3 of 4: Reducing Neonatal Mortality - Prevention, Early Detection and Treatment of Infections -...
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Transcript of 3 of 4: Reducing Neonatal Mortality - Prevention, Early Detection and Treatment of Infections -...
Neonatal infections: global
and regional burden and
interventions
Luke C. Mullany, PhD, MHS
Associate Professor, Johns Hopkins University
Kolkata, February 2015
Global Neonatal Mortality
• Almost 3 million neonatal deaths / yr
– Now at least 44% of child mortality
– Older infant and child mortality reductions out-
pacing those in newborns
• Sub Saharan African and South Asia
have highest rates and burden
• India almost 25% of all neonatal deaths
Source: Liu et al, Lancet, 2014
Up to 50% of neonatal
deaths are in the first 24 hours
75% of neonatal deaths are in the first week
Source: Lancet 2005;365:891-900
When do neonatal deaths occur?
Overall and infection-specific causes
• Top three causes:
– Complications of preterm
– Intra-partum related events
– Infections
• ~800,000 infection related deaths
– Sepsis, pneumonia, tetanus, meningitis,
omphalitis, diarrhea, etc
Etiology
• Overall, etiology not well characterized
in settings with highest risk
• Relative contribution of vertical vs.
environmental acquisition uncertain
• Bacterial vs viral etiologies not well
distinguished
• Most large community-based datasets
resort to “PSI”, “PSBI”
pSBI – Global Estimates
• Overall
incidence
– 7.6%
• Case-
fatality
– 9.8%
Source: Seale et al, Lancet Inf Dis, 2014
Causes/Risk Factors for Infections
• Baby factors – Underdeveloped immunity, preterm/LBW, sex
• Maternal/Caretaker factors – Maternal infection, under-nutrition
– Unhygienic labor/delivery practices
– Delayed recognition and care-seeking
• Health system factors – Low access, human resource gap, poor quality
• Environmental/Social factors – Decision making autonomy, cost, etc
Preventative Interventions
• Improved nutrition during pregnancy
• Identification and treatment of infections
in mother
• Clean and hygienic practices during
labor, delivery and postpartum
• Improved newborn care practices
(breastfeeding, cord care, thermal care)
• Extra care and attention for preterm/LBW
Ex 1: Early Initiation of Breastfeeding
• Recent studies show early initiation
(<24 hours) can reduce neonatal death
• Both a nutritional and thermal care
intervention
• Helps establish good feeding pattern
(i.e. establish exclusivity and duration)
• Numerous studies have shown
population based change is possible
Source: Debes, Kohli, Walker, Edmond, Mullany, BMC Public Health, 2013
Ex 2: Kangaroo Mother Care
1. Skin to skin contact with mother or other caretaker
2. Support for early breastfeeding
3. Rapid identification and support
• Established as a preventative intervention for hospitalized, preterm, stabilized infants
• Lack of strong evidence for community-wide scale up to all babies
Source: Lawn et al , 2014
Ex 3: Chlorhexidine Cord Care
• Accelerating use of chlorhexidine cord
cleansing in high-mortality settings
• Safe, readily available, broad spectrum
topical antiseptic
• Randomized trials in South Asia
demonstrate reduced death and
omphalitis
• Sarlahi District, Nepal: 2002-2006
– Mullany, Darmstadt et al, Lancet 2006
• Sylhet District, Bangladesh: 2007-2009
– Arifeen, Mullany et al, Lancet 2012
• Sindh Province, Pakistan: 2008-2009
– Soofi, Bhutta et al, Lancet 2012
S Asia CHX Cord Cleansing Trials
Pooled Analysis
MORTALITY: Any CHX vs. No CHX
Study
Overall 0.77 (0.63, 0.94)
RR (95% CI) RR (95% CI)
1 .5 .75 1.2
Nepal 0.76 (0.58, 1.00)
Bangladesh 0.88 (0.74, 1.04)
Pakistan 0.62 (0.45, 0.85)
MORTALITY: Any CHX vs. No CHX
23% reduction in mortality among
those receiving intervention
Source: Imdad, Mullany, Baqui, et al, BMC Public Health, 2013
Impact on Cord Infection
In all studies…
Multiple CHX reduced cord infection
• Nepal: 33% – 75% reduction
• Bangladesh: 15% – 45% reduction
• Pakistan: 40% – 50% reduction
Summary of Mode of Action
0 Day 7 14
Prevent continued
exposure with
repeat applications
Colonization
of the patent
vessels
Sepsis Death
Visible
infection Sepsis Death
Early applications
protect during
patent period
CHX Application
Mortality Risk HIGH MEDIUM LOWER
Primary benefit of early CHX cleansings
Additional benefit of multiple cleansing
Slide courtesy of Segre J September 2011
Updated WHO Cord Care Guidelines
• All trials done in settings with NMR>30 and very high proportion of home births
• WHO Guidelines now recommend CHX for use in these high risk settings
• Lower level facility-births may also benefit
• Pending African trials in lower mortality settings with lots of facility births
“We won’t benefit from chlorhexidine because harmful practices are no longer common”
– Not necessarily true. The cord stump is still exposed to pathogens through routine home and facility practices
– Among babies where caretakers followed suggested “cleaned cord practices”, chlorhexidine still reduced infection and mortality
Common Questions / Thoughts
“This intervention would only help babies born at home”
– Facility born babies in the Bangladesh and Nepal trials receiving CHX:
• Lower mortality, fewer cord infection, reduced colonization, and same relationship between cord separation time and cord care, as seen in home births
– facilities also struggle to achieve hygienic practices
– babies are discharged into same environment as home-born babies
Common Questions / Thoughts
“Promotion of chlorhexidine is
inconsistent with our previous
messages..”
– Messages can be shaped to fit consistently
with promotion of clean cord care
– Topical chlorhexidine can be promoted as a
“tool to help caretakers achieve a clean cord”
Common Questions / Thoughts
How to interpret the WHO guidelines?
• WHO recs (home, >30 NMR) reflect study
settings
• Impacts of interventions vary with context
• As systems and quality improve, benefits
realized will also vary over time
• Common sense required, recognizing
variable risks within country, across
health system levels, across season, etc
Treatment Interventions
• How do we achieve rapid and accurate identification and treatment of infection?
– Improve recognition and decision making by caretakers
– Appropriate and feasible scheduling of PNC through outreach (i.e. CHW) or in-facilities
– Additional targeting of those at highest risk
– Increase access to care at all levels of health system
– Improve quality of care in facilities
Simplified Antibiotic Trials
• Antibiotics in communities or lower level facilities challenged by:
– Non-specificity of algorithm(s) to identify sick babies
– Adherence to regimens is poor/difficult
– Unknown or ill-characterized antibiotic resistance
• Series of community/facility non-inferiority trials to identify simplified regimens
• Study designs released in PIDJ supplement (2013), results pending (2015)
Etiology of Infection
• Aetiology of Neonatal Infections in South Asia (ANISA)
– 3 country (Ind, Pak, Bang), 5-site cohort study
• CHWs visit babies over 0-59 days, refer “sick” babies to physician assessment
• Collect NP and blood from cases and controls
• Aim is to estimate etiologic distribution of infections in the region
Conclusions
• Despite progress, challenges remain
• Needs are clear:
– Improved routine and targeted preventative care across the pre-pregnancy, pregnancy, delivery, and post-partum continuum
– Improved recognition and care-seeking for infections
– Improved diagnostics at community and facility levels
– Better data on etiology and antibiotic resistance