistics Agency E. Consumer Price Index. http:\/\/www.csa.gov.et\/price-indices\/consumer-price-index"},{"issue":"10","key":"pone.0352122.ref022","doi-asserted-by":"crossref","first-page":"763","DOI":"10.2471\/BLT.08.058370","article-title":"Meeting oxygen needs in Africa: an options analysis from the Gambia","volume":"87","author":"SRC Howie","year":"2009","journal-title":"Bull World Health Organ"},{"issue":"1","key":"pone.0352122.ref023","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0260930","article-title":"Hospitalization costs for COVID-19 in Ethiopia: Empirical data and analysis from Addis Ababa\u2019s largest dedicated treatment center","volume":"17","author":"ST Memirie","year":"2022","journal-title":"PLoS One"},{"issue":"1","key":"pone.0352122.ref024","doi-asserted-by":"crossref","DOI":"10.1136\/bmjgh-2016-000166","article-title":"Household expenditures on pneumonia and diarrhoea treatment in Ethiopia: a facility-based study","volume":"2","author":"ST Memirie","year":"2017","journal-title":"BMJ Glob Health"},{"issue":"10","key":"pone.0352122.ref025","doi-asserted-by":"crossref","first-page":"763","DOI":"10.2471\/BLT.08.058370","article-title":"Meeting oxygen needs in Africa: an options analysis from the Gambia","volume":"87","author":"SRC Howie","year":"2009","journal-title":"Bull World Health Organ"},{"issue":"5","key":"pone.0352122.ref026","doi-asserted-by":"crossref","DOI":"10.9745\/GHSP-D-22-00058","article-title":"Financial Implications of Tariffs for Medical Oxygen on Rwandan Public Hospitals\u2019 Finance Management During the Coronavirus Epidemic","volume":"10","author":"D Kizza","year":"2022","journal-title":"Glob Health Sci Pract"},{"issue":"2","key":"pone.0352122.ref027","doi-asserted-by":"crossref","first-page":"118","DOI":"10.2471\/BLT.14.138206","article-title":"Thresholds for the cost-effectiveness of interventions: alternative approaches","volume":"93","author":"E Marseille","year":"2015","journal-title":"Bull World Health Organ"},{"issue":"1","key":"pone.0352122.ref028","doi-asserted-by":"crossref","first-page":"7","DOI":"10.1186\/s12962-021-00260-0","article-title":"Cost per DALY averted in low, middle- and high-income countries: evidence from the global burden of disease study to estimate the cost-effectiveness thresholds","volume":"19","author":"R Daroudi","year":"2021","journal-title":"Cost Eff Resour Alloc"},{"key":"pone.0352122.ref029","unstructured":"United Nations Development Programme. Human Development Report 2021-22. United Nations Development Programme. 2022."},{"key":"pone.0352122.ref030","author":"L Brenzel","year":"2006","journal-title":"Vaccine-preventable diseases"},{"issue":"6","key":"pone.0352122.ref031","doi-asserted-by":"crossref","first-page":"543","DOI":"10.1136\/archdischild-2021-323041","article-title":"Continuous positive airway pressure for children in resource-limited settings, effect on mortality and adverse events: systematic review and meta-analysis","volume":"107","author":"KL Sessions","year":"2022","journal-title":"Arch Dis Child"},{"issue":"7","key":"pone.0352122.ref032","doi-asserted-by":"crossref","DOI":"10.1136\/bmjopen-2016-015344","article-title":"Bubble continuous positive airway pressure in the treatment of severe paediatric pneumonia in Malawi: a cost-effectiveness analysis","volume":"7","author":"TB Kortz","year":"2017","journal-title":"BMJ Open"},{"key":"pone.0352122.ref033","doi-asserted-by":"crossref","first-page":"288","DOI":"10.1186\/s12887-014-0288-1","article-title":"Cost-effectiveness analysis of a low-cost bubble CPAP device in providing ventilatory support for neonates in Malawi - a preliminary report","volume":"14","author":"A Chen","year":"2014","journal-title":"BMC Pediatr"}],"container-title":["PLOS One"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0352122","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,6,23]],"date-time":"2026-06-23T17:29:28Z","timestamp":1782235768000},"score":1,"resource":{"primary":{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0352122"}},"subtitle":[],"editor":[{"given":"Oriana","family":"Rivera-Lozada de Bonilla","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"editor"}]}],"short-title":[],"issued":{"date-parts":[[2026,6,23]]},"references-count":33,"journal-issue":{"issue":"6","published-online":{"date-parts":[[2026,6,23]]}},"URL":"https:\/\/doi.org\/10.1371\/journal.pone.0352122","relation":{},"ISSN":["1932-6203"],"issn-type":[{"value":"1932-6203","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,6,23]]}}}