Community Case Management

for Neonatal Sepsis

Bangkok 8 March 2010 NIC – C1

Penny Dawson MD

JSI R&T, Nepal Family Health Program/MINI

Outline of the Presentation

• Rationale for CCM for Neonatal Sepsis

• Evidence from studies on CCM for Neonatal Sepsis

• Translation of evidence to country-level programs

• Issues for scaling up

• Other approaches to decrease infections

Rationale for CCM

• NMR - 38% of Under 5 Mortality*

• 98% of neonatal deaths in developing countries*

• > 60% of births and most deaths occur at home or in community**

• Poor careseeking for newborn illnessSource: *Lawn et al., Lancet. Neonatal Survival Series 2005 ** WHO publication 1996

Why CCM for Neonatal Sepsis?

• 35 – 50% of neonatal deaths due to sepsis*

• Incidence of Possible Severe Bacterial Infections (PSBI) - 4.9 - 17% of all live births**

• Rapid progression to death

• Multiple barriers to care seeking

Source: * Agrawal et al., Ind.J. Ped. Dec. 2001

**Thaver et al .,PIDJ Jan. 2009 - reviewed 32 studies

Evidence for CCM for Neonatal Sepsis

Sazawal, Black, et al - Pooled analysis of 5 RCT studies of CCM for neonatal pneumonia (India, Pakistan, Nepal, Tanzania, Bangladesh) – *

• 27% reduction - all cause NMR (95% CI 18 – 35%)• 42% reduction - pneumonia-specific NMR (95% CI

22 – 57%)

Source – * Sazawal et al., Lancet Infectious DIseases 2003

Evidence for CCM for Neonatal Sepsis

SEARCH *– Gadchiroli, India -62 % reduction in NMR

ANKUR **– Maharastra, India - 51% reduction in NMR

PROJAHNMO ***– Sylhet, Bangladesh – 34% reduction in NMR

• Bang et al Lancet 1999** MCHIP Presentation - 2009*** Baqui et al Lancet 2008

MINI/Nepal - Program Activities - All Babies

Early antenatal household contact by FCHVs

FCHVs informed of Birth By Families

FCHV - Post-natal Visit within 3 days: Weigh &assess baby, counsel, Issue Birth record

Low birth weight Normal weight

Weekly follow-up 4 times

Follow-up status at 2 months

Baby could be sick anytime within 2 months

MINI Program Activities for Sick Babies

Baby is sick anytime within 2 months

Family calls FCHV for assessment

Local Bacterial Infection (Eye, cord, skin) Possible Severe Bacterial Infection

FCHV manages using topical antibiotics

FCHV gives first dose oral cotrimoxazole-P (+ 5-day course) and sends a call form to health facility for gentamicin injection

Third day follow-up by FCHVs

Improved/Referred/DeadFacility-based health worker

responds and gives gentamicin injection for 7 days

Follow-up at two-months

Current Status

Indicators Results for 4th year

(May 2008-April 2009)

Birth Capture Rate 74%

Prevalence of Possible Severe Bacterial Infection (PSBI)

7%

% of PSBI episodes receiving gentamicin within 2 days of onset of illness

72%

% of PSBI episodes completing full 7-doses of gentamicin

94%

Estimated NMR (among birth cohort)

13/1000 live births

(baseline - 24/1000 LB)Source: MINI database

Issues for Scaling Up

GLOBALGLOBAL• Antibiotic choice – oral, oral-inj, injectable onlyAntibiotic choice – oral, oral-inj, injectable only• Refinement of clinical algorithmRefinement of clinical algorithm• Strategies for delivery in remote areasStrategies for delivery in remote areas• Political commitment and supportPolitical commitment and support

NEPALNEPAL• Morang – full district coverage/handoverMorang – full district coverage/handover• National – inclusion of CCM for NN sepsis in National – inclusion of CCM for NN sepsis in

MOHP’s CB –Newborn Care PackageMOHP’s CB –Newborn Care Package• Gentamicin in UNIJECT feasability trialGentamicin in UNIJECT feasability trial

Other approaches to decrease neonatal infections

PROMOTE• ANC including TT• Clean blade to cut umbilical cord• Cord care - Dry or application of chlorhexidine

to cord stump• Early and exclusive breastfeeding• Awareness of danger signs and rapid

careseeking• Handwashing• Newborn vitamin A supplementation

Conclusions• To achieve MDG -4 neonatal mortality due to

sepsis/pneumonia must be addressed urgently

• In settings where referral is not possible, CCM for neonatal sepsis has been proven to reduce mortality

• This is an effective and feasible approach which can be implemented within existing public health systems

Thank You