Management of possible serious bacterial infection in young infants where referral is not possible in the context of existing health system structure in Ibadan, South-west Nigeria

Effect of community-based newborn care implementation strategies on access to and effective coverage of possible serious bacterial infection (PSBI) treatment for sick young infants during COVID-19 pandemic

BACKGROUND

In Ethiopia, neonatal mortality is persistently high. The country has been implementing community-based treatment of possible serious bacterial infection (PSBI) in young infants when referral to a hospital is not feasible since 2012. However, access to and quality of PSBI services remained low and were worsened by COVID-19. From November 2020 to June 2022, we conducted implementation research to mitigate the impact of COVID-19 and improve PSBI management implementation uptake and delivery in two woredas in Ethiopia.

METHODS

In April-May 2021, guided by implementation research frameworks, we conducted formative research to understand the PSBI management implementation challenges, including those due to the COVID-19 pandemic. Through a participatory process engaging stakeholders, we designed adaptive implementation strategies to bridge identified gaps using mechanism mapping to achieve implementation outcomes. Strategies included training and coaching, supportive supervision and mentorship, technical support units, improved supply of essential commodities, and community awareness creation about PSBI and COVID-19. We conducted cross-sectional household surveys in the two woredas before (April 2021) and after the implementation of strategies (June 2022) to measure changes in targeted outcomes.

RESULTS

We interviewed 4,262 and 4,082 women who gave live birth 2-14 months before data collection and identified 374 and 264 PSBI cases in April 2021 and June 2022, respectively. The prevalence of PSBI significantly decreased (p-value = 0.018) from 8.7% in April 2021 to 6.4% while the mothers' care-seeking behavior from medical care for their sick newborns increased significantly from 56% to 91% (p-value <0.01). Effective coverage of severely ill young infants that took appropriate antibiotics significantly improved from 33% [95% CI: 25.5-40.7] to 62% [95% CI: 51.0-71.6]. Despite improvements in the uptake of PSBI treatment, persisting challenges at the facility and systems levels impeded optimal PSBI service delivery and uptake, including perceived low quality of service, lack of community trust, and shortage of supplies.

CONCLUSION

The participatory design and implementation of adaptive COVID-19 strategies effectively improved the uptake and delivery of PSBI treatment. Support systems were critical for frontline health workers to deliver PSBI services and create a resilient community health system to provide quality PSBI care during the pandemic. Additional strategies are needed to address persistent gaps, including improvement in client-provider interactions, supply of essential drugs, and increased social mobilization strategies targeting families and communities to further increase uptake.

Incidence of possible serious bacterial infection in young infants in the three high-burden countries of the Democratic Republic of the Congo, Kenya, and Nigeria: A secondary analysis of a large, multi-country, multi-centre clinical trial

Background

Neonatal infections are a major public health concern worldwide, particularly in low- and middle-income countries, where most of the infection-related deaths in under-five children occur. Sub-Saharan Africa has the highest mortality rates, but there is a lack of data on the incidence of sepsis from this region, hindering efforts to improve child survival. We aimed to determine the incidence of possible serious bacterial infection (PSBI) in young infants in three high-burden countries in Africa.

Methods

This is a secondary analysis of data from the African Neonatal Sepsis (AFRINEST) trial, conducted in the Democratic Republic of the Congo (DRC), Kenya, and Nigeria between 15 March 2012 and 15 July 2013. We recorded baseline characteristics, the incidence of PSBI (as defined by the World Health Organization), and the incidence of local infections among infants from 0-59 days after birth. We report descriptive statistics.

Results

The incidence of PSBI among 0-59-day-old infants across all three countries was 11.2% (95% confidence interval (CI) = 11.0-11.4). The DRC had the highest incidence of PSBI (19.0%; 95% CI = 18.2-19.8). Likewise, PSBI rates were higher in low birth weight infants (24.5%; 95% CI = 23.1-26.0) and infants born to mothers aged <20 years (14.1%; 95% CI = 13.4-14.8). The incidence of PSBI was higher among infants delivered at home (11.7%; 95% CI = 11.4-12.0).

Conclusions

The high burden of PSBI among young infants in DRC, Kenya, and Nigeria demonstrates the importance of addressing PSBI in improving child survival in sub-Saharan Africa to reach the Sustainable Development Goals (SDGs). These data can support government authorities, policymakers, programme implementers, non-governmental organisations, and international partners in reducing preventable under-five deaths.

Registration

Australian New Zealand Clinical Trials Registry: ACTRN12610000286044.

Labour conditions in dual-cadre community health worker programmes: a systematic review

BACKGROUND

Health care delivered by community health workers reduces morbidity and mortality while providing a considerable return on investment. Despite growing consensus that community health workers, a predominantly female workforce, should receive a salary, many community health worker programmes take the form of dual-cadre systems, where a salaried cadre of community health workers works alongside a cadre of unsalaried community health workers. We aimed to determine the presence, prevalence, and magnitude of exploitation in national dual-cadre programmes.

METHODS

We did a systematic review of available evidence from peer-reviewed databases and grey literature from database inception to Aug 2, 2021, for studies on unsalaried community health worker cadres in dual-cadre systems. Editorials, protocols, guidelines, or conference reports were excluded in addition to studies about single-tier community health worker programmes and those reporting on only salaried cadres of community health workers in a dual-cadre system. We extracted data on remuneration, workload, task complexity, and self-reported experiences of community health workers. Three models were created: a minimum model with the shortest time and frequency per task documented in the literature, a maximum model with the longest time, and a median model. Labour exploitation was defined as being engaged in work below the country's minimum wage together with excessive work hours or complex tasks. The study was registered with PROSPERO, CRD42021271500.

FINDINGS

We included 117 reports from 112 studies describing community health workers in dual-cadre programmes across 19 countries. The majority of community health workers were female. 13 (59%) of 22 unsalaried community health worker cadres and one (10%) of ten salaried cadres experienced labour exploitation. Three (17%) of 18 unsalaried community health workers would need to work more than 40 h per week to fulfil their assigned responsibilities. Unsalaried community health worker cadres frequently reported non-payment, inadequate or inconsistent payment of incentives, and an overburdensome workload.

INTERPRETATION

Unsalaried community health workers in dual-cadre programmes often face labour exploitation, potentially leading to inadequate health-care provision. Labour laws must be upheld and the creation of professional community health worker cadres with fair contracts prioritised, international funding allocated to programmes that rely on unsalaried workers should be transparently reported, the workloads of community health workers should be modelled a priori and actual time use routinely assessed, community health workers should have input in policies that affect them, and volunteers should not be responsible for the delivery of essential health services.

FUNDING

None.

How long should young infants less than two months of age with moderate-mortality-risk signs of possible serious bacterial infection be hospitalised for? Study protocol for a randomised controlled trial from low- and middle-income countries

Background

Hospitalisation and a seven-day injectable antibiotics course are recommended by the World Health Organization (WHO) to treat suspected clinical neonatal sepsis / possible serious bacterial infection (PSBI). Some infants presenting with PSBI signs associated with a moderate risk of mortality may only need a two-day hospitalisation followed by outpatient care treatment with oral antibiotics to complete seven days of antibiotics.

Methods

A multi-centre, individually randomised, open-label trial will be conducted in seven sites in six countries: Bangladesh, Ethiopia, India (two sites), Nigeria, Pakistan and Tanzania. A common protocol will be used with the same study design, including the participants, intervention, comparison, outcomes, quality control, and analysis procedures. 0-59 days old infants presenting with moderate-mortality risk signs (low body temperature (<35.5°C), movement only when stimulated, stopped feeding well) or two or more signs of clinical severe infection (CSI) will be assessed and pre-enrolled. After 48 hours of hospital stay, clinically stable infants with a negative C-reactive protein test will be randomised either to hospital discharge on oral amoxicillin (intervention) or continued hospitalisation (control) arm. The intervention arm will receive oral amoxicillin for five days, whereas the control arm will receive injection gentamicin plus injection ampicillin for five more days plus supportive therapy if needed. We plan to enrol 5250 eligible young infants, 2625 infants in each of the two study arms. An experienced, well-trained independent outcome assessor will visit all enrolled cases on days 4, 8 and 15 after the initiation of treatment to assess the study outcomes in both intervention and control arms. The primary outcome of poor clinical outcome defined as death between randomisation and day 15 of initiation of treatment, deterioration during the 7-day treatment period, or persistence of the presenting sign of CSI at the end of the 7-day treatment period will be compared to assess if an early discharge and outpatient treatment leads to superior or at least non-inferior clinical outcome than continued inpatient treatment. The harmonisation of activities, including methods and processes, will be carried out diligently. Central training will be conducted by the WHO coordinating team, a central data coordination centre to collate all data, standardisation exercises for all clinical signs and internal and external monitoring. All the selected sites have extensive research experience. Through regular online and physical meetings, data-based monitoring, and physical site visits by WHO monitors, quality assurance and harmonisation will be ensured. This trial has been approved by the WHO and local site institutional ethics committees.

Discussion

If the results show that young infants with moderate-mortality risk PSBI signs can be safely and effectively treated on an outpatient basis after a shorter hospital stay, it will reduce the burden on the hospitals, potentially reduce nosocomial hospital infections and increase access to treatment for families with poor access to health facilities. It may also reduce the health system costs (human and materials) and allow the overburdened hospitals to pay more attention to critically ill young infants. In addition, this evidence will contribute to making a case for reviewing the WHO PSBI guideline.

Registration

International Standard Randomised Controlled Trial Number, ISRCTN16872570.

Optimal place of treatment for young infants aged less than two months with any low-mortality-risk sign of possible serious bacterial infection: Study Protocol for a randomised controlled trial from low- and middle-income countries

Background

World Health Organization (WHO) recommends hospitalisation and injectable antibiotics for clinical sepsis / possible serious bacterial infection (PSBI) in young infants up to two months of age. However, some young infants with low-mortality risk signs of PSBI may not require hospitalisation, for which evidence needs to be generated.

Methods

This is a protocol for a multicentre, individually randomised, open-label trial that will be conducted in seven sites in six countries Bangladesh, Ethiopia, India (two sites), Nigeria, Pakistan and Tanzania. All sites will use this common protocol with the same study design, inclusion of participants, intervention, comparison, and outcomes, as well as quality control and analysis procedures to contribute to the overall sample size. All young infants (age <60 days) presenting at study hospitals with any single low-mortality risk sign (high body temperature ≥38°C, severe chest indrawing, or fast breathing of ≥60 breaths per minute in <7 days old infants) will be randomised to either outpatient care with injectable gentamicin for two days and oral amoxicillin for seven days (intervention) or inpatient care with injection gentamicin plus injection ampicillin along with supportive treatment, where needed, for seven days (control). We plan to enrol 7000 eligible young infants, 3500 infants in each of the two study arms. A trained and standardised independent outcome assessor will visit all enrolled cases on days two, four, eight and 15 post-randomisation to assess the study outcomes in both intervention and control groups. The primary outcome of poor clinical outcome, defined as death within two weeks of initiation of treatment, deterioration during the 7-day treatment period, or persistence of the presenting sign at the end of the 7-day treatment period, will be compared to assess if the outpatient treatment leads to superior or at least non-inferior clinical outcome than inpatient treatment. The selected sites have extensive research experience. The methods and all study procedures will be harmonised through central training of research staff by WHO, standardisation exercises for clinical signs, central data coordination centre and internal and external monitoring. Continuous evaluation of the enrolment by the sites will be carried out through regular calls, databased monitoring, and site visits by WHO monitors. This trial has received ethical approvals from the WHO and local site institutional ethics committees.

Discussion

If the results show that young infants with any single low-mortality risk PSBI sign can be effectively and safely treated on an outpatient basis, it may substantially increase access to treatment for infants and families with poor access to health facilities. It may also reduce the human, financial and material costs to the health system and allow the currently overloaded health facilities to focus on more critically ill infants. This evidence will contribute toward making a case for reviewing the current WHO PSBI management guideline.

Registration

International Standard Randomised Controlled Trial Number ISRCTN44033252.

Measuring implementation outcomes in the context of scaling up possible serious bacterial infection guidelines: Implications for measurement and programs

BACKGROUND

Reducing the burden of neonatal sepsis requires timely identification and initiation of suitable antibiotic treatment in primary health care (PHC) settings. Countries are encouraged to adopt simplified antibiotic regimens at the PHC level for treating sick young infants (SYI) with signs of possible serious bacterial infection (PSBI). As countries implement PSBI guidelines, more lessons on effective implementation strategies and outcome measurements are needed. We document pragmatic approaches used to design, measure and report implementation strategies and outcomes while adopting PSBI guidelines in Kenya.

METHODS

We designed implementation research using longitudinal mixed methods embedded in a continuous regular systematic learning and adoption of evidence in the PHC context. We synthesized formative data to co-create with stakeholders, implementation strategies to incorporate PSBI guidelines into routine service delivery for SYIs. This was followed by quarterly monitoring for learning and feedback on the effect of implementation strategies, documented lessons learned and tracked implementation outcomes. We collected endline data to measure the overall effect on service level outcomes.

RESULTS

Our findings show that characterizing implementation strategies and linking them with implementation outcomes, helps illustrate the pathway between the implementation process and outcomes. Although we have demonstrated that it is feasible to implement PSBI in PHC, effective investment in continuous capacity strengthening of providers through blended approaches, efficient use of available human resources, and improving the efficiency of service areas for managing SYIs optimizes timely identification and management of SYI. Sustained provision of commodities for management of SYI facilitates increased uptake of services. Strengthening facility-community linkages supports adherence to scheduled visits. Enhancing the caregiver's preparedness during postnatal contacts in the community or facility will facilitate the effective completion of treatment.

CONCLUSION

Careful design, and definition of terms related to the measurement of implementation outcomes and strategies enable ease of interpretation of findings. Using the taxonomy of implementation outcomes help frame the measurement process and provides empirical evidence in a structured way to demonstrate causal relationships between implementation strategies and outcomes. Using this approach, we have illustrated that the implementation of simplified antibiotic regimens for treating SYIs with PSBI in PHC settings is feasible in Kenya.

Institutionalizing the Management of Sick Young Infants: Kenya's Experience in Revising National Guidelines on Integrated Management of Newborn and Childhood Illnesses

INTRODUCTION

In 2015, the World Health Organization (WHO) developed guidelines for the management of sick young infants (SYIs) with possible serious bacterial infection (PSBI) where referral is not feasible. The Ponya Mtoto project was designed as an implementation research project to demonstrate how to adopt the WHO PSBI guidelines in the Kenyan context.

PONYA MTOTO PROJECT DESCRIPTION

Between October 2017 and June 2021, Ponya Mtoto was implemented in 4 Kenyan counties with higher infant and newborn mortality rates than the national mean. A total of 48 health facilities stratified by level of services were selected as study sites.

IMPLEMENTATION APPROACH

The following activities were done to institutionalize the management of SYIs with PSBI where referral is not feasible in Kenya's health system: (1) participating in a cocreation workshop and development of a theory of change; (2) revising the national integrated management of newborn and childhood illnesses guidelines to incorporate the management of PSBI where referral is not feasible; (3) improving availability of essential commodities; (4) strengthening provider confidence in the management of SYIs; (5) strengthening awareness about PSBI services for SYIs at the community level; and (6) harmonizing the national integrated management of newborn and childhood illnesses guidelines to address discrepancies in the content on the management of PSBI. In addition, the project focused on strengthening quality of care for SYIs and using implementation research to track progress in achieving project targets and outcomes.

CONCLUSION

Using an implementation research approach to introduce new WHO guidelines on PSBI where referral is not feasible into Kenya's health care service was critical to fostering engagement of a diverse range of stakeholders, monitoring provider skills and confidence-building, strengthening provision of key commodities for managing SYIs with PSBI, and sustaining community-facility linkages.

Implementation of distance learning IMCI training in rural districts of Tanzania

BACKGROUND

The standard face-to-face training for the integrated management of childhood illness (IMCI) continues to be plagued by concerns of low coverage of trainees, the prolonged absence of trainees from the health facility to attend training and the high cost of training. Consequently, the distance learning IMCI training model is increasingly being promoted to address some of these challenges in resource-limited settings. This paper examines participants' accounts of the paper-based IMCI distance learning training programme in three district councils in Mbeya region, Tanzania.

METHODS

A cross-sectional qualitative descriptive design was employed as part of an endline evaluation study of the management of possible serious bacterial infection in Busokelo, Kyela and Mbarali district councils of Mbeya Region in Tanzania. Key informant interviews were conducted with purposefully selected policymakers, partners, programme managers and healthcare workers, including beneficiaries and training facilitators.

RESULTS

About 60 key informant interviews were conducted, of which 53% of participants were healthcare workers, including nurses, clinicians and pharmacists, and 22% were healthcare administrators, including district medical officers, reproductive and child health coordinators and programme officers. The findings indicate that the distance learning IMCI training model (DIMCI) was designed to address concerns about the standard IMCI model by enhancing efficiency, increasing outputs and reducing training costs. DIMCI included a mix of brief face-to-face orientation sessions, several weeks of self-directed learning, group discussions and brief face-to-face review sessions with facilitators. The DIMCI course covered topics related to management of sick newborns, referral decisions and reporting with nurses and clinicians as the main beneficiaries of the training. The problems with DIMCI included technological challenges related to limited access to proper learning technology (e.g., computers) and unfriendly learning materials. Personal challenges included work-study-family demands, and design and coordination challenges, including low financial incentives, which contributed to participants defaulting, and limited mentorship and follow-up due to limited funding and transport.

CONCLUSION

DIMCI was implemented successfully in rural Tanzania. It facilitated the training of many healthcare workers at low cost and resulted in improved knowledge, competence and confidence among healthcare workers in managing sick newborns. However, technological, personal, and design and coordination challenges continue to face learners in rural areas; these will need to be addressed to maximize the success of DIMCI.

Using the Implementation Research Logic Model to design and implement community-based management of possible serious bacterial infection during COVID-19 pandemic in Ethiopia

BACKGROUND

Community-based treatment of possible serious bacterial infection (PSBI) in young infants, when referral to a hospital is not possible, can result in high treatment coverage and low case fatality. However, in Ethiopia, the coverage of PSBI treatment remains low, worsened by COVID-19. To understand the challenges of delivery of PSBI treatment and design and test adaptative strategies to mitigate the impact of COVID-19 on neonatal mortality, we did implementation research (IR) employing Implementation Research Logic Model (IRLM). In this paper, we describe IRLM application experiences in designing, implementing, and evaluating strategies to improve community-based treatment of PSBI during the COVID-19 pandemic in Ethiopia.

METHODS

This IR was conducted between November 2020-April 2022 at Dembecha and Lume woredas of Amhara and Oromia regions, respectively. We employed narrative reviews, formative assessment and facilitated stakeholder engagement to develop the PSBI treatment IRLM to identify barriers, understand the conceptual linkages among determinants, choose implementation strategies, elicit mechanisms, and link to implementation outcomes. In addition, we used the IRLM to structure the capture of emerging implementation challenges and resulting strategy adaptations throughout implementation.

RESULTS

This IR identified COVID-19 and multiple pre-existing contextual factors. We designed and implemented implementation strategies to address these challenges. These adaptive strategies were implemented with sufficient strength to maintain the delivery of PSBI services and improve mothers' care-seeking behavior for their sick young infants. The IRLM offers us a clear process and path to prioritize implementation challenges, choose strategies informed by mechanisms of action, and where the adaptive implementation of community-based management of PSBI would lead to high-implementation fidelity and change in mother behavior to seek care for their sick young infants. The IRLM was also an effective tool for stakeholder engagement, easily explained and used to structure discussion and decision-making during co-design meetings.

CONCLUSIONS

The use of the IRLM helps us to specify the conceptual links between the implementation challenges, strategies, mechanisms of action, and outcomes to explore the complex community-based management of PSBI during complex contexts to improve high-fidelity implementation and integration of PSBI treatment in the primary healthcare delivery systems through active engagement of stakeholders.

Global emergency medicine: A scoping review of the literature from 2021

OBJECTIVE

The objective was to identify the most important and impactful peer-reviewed global emergency medicine (GEM) articles published in 2021. The top articles are summarized in brief narratives and accompanied by a comprehensive list of all identified articles that address the topic during the year to serve as a reference for clinicians, researchers, and policy makers.

METHODS

A systematic PubMed search was carried out to identify all GEM articles published in 2021. Title and abstract screening was performed by trained reviewers and editors to identify articles in one of three categories based on predefined criteria: disaster and humanitarian response (DHR), emergency care in resource-limited settings (ECRLS), and emergency medicine development (EMD). Included articles were each scored by two reviewers using established rubrics for original (OR) and review (RE) articles. The top 5% of articles overall and the top 5% of articles from each category (DHR, ECRLS, EMD, OR, and RE) were included for narrative summary.

RESULTS

The 2021 search identified 44,839 articles, of which 444 articles screened in for scoring, 25% and 22% increases from 2020, respectively. After removal of duplicates, 23 articles were included for narrative summary. ECRLS constituted the largest category (n = 16, 70%), followed by EMD (n = 4, 17%) and DHR (n = 3, 13%). The majority of top articles were OR (n = 14, 61%) compared to RE (n = 9, 39%).

CONCLUSIONS

The GEM peer-reviewed literature continued to grow at a fast rate in 2021, reflecting the continued expansion and maturation of this subspecialty of emergency medicine. Few high-quality articles focused on DHR and EMD, suggesting a need for further efforts in those fields. Future efforts should focus on improving the diversity of GEM research and equitable representation.

Barriers to optimal care and strategies to promote safe and optimal management of sick young infants during the COVID-19 pandemic: A multi-country formative research study

Background

Essential health and nutrition services for pregnant women, newborns, and children, particularly in low- and middle-income countries (LMICs), are disrupted by the COVID-19 pandemic. This formative research was conducted at five LMICs to understand the pandemic's impact on barriers to and mitigation for strategies of care-seeking and managing possible serious bacterial infection (PSBI) in young infants.

Methods

We used a convergent parallel mixed-method design to explore the possible factors influencing PSBI management, barriers, and facilitators at three levels: 1) national and local policy, 2) the health systems, public and private facilities, and 3) community and caregivers. We ascertained trends in service provision and utilisation across pre-lockdown, lockdown, and post-lockdown periods by examining facility records and community health worker registers.

Results

The pandemic aggravated pre-existing challenges in the identification of young infants with PSBI; care-seeking, referral, and treatment due to several factors at the policy level (limited staff and resource reallocation), health facility level (staff quarantine, sub-optimal treatment in facilities, limited duration of service availability, lack of clear guidelines on the management of sick young infants, and inadequate supplies of protective kits and essential medicines) and at the community level (travel restrictions, lack of transportation, and fear of contracting the infection in hospitals). Care-seeking shifted to faith healers, traditional and informal private sources, or home remedies. However, caregivers were willing to admit their sick young infants to the hospital if advised by doctors. A review of facility records showed low attendance (<50%) of sick young infants in the OPD/emergencies during lockdowns in Bangladesh, India (both sites) and Pakistan, but it gradually increased as lockdowns eased. Stakeholders suggested aspirational and pragmatic mitigation strategies.

Conclusions

We obtained useful insights on health system preparedness during catastrophes and strategies to strengthen services and improve utilisation regarding PSBI management. The current pandemic provides an opportunity for implementing various mitigation strategies at the policy, health system, and community levels to improve preparedness.

Social autopsy analysis of the determinants of neonatal and under-five mortalities in Nigeria, 2013-2018

Background

Nigeria suffers from one of the world’s highest child mortality rates, with about 900,000 deaths in a single year, despite being classified as a middle-income country. Over the past few years, substantial efforts have been made to reduce child mortality, with under-five mortality declining by 31.6% between 1990 and 2018. However, this decline is slower than needed to reduce child mortality significantly. This study presents the social autopsy component of the 2019 verbal and social autopsy (VASA) survey to provide an in-depth understanding of the social determinants of under-five mortality in Nigeria.

Methods

The study was a cross-sectional inquiry into the social determinants of neonatal and 1-59 months child deaths from the 2018 Nigeria Demographic and Health Survey (NDHS) weighted to represent the Nigerian population. The social autopsy survey asked about maternal care for neonates and 1-59 months children during the final illness.

Results

Child mortality in Nigeria in children aged 1-59 months is strongly associated with levels of wealth, place of residence, and maternal education. The association of these same socio-economic factors with neonatal mortality is weaker. While there were significant associations with wealth quintiles and geopolitical zones, higher maternal education was not significantly associated with lower neonatal death rates. Maternal complications in pregnancy and/or labour and delivery were common and strongly associated with stillbirths and deaths in the first two days. Severity scores at the inception of the illnesses did not show differences between children who only received informal care versus those who went to formal care providers. The main barriers to care were distance, cost, transport, and the need to travel at night, and these barriers were interlinked. More distant facilities usually required vehicle transport, which was expensive for low-income families. Travelling for an emergency at night was even more difficult in terms of finding and paying for transport and involving problems with insecurity and bad roads.

Conclusions

The family, community, and health system factors related to neonatal and 1-59 months child deaths in Nigeria were highlighted in this study. Deaths were commonly associated with numerous factors, each of which could contribute to the sequence of events resulting in a preventable death.

A multi-country implementation research initiative to jump-start scale-up of outpatient management of possible serious bacterial infections (PSBI) when a referral is not feasible: Summary findings and implications for programs

INTRODUCTION

Research on simplified antibiotic regimens for outpatient treatment of 'Possible Serious Bacterial Infection' (PSBI) and the subsequent World Health Organization (WHO) guidelines provide an opportunity to increase treatment coverage. This multi-country implementation research initiative aimed to learn how to implement the WHO guideline in diverse contexts. These experiences have been individually published; this overview paper provides a summary of results and lessons learned across sites.

METHODS SUMMARY

A common mixed qualitative and quantitative methods protocol for implementation research was used in eleven sites in the Democratic Republic of Congo (Equateur province), Ethiopia (Tigray and Oromia regions), India (Haryana, Himachal Pradesh, Maharashtra, and Uttar Pradesh states), Malawi (Central Region), Nigeria (Kaduna and Oyo states), and Pakistan (Sindh province). Key steps in implementation research were: i) policy dialogue with the national government and key stakeholders, ii) the establishment of a 'Technical Support Unit' with the research team and district level managers, and iii) development of an implementation strategy and its refinement using an iterative process of implementation, programme learning and evaluation.

RESULTS SUMMARY

All sites successfully developed and evaluated an implementation strategy to increase coverage of PSBI treatment. During the study period, a total of 6677 young infants from the study catchment area were identified and treated at health facilities in the study area as inpatients or outpatients among 88179 live births identified. The estimated coverage of PSBI treatment was 75.7% (95% CI 74.8% to 78.6%), assuming a 10% incidence of PSBI among all live births. The treatment coverage was variable, ranging from 53.3% in Lucknow, India to 97.3% in Ibadan, Nigeria. The coverage of inpatient treatment ranged from 1.9% in Zaria, Nigeria, to 33.9% in Tigray, Ethiopia. The outpatient treatment coverage ranged from 30.6% in Pune, India, to 93.6% in Zaria, Nigeria. Overall, the case fatality rate (CFR) was 14.6% (95% CI 11.5% to 18.2%) for 0-59-day old infants with critical illness, 1.9% (95% CI 1.5% to 2.4%) for 0-59-day old infants with clinical severe infection and 0.1% for fast breathing in 7-59 days old. Among infants treated as outpatients, CFR was 13.7% (95% CI 8.7% to 20.2%) for 0-59-day old infants with critical illness, 0.9% (95% CI 0.6% to 1.2%) for 0-59-day old infants with clinical severe infection, and 0.1% for infants 7-59 days old with fast breathing.

CONCLUSION

Important lessons on how to conduct each step of implementation research, and the challenges and facilitators for implementation of PSBI management guideline in routine health systems are summarised and discussed. These lessons will be used to introduce and scale-up implementation in relevant Low- and middle-income countries.

Community-based amoxicillin treatment for fast breathing pneumonia in young infants 7-59 days old: a cluster randomised trial in rural Bangladesh, Ethiopia, India and Malawi

INTRODUCTION

Young infants 7-59 days old with fast breathing pneumonia presented to a primary level health facility receive a 7-day course of amoxicillin as per the WHO guideline. However, community-level health workers (CLHW) are not allowed to treat these infants. This trial evaluated the community level treatment of non-hypoxaemic young infants with fast breathing pneumonia by CLHWs.

METHODS

This cluster-randomised, open-label, non-inferiority trial was conducted in rural areas of Bangladesh, Ethiopia, India and Malawi. We randomly allocated clusters (first-level health facility) 1:1, stratified by the population size, to an intervention group (enhanced community case management) or control group (standard community case management). Infants aged 7-59 days with a respiratory rate of ≥60 breaths/min and oxygen saturation (SpO2) ≥90% were enrolled. In the intervention clusters, these infants were treated with a 7-day course of oral amoxicillin (according to WHO weight bands) and were regularly followed up by CLHWs. In the control clusters, CLHWs continued the standard management (assess and refer after pre-referral antibiotic dose) and followed up according to the national programme guideline. The primary outcome of treatment failure was assessed in both groups by independent outcome assessors on days 6 and 14 after enrolment. Secondary outcomes (accuracy and impact of pulse oximetry) were also assessed.

RESULTS

Between September 2016 and December 2018, we enrolled 2334 infants (1168 in intervention and 1166 in control clusters) from 208 clusters (104 intervention and 104 control). Of 2334, 22 infants with fast breathing were excluded from analysis, leaving 2312 (1155 in intervention clusters and 1157 in control clusters) for intention-to-treat analysis. The proportion of treatment failure was 5.4% (63/1155) in intervention and 6.3% (73/1157) in the control clusters, including two deaths (0.2%) in each group. The adjusted risk difference for treatment failure between the two groups was -1.0% (95% CI -3.0% to 1.1%). The secondary outcome showed that CLHWs in the intervention clusters performed all recommended steps of pulse oximetry assessment in 94% (1050/1115) of enrolled patients.

CONCLUSIONS

The 7-day amoxicillin treatment for 7-59 days old non-hypoxaemic infants with fast breathing pneumonia by CLHWs was non-inferior to the currently recommended referral strategy.

TRIAL REGISTRATION NUMBERS

CTRI/2017/02/007761 and ACTRN12617000857303.