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Strunk T, Molloy EJ, Mishra A, Bhutta ZA. Neonatal bacterial sepsis. Lancet 2024:S0140-6736(24)00495-1. [PMID: 38944044 DOI: 10.1016/s0140-6736(24)00495-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 02/06/2024] [Accepted: 03/07/2024] [Indexed: 07/01/2024]
Abstract
Neonatal sepsis remains one of the key challenges of neonatal medicine, and together with preterm birth, causes almost 50% of all deaths globally for children younger than 5 years. Compared with advances achieved for other serious neonatal and early childhood conditions globally, progress in reducing neonatal sepsis has been much slower, especially in low-resource settings that have the highest burden of neonatal sepsis morbidity and mortality. By contrast to sepsis in older patients, there is no universally accepted neonatal sepsis definition. This poses substantial challenges in clinical practice, research, and health-care management, and has direct practical implications, such as diagnostic inconsistency, heterogeneous data collection and surveillance, and inappropriate treatment, health-resource allocation, and education. As the clinical manifestation of neonatal sepsis is frequently non-specific and the current diagnostic standard blood culture has performance limitations, new improved diagnostic techniques are required to guide appropriate and warranted antimicrobial treatment. Although antimicrobial therapy and supportive care continue as principal components of neonatal sepsis therapy, refining basic neonatal care to prevent sepsis through education and quality improvement initiatives remains paramount.
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Affiliation(s)
- Tobias Strunk
- Neonatal Directorate, King Edward Memorial Hospital, Child and Adolescent Health Service, Perth, WA, Australia; Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, WA, Australia.
| | - Eleanor J Molloy
- Discipline of Paediatrics, Trinity College, University of Dublin and Trinity Research in Childhood Centre, Dublin, Ireland; Children's Health Hospital at Tallaght, Tallaght University Hospital, Dublin, Ireland; Trinity Translational Medicine Institute, St James Hospital, Dublin, Ireland; Neonatology, Children's Health Hospital at Crumlin, Dublin, Ireland; Paediatrics, Coombe Women's and Infant's University Hospital, Dublin, Ireland
| | - Archita Mishra
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, WA, Australia
| | - Zulfiqar A Bhutta
- Centre for Global Child Health, Hospital for Sick Children, Toronto, ON, Canada; Institute for Global Health and Development, The Aga Khan University South-Central Asia, Karachi, Pakistan
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Singh K, Simmons E, Garriga B, Hoover G, Ijdi RE, Kc A. National chlorhexidine coverage and factors associated with newborn umbilical cord care in Bangladesh and Nepal: a cross-sectional analysis using household data. Matern Health Neonatol Perinatol 2024; 10:12. [PMID: 38845007 PMCID: PMC11157876 DOI: 10.1186/s40748-024-00182-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Accepted: 04/24/2024] [Indexed: 06/09/2024] Open
Abstract
BACKGROUND Preventable newborn deaths are a global tragedy with many of these deaths concentrated in the first week and day of life. A simple low-cost intervention, chlorhexidine cleansing of the umbilical cord, can prevent deaths from omphalitis, an infection of the umbilical cord. Bangladesh and Nepal have national policies promoting chlorhexidine use, as well as routinely collected household survey data, which allows for an assessment of coverage and predictors of the intervention. METHODS We used data from the 2017-2018 Bangladesh Demographic and Health Survey and the 2016 Nepal Demographic and Health Survey, two large-scale nationally representative household surveys. We studied coverage of single application of chlorhexidine to the umbilical cord of newborns born in the past year using descriptive, bivariate and multivariable analyses. Key predictors of newborns receiving chlorhexidine cleansing, including socio-economic factors, healthcare related factors and the application of harmful and nonharmful substances, were explored in this study. RESULTS Coverage of chlorhexidine cleansing was 15.0% in Bangladesh and 50.7% in Nepal, while the application of a harmful substance was 16.9% in Bangladesh and 22.6% in Nepal. Results from the multivariable analyses indicated that delivery in a health facility was strongly associated with a newborn's receipt of chlorhexidine in both countries (Bangladesh: OR = 2.23, p = 0.002; Nepal: OR = 5.01, p = 0.000). In Bangladesh, delivery by Cesarean section and application of another non-harmful substance were significantly and positively associated with the receipt of chlorhexidine. In Nepal antenatal care was significantly and positively associated with chlorhexidine, while application of a harmful substance was significantly and negatively associated with receipt of chlorhexidine. Maternal education, urban/rural residence, religion and sex were not significant in the multivariable analysis. Wealth was not a significant factor in Bangladesh, but in Nepal newborns in the two highest wealth quintiles were significantly less likely to receive chlorhexidine than newborns in the lowest wealth quintile. CONCLUSION As Bangladesh and Nepal continue to scale-up chlorhexidine for newborn umbilical cord care, additional focus on newborns born in non-facility environments may be warranted. Chlorhexidine cleansing may have the potential to be an equitable intervention, as newborns from the poorest wealth quintiles and whose mothers had less education were not disadvantaged in receiving the intervention in these two settings.
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Affiliation(s)
- Kavita Singh
- Data for Impact (D4I), University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
- Department of Maternal and Child Health, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC, USA.
- Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, USA.
| | - Elizabeth Simmons
- Department of Maternal and Child Health, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC, USA
- Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Bliss Garriga
- Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Grace Hoover
- Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Rashida E Ijdi
- Department of Maternal and Child Health, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC, USA
- Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Ashish Kc
- School of Public Health and Community Medicine, University of Gothenburg, Gothenburg, Sweden
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Tumuhamye J, Sommerfelt H, Tumwine JK, Mukunya D, Ndeezi G, Namugga O, Bwanga F, Steinsland H, Nankabirwa V. Umbilical Cord Stump Infections in Central Uganda: Incidence, Bacteriological Profile, and Risk Factors. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:16055. [PMID: 36498131 PMCID: PMC9735496 DOI: 10.3390/ijerph192316055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 11/27/2022] [Accepted: 11/28/2022] [Indexed: 06/17/2023]
Abstract
Umbilical cord stump infection (omphalitis) is a risk factor for neonatal sepsis and death. We assessed the incidence of omphalitis, described the bacteriological and antibiotic-resistance profile of potentially pathogenic bacteria isolated from the umbilical cord stump of omphalitis cases, and evaluated whether bacteria present in the birth canal during birth predicted omphalitis. We enrolled 769 neonates at birth at three primary healthcare facilities and followed them for 28 days with scheduled visits on days 3, 7, 14, and 28. Cox regression models were used to estimate the rates of omphalitis associated with potential risk factors. Sixty-five (8.5%) neonates developed omphalitis, with an estimated incidence of 0.095 cases per 28 child-days (95% CI 0.073, 0.12). Potentially pathogenic bacteria were isolated from the cord stump area of 41 (63.1%) of the 65 neonates with omphalitis, and the most commonly isolated species were Escherichia coli (n = 18), Klebsiella pneumoniae (n = 10), Citrobacter freundii (n = 5), and Enterobacter spp. (n = 4). The Enterobacteriaceace isolates were resistant to gentamicin (10.5%, 4/38), ampicillin (86.8%, 33/38), and ceftriaxone (13.2%, 5/38). Delayed initiation of breastfeeding was associated with an increased risk of omphalitis (aHR 3.1; 95% CI 1.3, 7.3); however, vaginal colonization with potentially pathogenic bacteria did not predict omphalitis.
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Affiliation(s)
- Josephine Tumuhamye
- Centre for Intervention Science for Maternal and Child Health, Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, 5020 Bergen, Norway
| | - Halvor Sommerfelt
- Centre for Intervention Science for Maternal and Child Health, Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, 5020 Bergen, Norway
- Cluster for Global Health, Division for Health Services, Norwegian Institute of Public Health, 0430 Oslo, Norway
| | - James K. Tumwine
- Department of Paediatric and Child Health, Makerere University, Kampala P.O. Box 7062, Uganda
- School of Medicine, Kabale University, Kabale P.O. Box 317, Uganda
| | - David Mukunya
- Department of Community and Public Health, Busitema University, Mbale P.O. Box 236, Uganda
| | - Grace Ndeezi
- Department of Paediatric and Child Health, Makerere University, Kampala P.O. Box 7062, Uganda
| | - Olive Namugga
- Centre for Intervention Science for Maternal and Child Health, Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, 5020 Bergen, Norway
| | - Freddie Bwanga
- Department of Immunology and Molecular Biology, Makerere University, Kampala P.O. Box 7062, Uganda
| | - Hans Steinsland
- Centre for Intervention Science for Maternal and Child Health, Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, 5020 Bergen, Norway
- Department of Biomedicine, University of Bergen, 5020 Bergen, Norway
| | - Victoria Nankabirwa
- Centre for Intervention Science for Maternal and Child Health, Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, 5020 Bergen, Norway
- Department of Epidemiology, Biostatics School of Public Health, Makerere University, Kampala P.O. Box 7062, Uganda
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DeAngelis E, Clarke A, Gibson R, Karrar K, Williams P. Increasing access to essential medicines through partnership: experience in developing and delivering chlorhexidine gel for newborn cord care. BMJ Paediatr Open 2022; 6:10.1136/bmjpo-2022-001467. [PMID: 36645765 PMCID: PMC9453998 DOI: 10.1136/bmjpo-2022-001467] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 05/17/2022] [Indexed: 02/02/2023] Open
Abstract
Sustainable access to essential medicines in low-income and middle-income countries requires innovative cross-sectoral collaboration throughout the lifecycle of a medicine. Partnerships are essential to address the systemic challenges of global health and health inequity. Pharmaceutical companies, funders, governments, international non-governmental organisations (I-NGOs) and other key stakeholders can leverage, through effective partnership working, their unique expertise to help drive innovation and share learnings and risks. Here, we reflect on one approach taken in the development and supply of chlorhexidine digluconate 7.1% w/w gel (equivalent to 4% w/w chlorhexidine) for neonatal cord care. We describe and analyse the steps taken by GSK to increase access to chlorhexidine gel, including partnering with the I-NGO Save the Children in Western Kenya. Learning points gained along the journey are shared, together with subsequent steps taken to increase access, with the aim of making recommendations that may be applicable to similar enterprises in the future.
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Chlorhexidine cord care after a national scale-up as a newborn survival strategy: A survey in four regions of Ethiopia. PLoS One 2022; 17:e0271558. [PMID: 35930577 PMCID: PMC9355194 DOI: 10.1371/journal.pone.0271558] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 07/04/2022] [Indexed: 11/25/2022] Open
Abstract
Introduction Chlorhexidine cord care is an effective intervention to reduce neonatal infection and death in resource constrained settings. The Federal Ministry of Health of Ethiopia adopted chlorhexidine cord care in 2015, with national scale-up in 2017. However, there is lack of evidence on the provision of this important intervention in Ethiopia. In this paper, we report on the coverage and determinants of chlorhexidine cord care for newborns in Ethiopia. Methods A standardized Nutrition International Monitoring System (NIMS) survey was conducted from January 01 to Feb 13, 2020 in four regions of Ethiopia (Tigray, Amhara, Oromia, and Southern Nations, Nationalities and Peoples Region [SNNPR]) on sample of 1020 women 0–11 months postpartum selected through a multistage cluster sampling approach. Data were collected using interviewer-administered questionnaires in the local languages through home-to-home visit. Accounting for the sampling design of the study, we analyzed the data using complex data analysis approach. Complex sample multivariable logistic regression was used to identify the determinants of chlorhexidine cord care practice. Results Overall, chlorhexidine was reportedly applied to the umbilical cord at some point postpartum among 46.1% (95% confidence interval [CI]: 41.1%– 51.2%) of all newborns. Chlorhexidine cord care started within 24 hours after birth for 34.4% (95% CI: 29.5%– 39.6%) of newborns, though this varied widely across regions: from Oromia (24.4%) to Tigray (60.0%). Among the newborns who received chlorhexidine cord care, 48.3% received it for the recommended seven days or more. Further, neonates whose birth was assisted by skilled birth attendants had more than ten times higher odds of receiving chlorhexidine cord care, relative to those born without a skilled attendant (adjusted odds ratio [AOR]: 10.36, 95% CI: 3.73–28.75). Besides, neonates born to mothers with knowledge of the benefit of chlorhexidine cord care had significantly higher odds of receiving chlorhexidine cord care relative to newborns born to mothers who did not have knowledge of the benefit of chlorhexidine cord care (AOR: 39.03, 95% CI: 21.45–71.04). Conclusion A low proportion of newborns receive chlorhexidine cord care in Ethiopia. The practice of chlorhexidine cord care varies widely across regions and is limited mostly to births attended by skilled birth attendants. Efforts must continue to ensure women can reach skilled care at delivery, and to ensure adequate care for newborns who do not yet access skilled delivery.
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Verma J, Sankar MJ, Atmakuri K, Agarwal R, Das B. Gut microbiome dysbiosis in neonatal sepsis. PROGRESS IN MOLECULAR BIOLOGY AND TRANSLATIONAL SCIENCE 2022; 192:125-147. [DOI: 10.1016/bs.pmbts.2022.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Wastnedge E, Waters D, Murray SR, McGowan B, Chipeta E, Nyondo-Mipando AL, Gadama L, Gadama G, Masamba M, Malata M, Taulo F, Dube Q, Kawaza K, Khomani PM, Whyte S, Crampin M, Freyne B, Norman JE, Reynolds RM. Interventions to reduce preterm birth and stillbirth, and improve outcomes for babies born preterm in low- and middle-income countries: A systematic review. J Glob Health 2021; 11:04050. [PMID: 35003711 PMCID: PMC8709903 DOI: 10.7189/jogh.11.04050] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Reducing preterm birth and stillbirth and improving outcomes for babies born too soon is essential to reduce under-5 mortality globally. In the context of a rapidly evolving evidence base and problems with extrapolating efficacy data from high- to low-income settings, an assessment of the evidence for maternal and newborn interventions specific to low- and middle-income countries (LMICs) is required. METHODS A systematic review of the literature was done. We included all studies performed in LMICs since the Every Newborn Action Plan, between 2013 - 2018, which reported on interventions where the outcome assessed was reduction in preterm birth or stillbirth incidence and/or a reduction in preterm infant neonatal mortality. Evidence was categorised according to maternal or neonatal intervention groups and a narrative synthesis conducted. RESULTS 179 studies (147 primary evidence studies and 32 systematic reviews) were identified in 82 LMICs. 81 studies reported on maternal interventions and 98 reported on neonatal interventions. Interventions in pregnant mothers which resulted in significant reductions in preterm birth and stillbirth were (i) multiple micronutrient supplementation and (ii) enhanced quality of antenatal care. Routine antenatal ultrasound in LMICs increased identification of fetal antenatal conditions but did not reduce stillbirth or preterm birth due to the absence of services to manage these diagnoses. Interventions in pre-term neonates which improved their survival included (i) feeding support including probiotics and (ii) thermal regulation. Improved provision of neonatal resuscitation did not improve pre-term mortality rates, highlighting the importance of post-resuscitation care. Community mobilisation, for example through community education packages, was found to be an effective way of delivering interventions. CONCLUSIONS Evidence supports the implementation of several low-cost interventions with the potential to deliver reductions in preterm birth and stillbirth and improve outcomes for preterm babies in LMICs. These, however, must be complemented by overall health systems strengthening to be effective. Quality improvement methodology and learning health systems approaches can provide important means of understanding and tackling implementation challenges within local contexts. Further pragmatic efficacy trials of interventions in LMICs are essential, particularly for interventions not previously tested in these contexts.
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Affiliation(s)
- Elizabeth Wastnedge
- Medical Research Council Centre for Reproductive Health, University of Edinburgh, Queen's Medical Research Institute, Edinburgh, UK
| | - Donald Waters
- Medical Research Council Centre for Reproductive Health, University of Edinburgh, Queen's Medical Research Institute, Edinburgh, UK
| | - Sarah R Murray
- Medical Research Council Centre for Reproductive Health, University of Edinburgh, Queen's Medical Research Institute, Edinburgh, UK
| | - Brian McGowan
- Medical Research Council Centre for Reproductive Health, University of Edinburgh, Queen's Medical Research Institute, Edinburgh, UK
| | - Effie Chipeta
- Centre for Reproductive Health, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Alinane Linda Nyondo-Mipando
- Department of Health Systems & Policy, School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Luis Gadama
- Department of Obstetrics & Gynaecology, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Gladys Gadama
- Department of Obstetrics & Gynaecology, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Martha Masamba
- Department of Obstetrics & Gynaecology, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Monica Malata
- Centre for Reproductive Health, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Frank Taulo
- Department of Obstetrics & Gynaecology, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Queen Dube
- Department of Paediatrics, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Kondwani Kawaza
- Department of Paediatrics, College of Medicine, University of Malawi, Blantyre, Malawi
| | | | - Sonia Whyte
- Medical Research Council Centre for Reproductive Health, University of Edinburgh, Queen's Medical Research Institute, Edinburgh, UK
| | - Mia Crampin
- Malawi Epidemiology and Intervention Research Unit, Lilongwe, Malawi
| | - Bridget Freyne
- Malawi-Liverpool Wellcome Trust Research Program, Blantyre, Malawi
- Institute of Infection & Global Health, University of Liverpool, Liverpool, UK
| | - Jane E Norman
- Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - Rebecca M Reynolds
- Medical Research Council Centre for Reproductive Health, University of Edinburgh, Queen's Medical Research Institute, Edinburgh, UK
- Centre for Cardiovascular Science, University of Edinburgh, Queen's Medical Research Institute, Edinburgh, UK
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Brown L, Martin A, Were C, Biswas N, Liakos A, DeAngelis E, Evitt LA. Cost and consequences of using 7.1 % chlorhexidine gel for newborn umbilical cord care in Kenya. BMC Health Serv Res 2021; 21:1249. [PMID: 34794442 PMCID: PMC8603569 DOI: 10.1186/s12913-021-06971-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 08/26/2021] [Indexed: 11/17/2022] Open
Abstract
Background Omphalitis is an important contributor to neonatal mortality in Kenya. Chlorhexidine digluconate 7.1 % w/w (CHX; equivalent to 4 % w/w chlorhexidine) was identified as a life-saving commodity for newborn cord care by the United Nations and is included on World Health Organization and Kenyan Essential Medicines Lists. This pilot study assessed the potential resource savings and breakeven price of implementing CHX for neonatal umbilical cord care versus dry cord care (DCC) in Kenya. Methods We employed a cost-consequence model in a Kenyan birth cohort. Firstly, the number of omphalitis cases and cases avoided by healthcare sector were estimated. Incidence rates and treatment effect inputs were calculated from a Cochrane meta-analysis of randomised clinical trials (RCTs) (base case) and 2 other RCTs. Economic outcomes associated with omphalitis cases avoided were determined, including direct, indirect and total cost of care associated with omphalitis, resource use (outpatient visits and bed days) and societal impact (caregiver workdays lost). Costs and other inputs were sourced from literature and supplemented by expert clinical opinion/informed inputs, making necessary assumptions. Results The model estimated that, over 1 year, ~ 23,000 omphalitis cases per 500,000 births could be avoided through CHX application versus DCC, circumventing ~ 13,000 outpatient visits, ~ 43,000 bed days and preserving ~ 114,000 workdays. CHX was associated with annual direct cost savings of ~ 590,000 US dollars (USD) versus DCC (not including drug-acquisition cost), increasing to ~ 2.5 million USD after including indirect costs (productivity, notional salary loss). The most-influential model parameter was relative risk of omphalitis with CHX versus DCC. Breakeven analysis identified a budget-neutral price for CHX use of 1.18 USD/course when accounting for direct cost savings only, and 5.43 USD/course when including indirect cost savings. The estimated breakeven price was robust to parameter input changes. DCC does not necessarily represent standard of care in Kenya; other, potentially harmful, approaches may be used, meaning cost savings may be understated. Conclusions Estimated healthcare cost savings and potential health benefits provide compelling evidence to implement CHX for umbilical cord care in Kenya. We encourage comprehensive data collection to make future models and estimates of impacts of upscaling CHX use more robust. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06971-7.
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Affiliation(s)
- Lecia Brown
- Global Health, GSK, London, UK. .,Present affiliation: Clinical Development, GSK, Pennsylvania, Philadelphia, USA.
| | - Alan Martin
- Value Evidence and Outcomes, GSK, Uxbridge, Middlesex, UK
| | | | | | | | | | - Lee Alexandra Evitt
- Global Health, GSK, London, UK.,Present affiliation: Global Health Outcomes, ViiV Healthcare, Middlesex, Brentford, UK
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First Isolation and Clinical Case of Brevundimonas diminuta in a Newborn with Low Birth Weight, in Democratic Republic of Congo: A Case Report. Medicina (B Aires) 2021; 57:medicina57111227. [PMID: 34833445 PMCID: PMC8617665 DOI: 10.3390/medicina57111227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 11/04/2021] [Accepted: 11/05/2021] [Indexed: 12/01/2022] Open
Abstract
Brevundimonas diminuta is rarely described in clinical specimens, never at the umbilical stump. Most of the reported cases are in patients with underlying pathologies. We must integrate this microorganism in the etiological agents of nosocomial infections, but much remains to be understood about its virulence. We present a case of umbilical stump infection (omphalitis) caused by B. diminuta, in a preterm and hypotrophic new-born and discuss the diagnosis of this bacterium and its role as responsible of nosocomial neonatal infections.
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Osuchukwu EC, Ezeruigbo CF, Akpan-Idiok PA, Asuquo EF. Effect of a supportive-educative nursing intervention programme on knowledge of chlorhexidine gel for umbilical cord management amongst mothers in Cross River State, Nigeria. Afr J Prim Health Care Fam Med 2021; 13:e1-e7. [PMID: 33970012 PMCID: PMC8111657 DOI: 10.4102/phcfm.v13i1.2653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 01/10/2021] [Accepted: 01/17/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Umbilical cord infection contributes significantly to neonatal mortality rate in sub-Saharan Africa. Studies have shown low knowledge of chlorhexidine (CHX) gel for umbilical cord management amongst mothers in low-resource settings, including Nigeria. OBJECTIVE The objective of this study was to assess the effectiveness of a supportive-educative nursing intervention programme on knowledge of CHX gel amongst mothers in Cross River State, Nigeria. METHODS A quasi-experimental study design was used, and study participants comprised 168 expectant mothers, who were purposely selected and assigned to randomised control and intervention groups. The instrument for data collection was a researcher-developed structured questionnaire. The data were analysed using Statistical Package for Social Sciences version 23 for descriptive and inferential statistics at significant level was set at p 0.05. RESULTS The result showed that at post-test the knowledge score of mothers on CHX gel improved significantly in the intervention group (t 77 = 24.394; p 0.05). The result showed no significant difference between mothers' demographic variables and knowledge of CHX gel. CONCLUSION A supportive-educative nursing intervention programme could effectively improve knowledge of CHX gel for umbilical cord management amongst mothers. This underscores the need to improve mothers' knowledge of CHX gel by healthcare personnel.
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Affiliation(s)
- Easter C Osuchukwu
- Department of Nursing Sciences, College of Medicine, Faculty of Allied Medical Sciences, University of Calabar, Calabar.
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Zaman SB, Siddique AB, Ruysen H, Kc A, Peven K, Ameen S, Thakur N, Rahman QSU, Salim N, Gurung R, Tahsina T, Rahman AE, Coffey PS, Rawlins B, Day LT, Lawn JE, Arifeen SE. Chlorhexidine for facility-based umbilical cord care: EN-BIRTH multi-country validation study. BMC Pregnancy Childbirth 2021; 21:239. [PMID: 33765947 PMCID: PMC7995704 DOI: 10.1186/s12884-020-03338-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Umbilical cord hygiene prevents sepsis, a leading cause of neonatal mortality. The World Health Organization recommends 7.1% chlorhexidine digluconate (CHX) application to the umbilicus after home birth in high mortality contexts. In Bangladesh and Nepal, national policies recommend CHX use for all facility births. Population-based household surveys include optional questions on CHX use, but indicator validation studies are lacking. The Every Newborn Birth Indicators Research Tracking in Hospitals (EN-BIRTH) was an observational study assessing measurement validity for maternal and newborn indicators. This paper reports results regarding CHX. METHODS The EN-BIRTH study (July 2017-July 2018) included three public hospitals in Bangladesh and Nepal where CHX cord application is routine. Clinical-observers collected tablet-based, time-stamped data regarding cord care during admission to labour and delivery wards as the gold standard to assess accuracy of women's report at exit survey, and of routine-register data. We calculated validity ratios and individual-level validation metrics; analysed coverage, quality and measurement gaps. We conducted qualitative interviews to assess barriers and enablers to routine register-recording. RESULTS Umbilical cord care was observed for 12,379 live births. Observer-assessed CHX coverage was very high at 89.3-99.4% in all 3 hospitals, although slightly lower after caesarean births in Azimpur (86.8%), Bangladesh. Exit survey-reported coverage (0.4-45.9%) underestimated the observed coverage with substantial "don't know" responses (55.5-79.4%). Survey-reported validity ratios were all poor (0.01 to 0.38). Register-recorded coverage in the specific column in Bangladesh was underestimated by 0.2% in Kushtia but overestimated by 9.0% in Azimpur. Register-recorded validity ratios were good (0.9 to 1.1) in Bangladesh, and poor (0.8) in Nepal. The non-specific register column in Pokhara, Nepal substantially underestimated coverage (20.7%). CONCLUSIONS Exit survey-report highly underestimated observed CHX coverage in all three hospitals. Routine register-recorded coverage was closer to observer-assessed coverage than survey reports in all hospitals, including for caesarean births, and was more accurately captured in hospitals with a specific register column. Inclusion of CHX cord care into registers, and tallied into health management information system platforms, is justified in countries with national policies for facility-based use, but requires implementation research to assess register design and data flow within health information systems.
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Affiliation(s)
- Sojib Bin Zaman
- Maternal and Child Health Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), 68 Shahid Tajuddin Ahmed Sarani, Mohakhali, Dhaka, Bangladesh.
| | - Abu Bakkar Siddique
- Maternal and Child Health Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), 68 Shahid Tajuddin Ahmed Sarani, Mohakhali, Dhaka, Bangladesh
| | - Harriet Ruysen
- The Maternal, Adolescent, Reproductive, & Child, Health (MARCH) Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - Ashish Kc
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Kimberly Peven
- The Maternal, Adolescent, Reproductive, & Child, Health (MARCH) Centre, London School of Hygiene & Tropical Medicine, London, UK
- Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK
| | - Shafiqul Ameen
- Maternal and Child Health Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), 68 Shahid Tajuddin Ahmed Sarani, Mohakhali, Dhaka, Bangladesh
| | | | - Qazi Sadeq-Ur Rahman
- Maternal and Child Health Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), 68 Shahid Tajuddin Ahmed Sarani, Mohakhali, Dhaka, Bangladesh
| | - Nahya Salim
- Department of Paediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
- Department of Health Systems, Impact Evaluation and Policy, Ifakara Health Institute, Dar es Salaam, Tanzania
| | - Rejina Gurung
- Research Division, Golden Community, Lalitpur, Nepal
| | - Tazeen Tahsina
- Maternal and Child Health Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), 68 Shahid Tajuddin Ahmed Sarani, Mohakhali, Dhaka, Bangladesh
| | - Ahmed Ehsanur Rahman
- Maternal and Child Health Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), 68 Shahid Tajuddin Ahmed Sarani, Mohakhali, Dhaka, Bangladesh
| | | | - Barbara Rawlins
- Maternal and Child Survival Program, jhpiego, Baltimore, MD, USA
| | - Louise T Day
- The Maternal, Adolescent, Reproductive, & Child, Health (MARCH) Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - Joy E Lawn
- The Maternal, Adolescent, Reproductive, & Child, Health (MARCH) Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - Shams El Arifeen
- Maternal and Child Health Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), 68 Shahid Tajuddin Ahmed Sarani, Mohakhali, Dhaka, Bangladesh
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Mwananyanda L, Pierre C, Mwansa J, Cowden C, Localio AR, Kapasa ML, Machona S, Musyani CL, Chilufya MM, Munanjala G, Lyondo A, Bates MA, Coffin SE, Hamer DH. Preventing Bloodstream Infections and Death in Zambian Neonates: Impact of a Low-cost Infection Control Bundle. Clin Infect Dis 2020; 69:1360-1367. [PMID: 30596901 DOI: 10.1093/cid/ciy1114] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2018] [Accepted: 12/24/2018] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Sepsis is a leading cause of neonatal mortality in low-resource settings. As facility-based births become more common, the proportion of neonatal deaths due to hospital-onset sepsis has increased. METHODS We conducted a prospective cohort study in a neonatal intensive care unit in Zambia where we implemented a multifaceted infection prevention and control (IPC) bundle consisting of IPC training, text message reminders, alcohol hand rub, enhanced environmental cleaning, and weekly bathing of babies ≥1.5 kg with 2% chlorhexidine gluconate. Hospital-associated sepsis, bloodstream infection (BSI), and mortality (>3 days after admission) outcome data were collected for 6 months prior to and 11 months after bundle implementation. RESULTS Most enrolled neonates had a birth weight ≥1.5 kg (2131/2669 [79.8%]). Hospital-associated mortality was lower during the intervention than baseline period (18.0% vs 23.6%, respectively). Total mortality was lower in the intervention than prior periods. Half of enrolled neonates (50.4%) had suspected sepsis; 40.8% of cultures were positive. Most positive blood cultures yielded a pathogen (409/549 [74.5%]), predominantly Klebsiella pneumoniae (289/409 [70.1%]). The monthly rate and incidence density rate of suspected sepsis were lower in the intervention period for all birth weight categories, except babies weighing <1.0 kg. The rate of BSI with pathogen was also lower in the intervention than baseline period. CONCLUSIONS A simple IPC bundle can reduce sepsis and death in neonates hospitalized in high-risk, low-resource settings. Further research is needed to validate these findings in similar settings and to identify optimal implementation strategies for improvement and sustainability. CLINICAL TRIALS REGISTRATION NCT02386592.
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Affiliation(s)
- Lawrence Mwananyanda
- Right to Care, Lusaka, Zambia.,Department of Global Health, Boston University School of Public Health
| | - Cassandra Pierre
- Section of Infectious Diseases, Department of Medicine, Boston Medical Center, Massachusetts
| | - James Mwansa
- Department of Pathology and Microbiology, University Teaching Hospital.,Lusaka Apex Medical University, Zambia
| | - Carter Cowden
- Division of Infectious Diseases, Children's Hospital of Philadelphia
| | - A Russell Localio
- Division of Biostatistics, Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Monica L Kapasa
- Neonatal Intensive Care Unit, University Teaching Hospital, Lusaka, Zambia
| | - Sylvia Machona
- Neonatal Intensive Care Unit, University Teaching Hospital, Lusaka, Zambia
| | | | | | | | - Angela Lyondo
- Department of Pathology and Microbiology, University Teaching Hospital
| | - Matthew A Bates
- School of Life Sciences, University of Lincoln, United Kingdom
| | - Susan E Coffin
- Division of Infectious Diseases, Children's Hospital of Philadelphia
| | - Davidson H Hamer
- Department of Global Health, Boston University School of Public Health.,Section of Infectious Diseases, Department of Medicine, Boston Medical Center, Massachusetts
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Impact of chlorhexidine baths on suspected sepsis and bloodstream infections in hospitalized neonates in Zambia. Int J Infect Dis 2020; 96:54-60. [PMID: 32304821 DOI: 10.1016/j.ijid.2020.03.043] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 03/10/2020] [Accepted: 03/18/2020] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Sepsis is the leading cause of infectious morbidity and mortality among hospitalized neonates. In high-resource pediatric and adult intensive care units, use of aqueous chlorhexidine (CHG) solution has been associated with reduced risk of bloodstream infections (BSI). OBJECTIVES To assess the impact of bathing of neonates with 2% CHG on BSI, suspected sepsis, and mortality in a low-income country neonatal care unit. METHODS We conducted a secondary analysis of data from the Sepsis Prevention in Neonates in Zambia (SPINZ) study, a prospective observational cohort study performed at a large public referral hospital in Lusaka, Zambia. The SPINZ study assessed the impact of an infection control bundle (consisting of alcohol hand rub, SMS hygiene reminders, enhanced environmental cleaning, and CHG baths for babies ≥1.5 kg) on sepsis, BSI, and all-cause mortality. Episodic shortages in study staffing resulted in some enrolled babies not receiving a CHG bath. Using Longitudinal Targeted Maximum Likelihood Estimation and Cox proportional hazards regression to adjust for observed confounding, we estimated the causal effect of receiving a CHG bath within the first 3 days of life on suspected sepsis, BSI, and death among inborn babies enrolled during the study implementation and intervention phases. RESULTS The majority of inborn, enrolled babies ≥1.5 kg received a CHG bath within 3 days of NICU admission (864 of 1233, 70%). We found that CHG bathing reduced the hazard rate of BSI among inborn babies ≥1.5 kg by a factor of 0.58 (p = 0.10, 95% CI: 0.31, 1.11), corresponding to an absolute risk reduction of 9.6 percentage points within a week of admission (p = 0.002, 95% CI: 3.4-15.7 percentage points). We did not find a statistically significant effect of CHG bathing on culture-negative sepsis (p = 0.54) or death (p = 0.85). CONCLUSION In our single center study, CHG bathing at admission was associated with a reduced risk of BSI due to a pathogenic organism after adjusting for potential confounding. Our results suggest that CHG may be an effective intervention for preventing neonatal sepsis in high-risk, low-income country settings.
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Roba AA, Tefera M, Worku T, Dasa TT, Estifanos AS, Assefa N. Application of 4% chlorhexidine to the umbilical cord stump of newborn infants in lower income countries: a systematic review and meta-analysis. Matern Health Neonatol Perinatol 2019; 5:16. [PMID: 31641528 PMCID: PMC6796424 DOI: 10.1186/s40748-019-0111-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 09/11/2019] [Indexed: 01/01/2023] Open
Abstract
Abstract There are conflicting results from large randomized controlled trials in different populations regarding the effectiveness of topical application of 4% chlorhexidine to the umbilical stump of newborn infants at reducing neonatal mortality. Meta-analysis and systematic review of trials performed in South Asia and Europe support 4% chlorhexidine application to reduce neonatal mortality, whereas trials performed in Sub-Saharan Africa do not. The aim of this review is to determine the effectiveness of 4% chlorhexidine application to the umbilical stump of newborn infants born in lower income countries in order to reduce neonatal mortality when compared with usual cord care. Our search strategy included randomized trials published between January1st 2000 and September 4th, 2018, that compared 4% chlorhexidine with usual cord care (“dry cord care”). The outcome variable of interest was neonatal mortality. Pooled relative risks (RR) with 95% confidence intervals (CIs) using a random-effects model were calculated. Nine trials were included, from six countries: Zambia, Tanzania, Bangladesh, Nepal, India and Pakistan, with a total of 257,153 participants. Five studies (N = 119,833) reported neonatal mortality. There was a 21% reduction in neonatal mortality among with 4% chlorhexidine application: pooled RR (95% CI) 0.79 (0.69–0.90), P = 0.0005. The incidence of omphalitis was decreased by 35% with 4% chlorhexidine (6 studies, N = 108,263): pooled RR (95% CI) 0.65 (0.56–0.75), P = 0.00001. Chlorhexidine application delayed the umbilical cord separation time (4 studies, N = 28,917): mean difference (95% CI) 2.71 (2.63–2.78) days. In conclusion, this systematic review found that topical application of 4% chlorhexidine to the umbilical cord stump of newborn infants in lower income countries significantly reduces the incidence of neonatal mortality. Chlorhexidine also reduces the incidence of omphalitis, but prolongs umbilical cord separation time. Trial registration Systematic Review Registration: CRD42018109280.
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Affiliation(s)
- Aklilu Abrham Roba
- 1College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Maleda Tefera
- 1College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Teshager Worku
- 1College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | | | - Abiy Seifu Estifanos
- 2Department of Reproductive Health and Health Service Management, School Of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | - Nega Assefa
- 1College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
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Hodgins S, Khanal L, Joshi N, Penfold S, Tuladhar S, Shrestha PR, Lamichhane B, Dawson P, Guenther T, Singh S, Sharma G, Oyloe P. Achieving and sustaining impact at scale for a newborn intervention in Nepal: a mixed-methods study. JOURNAL OF GLOBAL HEALTH REPORTS 2019. [DOI: 10.29392/joghr.3.e2019046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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16
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Ditai J, Abeso J, Odeke NM, Mobbs N, Dusabe-Richards J, Mudoola M, Carrol ED, Olupot-Olupot P, Storr J, Medina-Lara A, Gladstone M, Faragher EB, Weeks AD. BabyGel pilot: a pilot cluster randomised trial of the provision of alcohol handgel to postpartum mothers to prevent neonatal and young infant infection-related morbidity in the community. Pilot Feasibility Stud 2019; 5:49. [PMID: 30962946 PMCID: PMC6436217 DOI: 10.1186/s40814-019-0432-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 03/12/2019] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Alcohol-based hand rub (ABHR) is widely used in both health and social facilities to prevent infection, but it is not known whether supplying it for regular perinatal use can prevent newborn sepsis in African rural homes. Our study piloted a cluster randomised trial of providing ABHR to postpartum mothers to prevent neonatal infection-related morbidity in the communities. METHODS We conducted a pilot parallel cluster randomised controlled trial across ten villages (clusters) in rural Eastern Uganda. Pregnant women of over 34 weeks' gestation were recruited over a period of 3 months. Both clusters received the standard of care of antenatal health education, Maama Kit, and clinic appointments. In addition, women in the intervention villages received ABHR, instructions on ABHR use, a poster on the 'three moments of hand hygiene', and training. We followed up each mother-baby pair for 3 months after birth and measured rates of consent, recruitment, and follow-up (our target rate was more than 80%). Other measures included ABHR use (the acceptable use was more than four times a day) and its mode of distribution (village health workers (VHWs) or pharmacy), acceptability of study protocol and electronic data capture, and the use of WHO Integrated Management of Childhood Illness (IMCI) tool to screen for newborn infection. RESULTS We selected 36% (10/28) of villages for randomisation to either intervention or control. Over 12 weeks, 176 pregnant women were screened and 58.5% (103/176) were eligible. All, 100% (103/103), eligible women gave consent and were enrolled into the trial (55 intervention and 48 control). After birth, 94.5% (52/55) of mothers in the intervention and 100% (48/48) of mothers in the control villages were followed up within 72 h. Most, 90.9% (50/55), of the mothers in the intervention villages (96.2% of live births) and 95.8% (46/48) of mothers in the control villages (95.9% of live births) were followed up at 3 months. In intervention villages, the average hand rub use was 6.6 times per day. VHWs accounted for all ABHR stock, compared to the pharmacy that could not account for 5 l of ABHR. The screening tool was positive for infection among a third of babies, i.e. 29.2% (14/48) in the intervention villages versus 31.4% (16/51) in the control villages.VHWs completed the first four questions of IMCI screening tool with ease and accuracy. There were no adverse reactions with the ABHR. CONCLUSION It is feasible to conduct a cluster-randomised controlled trial (cRCT) of the provision of ABHR to postpartum mothers to prevent neonatal infection-related morbidity in the community in resource-poor settings. Our results indicate that home recruitment promotes excellent follow-up and retention of participants in community trials. The intervention was safe. This pilot study informed the substantial changes necessary in the larger cRCT, including a change in the primary outcome to a composite outcome considering multiple methods of infection detection. A large BabyGel cluster randomised controlled trial is now required. TRIAL REGISTRATION ISRCTN67852437, registered March 02, 2015. TRIAL FUNDING Medical Research Council/WellcomeTrust/DfID (Global Health Trials Scheme).
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Affiliation(s)
- J. Ditai
- Sanyu Africa Research Institute (SAfRI), Mbale Regional Referral Hospital, Pallisa-Kumi Road Junction, P.O Box 2190, Mbale, Uganda
- Sanyu Research Unit, Department of Women’s and Children’s Health, Liverpool Women’s Hospital, University of Liverpool, Crown Street, Liverpool, L8 7SS UK
- Busitema University Faculty of Health Sciences, P.O Box 1460, Mbale, Uganda
| | - J. Abeso
- Sanyu Research Unit, Department of Women’s and Children’s Health, Liverpool Women’s Hospital, University of Liverpool, Crown Street, Liverpool, L8 7SS UK
- Department of Paediatrics and Child Health, Mbale Regional Referral Hospital, Mbale, Uganda
| | - N. M. Odeke
- Sanyu Africa Research Institute (SAfRI), Mbale Regional Referral Hospital, Pallisa-Kumi Road Junction, P.O Box 2190, Mbale, Uganda
| | - N. Mobbs
- Sanyu Research Unit, Department of Women’s and Children’s Health, Liverpool Women’s Hospital, University of Liverpool, Crown Street, Liverpool, L8 7SS UK
| | - J. Dusabe-Richards
- Tropical Clinical Trials Unit, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA UK
| | - M. Mudoola
- Sanyu Africa Research Institute (SAfRI), Mbale Regional Referral Hospital, Pallisa-Kumi Road Junction, P.O Box 2190, Mbale, Uganda
| | - E. D. Carrol
- Department of Clinical Infection, Microbiology and Immunology, Institute of Infection and Global Health, University of Liverpool, 8 West Derby Street, Liverpool, L69 7BE UK
| | - P. Olupot-Olupot
- Busitema University Faculty of Health Sciences, P.O Box 1460, Mbale, Uganda
| | | | - A. Medina-Lara
- Health Economics Group, University of Exeter, Exeter, UK
| | - M. Gladstone
- Sanyu Research Unit, Department of Women’s and Children’s Health, Liverpool Women’s Hospital, University of Liverpool, Crown Street, Liverpool, L8 7SS UK
| | - E. B. Faragher
- Busitema University Faculty of Health Sciences, P.O Box 1460, Mbale, Uganda
| | - A. D. Weeks
- Sanyu Research Unit, Department of Women’s and Children’s Health, Liverpool Women’s Hospital, University of Liverpool, Crown Street, Liverpool, L8 7SS UK
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López-Medina MD, Linares-Abad M, López-Araque AB, López-Medina IM. Dry care versus chlorhexidine cord care for prevention of omphalitis. Systematic review with meta-analysis. Rev Lat Am Enfermagem 2019. [PMCID: PMC6358141 DOI: 10.1590/1518-8345.2695.3106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objective: to compare the effect of dry care and the application of chlorhexidine to the umbilical cord of newborns at risk of developing omphalitis. Method: systematic review with meta-analysis. Clinical trials comparing dry care with the application of clorexidine to evaluate omphalitis were selected. Methodological quality was evaluated using the Consolidated Standards of Reporting Trials. Results: the joint analysis of the studies shows a significant decrease in the risk of omphalitis in the chlorhexidine group compared to the dry care group (RR=0.58, CI: 0.53-0.64). However, in the analysis by subgroups, chlorhexidine umbilical cord care did not reduce the risk of omphalitis in hospital births (RR=0.82, CI: 0.64-1.05), in countries with a low infant mortality rate (RR=0.8, CI: 0.5-1.28), or at chlorhexidine concentrations below 4% (RR=0.55, CI: 0.31-1). Chlorhexidine acted as a protective factor at a concentration of 4% (RR=0.58, CI: 0.53-0.64), when applied in cases of home births (RR=0.57, CI: 0.51-0.62), in countries with a high infant mortality rate (RR=0.57, CI: 0.52-0.63). Conclusion: dry cord care is effective in countries with low infant mortality rate and in hospital births. However, 4% chlorhexidine for umbilical cord care protects against omphalitis in home births, in countries with a high infant mortality rate.
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18
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Herlihy JM, Gille S, Grogan C, Bobay L, Simpamba K, Akonkwa B, Chisenga T, Hamer DH, Semrau K. Can community health workers identify omphalitis? A validation study from Southern Province, Zambia. Trop Med Int Health 2018; 23:806-813. [PMID: 29752848 DOI: 10.1111/tmi.13074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Omphalitis, or umbilical cord infection, is an important cause of newborn morbidity and mortality in low-resource settings. We tested an algorithm that task-shifts omphalitis diagnosis to community-level workers in sub-Saharan Africa. METHODS Community-based field monitors and Zambian paediatricians independently evaluated newborns presenting to health facilities in Southern Zambia using a signs and symptoms checklist. Responses were compared against the paediatrician's gold standard clinical diagnosis. RESULTS Of 1009 newborns enrolled, 6.2% presented with omphalitis per the gold standard clinical diagnosis. Paediatricians' signs and symptoms with the highest sensitivity were presence of pus (79.4%), redness at the base (50.8%) and newborn flinching when cord was palpated (33.3%). The field monitor's signs and symptoms answers had low correlation with paediatrician's answers; all signs and symptoms assessed had sensitivity <16%. CONCLUSION Despite extensive training, field monitors could not consistently identify signs and symptoms associated with omphalitis in the sub-Saharan African setting.
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Affiliation(s)
- Julie M Herlihy
- Department of Pediatrics, School of Medicine, University of California Davis, Sacramento, CA, USA
| | - Sara Gille
- Kaiser Permanente Center for Health Research, Portland, OR, USA
| | | | | | - Kelvin Simpamba
- Ministry of Health, Government of the Republic of Zambia, Lusaka, Zambia
| | | | - Tina Chisenga
- Ministry of Health, Government of the Republic of Zambia, Lusaka, Zambia
| | - Davidson H Hamer
- Center for Global Health and Development, Boston University School of Public Health, Boston, MA, USA.,Department of Global Health, Boston University School of Public Health, Boston, MA, USA.,Section of Infectious Diseases, Department of Medicine, Boston Medical Center, Boston, MA, USA
| | - Katherine Semrau
- Ariadne Labs, Boston, MA, USA.,Department of Medicine, Harvard Medical School, Boston, MA, USA.,Division of Global Health Equity, Brigham & Women's Hospital, Boston, MA, USA
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19
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Coffey PS, Hodgins S, Bishop A. Effective Collaboration for Scaling Up Health Technologies: A Case Study of the Chlorhexidine for Umbilical Cord Care Experience. GLOBAL HEALTH: SCIENCE AND PRACTICE 2018; 6:178-191. [PMID: 29602871 PMCID: PMC5878071 DOI: 10.9745/ghsp-d-17-00380] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Accepted: 01/29/2018] [Indexed: 11/15/2022]
Abstract
Facilitating factors for the Chlorhexidine Working Group: (1) strong, transparent leadership by a neutral broker, promoting shared ownership among all members; (2) reliable internal and external communication; (3) well-defined terms of reference building on common interest around a simple, effective health intervention; (4) clear benefits of participation, including access to evidence and technical assistance; and (5) adequate resources to support the secretariat functions. The global health field is replete with examples of cross-organizational collaborative partnerships, such as networks, alliances, coalitions, task forces, and working groups, often established to tackle a shared global health concern, condition, or threat affecting low-income countries or communities. The purpose of this article is to review factors influencing the effectiveness of a multi-agency global health collaborative effort using the Chlorhexidine Working Group (CWG) as our case study. The CWG was established to accelerate the introduction and global scale-up of chlorhexidine for umbilical cord care to reduce infection-related neonatal morbidity and mortality in low-income countries. Questions included: how current and past CWG members characterized the effectiveness, productivity, collaboration, and leadership of the CWG; what factors facilitated or hindered group function; institutional or individual reasons for participating and length of participation in the CWG; and lessons that might be relevant for future global collaborative partnerships. Data were collected through in-depth, semistructured individual interviews with 19 group members and a review of key guiding documents. Six domains of internal coalition functioning (leadership, interpersonal relationships, task focus, participant benefits and costs, sustainability planning, and community support) were used to frame and describe the functioning of the CWG. Collaboration effectiveness was found to depend on: (1) leadership that maintained a careful balance between discipline and flexibility, (2) a strong secretariat structure that supported the evolution of trust and transparent communication in interpersonal relationships, (3) shared goals that allowed for task focus, (4) diverse membership and active involvement from country-level participants, which created a positive benefit-cost ratio for participants, (5) sufficient resources to support the partnership and build sustainable capacity for members to accelerate the transfer of knowledge, and (6) support from the global health community across multiple organizations. Successful introduction and scale-up of new health interventions require effective collaboration across multiple organizations and disciplines, at both global and country levels. The participatory collaborative partnership approach utilized by the Chlorhexidine Working Group offers an instructive learning case.
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Affiliation(s)
| | - Steve Hodgins
- Save the Children, Washington, DC, USA. Now with School of Public, University of Alberta, Edmonton, Canada
| | - Amie Bishop
- Consultant, Global Health and Human Rights, Seattle, WA, USA
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20
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Impact of Chlorhexidine Cord Cleansing on Mortality, Omphalitis and Cord Separation Time Among Facility-Born Babies in Nepal and Bangladesh. Pediatr Infect Dis J 2017; 36:1011-1013. [PMID: 28430753 PMCID: PMC5600668 DOI: 10.1097/inf.0000000000001617] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Guidance is needed regarding potential extension of the World Health Organization recommendation for cord cleansing with chlorhexidine to babies born in facilities. Among 3223 facility-born babies from Nepal and Bangladesh, mortality was approximately halved among those allocated to the intervention clusters [10.5/1000 vs. 19.4/1000; relative risk (RR): 0.54; 95% confidence interval: 0.30-0.97]. In high-mortality settings, a single policy for home and facility births is warranted.
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Abstract
Lack of success in achieving considerable reductions in neonatal mortality is a contributory factor in failing to achieve Millennium Development Goal 4.2.6 million neonates still die each year, with preterm birth and infections the two leading causes. Maternal infections and environmental and infant factors influence acquisition of viral and bacterial infections in the perinatal and neonatal period. Scaling up evidence-based interventions addressing maternal risk factors and underlying causes could reduce neonatal infections by 84%. The emergence of new infections and increasing antimicrobial resistance present public health challenges that must be addressed to achieve substantial reductions in neonatal mortality.
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Affiliation(s)
- Amira M Khan
- Peter Gilgan Centre for Research and Learning (PGCRL), Centre for Global Child Health, The Hospital for Sick Children, 686 Bay Street, 11th Floor, Suite 11.9805, Toronto, Ontario M5G 0A4, Canada
| | - Shaun K Morris
- Division of Infectious Diseases, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, Ontario M5G1X8, Canada
| | - Zulfiqar A Bhutta
- Peter Gilgan Centre for Research and Learning (PGCRL), Centre for Global Child Health, The Hospital for Sick Children, 686 Bay Street, 11th Floor, Suite 11.9805, Toronto, Ontario M5G 0A4, Canada; Centre for Excellence in Women and Child Health, Aga Khan University, Stadium Road, Karachi 74800, Pakistan.
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Nankabirwa V, Tylleskär T, Tumuhamye J, Tumwine JK, Ndeezi G, Martines JC, Sommerfelt H. Efficacy of umbilical cord cleansing with a single application of 4% chlorhexidine for the prevention of newborn infections in Uganda: study protocol for a randomized controlled trial. Trials 2017; 18:322. [PMID: 28701228 PMCID: PMC5508681 DOI: 10.1186/s13063-017-2050-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Accepted: 06/05/2017] [Indexed: 11/10/2022] Open
Abstract
Background Yearly, nearly all the estimated worldwide 2.7 million neonatal deaths occur in low- and middle-income countries. Infections, including those affecting the umbilical cord (omphalitis), are a significant factor in approximately a third of these deaths. In fact, the odds of all-cause mortality are 46% higher among neonates with omphalitis than in those without. Five large randomized controlled trials in Asia and Sub-Saharan Africa (SSA) have examined the effect of multiple cord stump applications with 4% chlorhexidine (CHX) for at least 7 days on the risk of omphalitis and neonatal death. These studies, all community-based, show that multiple CHX applications reduced the risk of omphalitis. Of these trials, only one study from South Asia (the Bangladeshi study) and none from Africa examined the effect of a single application of CHX as soon as possible after birth. In this Bangladeshi trial, CHX led to a reduction in the risk of mild-moderate omphalitis and neonatal death. It is important, in an African setting, to explore the effect of a single application among health-facility births. A single application is programmatically much simpler to implement than daily applications for 7 days. Therefore, our study compares umbilical cord cleansing with a single application of 4% CHX at birth with dry cord care among Ugandan babies born in health facilities, on the risk of omphalitis and severe neonatal illness. Methods The CHX study is a facility-based, individually randomized controlled trial that will be conducted among 4760 newborns in Uganda. The primary outcomes are severe illness and omphalitis during the neonatal period. Analysis will be by intention-to-treat. Discussion This study will provide novel evidence, from a Sub-Saharan African setting, of the effect of umbilical cord cleansing with a single application of 4% CHX at birth and identify modifiable risk factors for omphalitis. Trial registration ClinicalTrials.gov, identifier: NCT02606565. Registered on 12 November 2015. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-2050-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Victoria Nankabirwa
- Department of Epidemiology and Biostatistics, School of Public Health, College of Health Sciences, Makerere University, PO Box 7072, Kampala, Uganda. .,Centre for Intervention Science in Maternal and Child Health, Centre for International Health, University of Bergen, Bergen, Norway.
| | - Thorkild Tylleskär
- Centre for Intervention Science in Maternal and Child Health, Centre for International Health, University of Bergen, Bergen, Norway
| | - Josephine Tumuhamye
- Centre for Intervention Science in Maternal and Child Health, Centre for International Health, University of Bergen, Bergen, Norway
| | - James K Tumwine
- Department of Paediatrics and Child Health, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Grace Ndeezi
- Department of Paediatrics and Child Health, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - José C Martines
- Centre for Intervention Science in Maternal and Child Health, Centre for International Health, University of Bergen, Bergen, Norway
| | - Halvor Sommerfelt
- Centre for Intervention Science in Maternal and Child Health, Centre for International Health, University of Bergen, Bergen, Norway.,Global Women and Children's Health, Norwegian Institute of Public Health, Oslo, Norway
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23
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Muriuki A, Obare F, Ayieko B, Matanda D, Sisimwo K, Mdawida B. Health care providers' perspectives regarding the use of chlorhexidine gel for cord care in neonates in rural Kenya: implications for scale-up. BMC Health Serv Res 2017; 17:305. [PMID: 28446176 PMCID: PMC5406932 DOI: 10.1186/s12913-017-2262-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Accepted: 04/24/2017] [Indexed: 12/04/2022] Open
Abstract
Background This paper explores the perspectives of health care providers regarding the use of 7.1% Chlorhexidine Digluconate (CHX) gel that releases 4% chlorhexidine for newborn umbilical cord care under a managed access program (MAP) implemented in Bungoma County of Kenya. Understanding the perspectives of providers regarding CHX is important since they play a key role in the health system and the fact that their views could be influenced by prior beliefs and inconsistent practices regarding umbilical cord care. Methods Data are from in-depth interviews conducted between April and June 2016 with 39 service providers from 21 facilities that participated in the program. The data were transcribed, typed in Word and analyzed for content. Analysis entailed identifying recurring themes based on the interview guides. Results Use of CHX gel for cord care in neonates was acceptable to the health care providers, with all of them supporting scaling up its use throughout the country. Their views were largely influenced by positive outcomes of the medication including fast healing of the cord as reported by mothers, minimal side effects, reduced newborn infections based on what their records showed and mothers’ reports, ease of use that made it simple for them to counsel mothers on how to apply it, positive feedback from mothers which demonstrated satisfaction with the medication, and general acceptance of the medication by the community. They further noted that successful scale-up of the medication required community sensitization, adequate follow-up mechanisms to ensure mothers use the medication correctly, addressing issues of staffing levels and staff training, developing guidelines and protocols for provision of the medication, adopting appropriate service delivery approaches to ensure all groups of mothers are reached, and ensuring constant supply of the medication. Conclusion Use of CHX gel for cord care in neonates is likely to be acceptable to health care workers in settings with high prevalence of neonatal morbidity and mortality arising from cord infections. In scaling up the use of the medication in such settings, some of the health systems requirements for successful roll-out can be addressed by programs while others are likely to be a persistent challenge.
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Affiliation(s)
- Angela Muriuki
- Save the Children, Matundu Close, Off School Lane, Westlands, P.O. Box 27679, Nairobi, 00506, Kenya
| | - Francis Obare
- Population Council, Avenue 5, Rose Avenue, P.O. Box 17643, Nairobi, 00500, Kenya.
| | - Bill Ayieko
- Save the Children, Matundu Close, Off School Lane, Westlands, P.O. Box 27679, Nairobi, 00506, Kenya
| | - Dennis Matanda
- Population Council, Avenue 5, Rose Avenue, P.O. Box 17643, Nairobi, 00500, Kenya
| | - Kenneth Sisimwo
- Save the Children, Matundu Close, Off School Lane, Westlands, P.O. Box 27679, Nairobi, 00506, Kenya
| | - Brian Mdawida
- Population Council, Avenue 5, Rose Avenue, P.O. Box 17643, Nairobi, 00500, Kenya
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24
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Chlorhexidine and newborn omphalitis and mortality – Authors' reply. THE LANCET GLOBAL HEALTH 2017; 5:e272-e273. [DOI: 10.1016/s2214-109x(17)30053-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Accepted: 12/12/2016] [Indexed: 01/26/2023] Open
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Hodgins S. Chlorhexidine and newborn omphalitis and mortality. THE LANCET GLOBAL HEALTH 2017; 5:e270-e271. [DOI: 10.1016/s2214-109x(17)30052-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Accepted: 12/12/2016] [Indexed: 11/26/2022] Open
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26
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Coffey PS, Brown SC. Umbilical cord-care practices in low- and middle-income countries: a systematic review. BMC Pregnancy Childbirth 2017; 17:68. [PMID: 28219420 PMCID: PMC5319165 DOI: 10.1186/s12884-017-1250-7] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Accepted: 02/08/2017] [Indexed: 01/23/2023] Open
Abstract
Background Neonatal sepsis is the third leading cause of deaths for infants in their first month of life. The newly cut umbilical cord can be a pathway for bacteria that can cause newborn sepsis and death. Optimal umbilical cord care practices for newborns and during the first week of life, especially in settings with poor hygiene, has the potential to avoid these preventable neonatal deaths. The purpose of this review of cord care practices is to assist in the development of behavior-change strategies to support introduction of novel cord-care regimens, particularly 7.1% chlorhexidine digluconate for umbilical cord care. Methods We searched domestic and international databases for articles that were published in English between January 1, 2000, and August 24, 2016. We found 321 articles and reviewed 65 full-text articles using standardized inclusion criteria. The primary criteria for inclusion was a description of substances applied to the umbilical cord stump in the days following birth. Results We included 46 articles in this review of umbilical cord-care practices. Articles included data from 15 low- and middle-income countries in sub-Saharan Africa (8 countries), Asia (5 countries), North Africa (1 country), and Latin America and the Caribbean (1 country). Findings from this review suggest that documentation of cord-care practices is not consistent throughout low- and middle-income countries, yet existing literature depicts a firm tradition of umbilical cord care in every culture. Cord-care practices vary by country and by regions or cultural groups within a country and employ a wide range of substances. The desire to promote healing and hasten cord separation are the underlying beliefs related to application of substances to the umbilical cord. The frequency of application of the substance (either the number of days or the number of times per day the substance was applied), and source and cost of products used is not well-characterized. Conclusions This desire to actively care for the umbilical cord of a newborn—as noted in the variety of cord care practices and beliefs identified in this review—points toward the need to contextualize any behavior change approach to align with the local culture. Electronic supplementary material The online version of this article (doi:10.1186/s12884-017-1250-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | - Siobhan C Brown
- PATH, 2201 Westlake Avenue, Suite 200, Seattle, WA, 98121, USA
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27
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Semrau KEA, Herlihy J, Grogan C, Musokotwane K, Yeboah-Antwi K, Mbewe R, Banda B, Mpamba C, Hamomba F, Pilingana P, Zulu A, Chanda-Kapata P, Biemba G, Thea DM, MacLeod WB, Simon JL, Hamer DH. Effectiveness of 4% chlorhexidine umbilical cord care on neonatal mortality in Southern Province, Zambia (ZamCAT): a cluster-randomised controlled trial. LANCET GLOBAL HEALTH 2016; 4:e827-e836. [PMID: 27693439 DOI: 10.1016/s2214-109x(16)30215-7] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Revised: 05/11/2016] [Accepted: 08/08/2016] [Indexed: 11/17/2022]
Abstract
BACKGROUND Chlorhexidine umbilical cord washes reduce neonatal mortality in south Asian populations with high neonatal mortality rates and predominantly home-based deliveries. No data exist for sub-Saharan African populations with lower neonatal mortality rates or mostly facility-based deliveries. We compared the effect of chlorhexidine with dry cord care on neonatal mortality rates in Zambia. METHODS We undertook a cluster-randomised controlled trial in Southern Province, Zambia, with 90 health facility-based clusters. We enrolled women who were in their second or third trimester of pregnancy, aged at least 15 years, and who would remain in the catchment area for follow-up of 28 days post-partum. Newborn babies received clean dry cord care (control) or topical application of 10 mL of a 4% chlorhexidine solution once per day until 3 days after cord drop (intervention), according to cluster assignment. We used stratified, restricted randomisation to divide clusters into urban or two rural groups (located <40 km or ≥40 km to referral facility), and randomly assigned clusters (1:1) to use intervention (n=45) or control treatment (n=45). Sites, participants, and field monitors were aware of their study assignment. The primary outcomes were all-cause neonatal mortality within 28 days post-partum and all-cause neonatal mortality within 28 days post-partum among babies who survived the first 24 h of life. Analysis was by intention to treat. Neonatal mortality rate was compared with generalised estimating equations. This study is registered at ClinicalTrials.gov (NCT01241318). FINDINGS From Feb 15, 2011, to Jan 30, 2013, we screened 42 356 pregnant women and enrolled 39 679 women (mean 436·2 per cluster [SD 65·3]), who had 37 856 livebirths and 723 stillbirths; 63·8% of deliveries were facility-based. Of livebirths, 18 450 (99·7%) newborn babies in the chlorhexidine group and 19 308 (99·8%) newborn babies in the dry cord care group were followed up to day 28 or death. 16 660 (90·0%) infants in the chlorhexidine group had chlorhexidine applied within 24 h of birth. We found no significant difference in neonatal mortality rate between the chlorhexidine group (15·2 deaths per 1000 livebirths) and the dry cord care group (13·6 deaths per 1000 livebirths; risk ratio [RR] 1·12, 95% CI 0·88-1·44). Eliminating day 0 deaths yielded similar findings (RR 1·12, 95% CI 0·86-1·47). INTERPRETATION Despite substantial reductions previously reported in south Asia, chlorhexidine cord applications did not significantly reduce neonatal mortality rates in Zambia. Chlorhexidine cord applications do not seem to provide clear benefits for newborn babies in settings with predominantly facility-based deliveries and lower (<30 deaths per 1000 livebirths) neonatal mortality rates. FUNDING Bill & Melinda Gates Foundation.
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Affiliation(s)
- Katherine E A Semrau
- Center for Global Health and Development, Boston University School of Public Health, Boston, MA, USA; Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | - Julie Herlihy
- Center for Global Health and Development, Boston University School of Public Health, Boston, MA, USA; Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | - Caroline Grogan
- Center for Global Health and Development, Boston University School of Public Health, Boston, MA, USA
| | - Kebby Musokotwane
- Center for Global Health and Development, Boston University School of Public Health, Boston, MA, USA; Ministry of Community Development, Mother and Child Health, Lusaka, Zambia
| | - Kojo Yeboah-Antwi
- Center for Global Health and Development, Boston University School of Public Health, Boston, MA, USA; Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | | | - Bowen Banda
- ZamCAT Field Office, Zambia Centre for Applied Research and Development (ZCAHRD), Choma, Zambia
| | - Chipo Mpamba
- ZamCAT Field Office, Zambia Centre for Applied Research and Development (ZCAHRD), Choma, Zambia
| | - Fern Hamomba
- ZamCAT Field Office, Zambia Centre for Applied Research and Development (ZCAHRD), Choma, Zambia
| | - Portipher Pilingana
- ZamCAT Field Office, Zambia Centre for Applied Research and Development (ZCAHRD), Choma, Zambia
| | - Andisen Zulu
- ZamCAT Field Office, Zambia Centre for Applied Research and Development (ZCAHRD), Choma, Zambia
| | | | - Godfrey Biemba
- Center for Global Health and Development, Boston University School of Public Health, Boston, MA, USA; Department of Global Health, Boston University School of Public Health, Boston, MA, USA; ZCAHRD, Lusaka, Zambia
| | - Donald M Thea
- Center for Global Health and Development, Boston University School of Public Health, Boston, MA, USA; Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | - William B MacLeod
- Center for Global Health and Development, Boston University School of Public Health, Boston, MA, USA; Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | - Jonathon L Simon
- Center for Global Health and Development, Boston University School of Public Health, Boston, MA, USA; Department of Global Health, Boston University School of Public Health, Boston, MA, USA; ZCAHRD, Lusaka, Zambia
| | - Davidson H Hamer
- Center for Global Health and Development, Boston University School of Public Health, Boston, MA, USA; Department of Global Health, Boston University School of Public Health, Boston, MA, USA; ZCAHRD, Lusaka, Zambia; Section of Infectious Diseases, Department of Medicine, Boston Medical Center, Boston, MA, USA.
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Osrin D, Colbourn T. No reason to change WHO guidelines on cleansing the umbilical cord. LANCET GLOBAL HEALTH 2016; 4:e766-e768. [PMID: 27693440 DOI: 10.1016/s2214-109x(16)30258-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Accepted: 09/06/2016] [Indexed: 11/26/2022]
Affiliation(s)
- David Osrin
- Institute for Global Health, University College London, London WC1N 1EH, UK.
| | - Tim Colbourn
- Institute for Global Health, University College London, London WC1N 1EH, UK
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