Date of Award
Master of Public Health (MPH)
Ike Solomon Okosun, MS, MPH, PhD, FTOS, FACE
Nancy Bryant, CCRC
INTRODUCTION: Four million infants die annually within the first 28 days of life (Mir, 2008). This first four weeks of life is known as the neonatal period, a time frame when infants are most vulnerable to disease and infection. Ninety-nine percent of neonatal deaths occur in low to middle income countries (Mir, 2008). A systemic infection known as sepsis is the ultimate cause of death in 36% of neonates (Mullany, 2006). Due to lack of population-wide surveillance in the developing world, the proportion of cases originating from umbilical cord infection is largely unknown. Researchers at Aga Khan University Hospital concluded in their community-based study that home births place neonates at risk for umbilical infection and sepsis. Home births are not sterilely performed and the resulting risk of infection is high (Karumbi et al., 2013). Sequelae of umbilical cord infections have been identified as necrotizing fasciitis and sepsis, which is a systemic infection that is often fatal. (Mir, 2008; Mullany 2007).
AIM: The aim of this study is to review proximal, intermediate and distal risk factors in order to determine which omphalitis interventions show the most promise.
METHODS: Community-based randomized trials in India, Nepal and Pakistan were reviewed to discern the proximal, intermediate and distal risk factors of omphalitis to determine whether a single or multi-level intervention would best address neonatal omphalitis.
RESULTS: A single intervention of 4% CHX has been displayed by numerous studies to effectively reduce the incidence of omphalitis-related mortality by approximately 25%.
DISCUSSION: Due to the high incidence of omphalitis among neonates, similarities in cultural practices surrounding childbirth, and existing study data, India, Pakistan and Nepal have been chosen as countries of interest. Proximally, agents of disease were identified and the etiologies of such pathogens were explored. Intermediately, delivery practices, hygiene of both caregiver and birthing attendant, the occurrence of skin-to-skin contact encountered by the newborn, cultural practices of applying unsanitary substances to the umbilical cord, and breastfeeding norms are analyzed. Distally, environment, ethnicity, socioeconomic status, health systems, and education levels are considered as determinants of this disease (Mullany, et al., 2006).
Numerous studies conducting community-based randomized trials have determined that implementation of the topical antiseptic 4% Chlorhexidine (CHX) can result in an approximate 25% reduction in overall neonate mortality and between a 27% to 54% reduction in the incidence of omphalitis (Imdad et al., 2013). Researcher also cited the long-standing safety record, low cost, strong adhesion rate and activity against both Gram positive and Gram negative bacteria as the reasoning behind the decision to choose CHX as the topical antiseptic (Mullany et al., 2006).
The United Nations Commission on Life-Saving Commodities for Women and Children have requested for the WHO to add 4% CHX to the list of essential medicines for children. The council is fast-tracking the registration of the medicine to promote manufacturers to produce the drug and drop the cost of it for commercial use. New training protocols for birth attendants will also include instruction on how to correctly apply the antiseptic. Continued stewardship of the CHX intervention could lead to a dramatic reduction in neonatal mortality in the rural regions of South-central Asia potentially saving the lives of over 450,000 newborns annually (Mullany et al., 2009).
Patel, Nina, "Review of Omphalitis Interventions in India, Nepal and Pakistan Using Proximal, Intermediate and Distal Risk Factors." , Georgia State University, 2016.