Preliminary experie ence with CHX for cord care in Nepal p Dr Naresh Dr. Naresh Pratap KC Pratap KC Direc ctor Family Health D Division, Nepal
Existing Policy o Existing Policy o on Cord Care on Cord Care • WHO Recommendation: I Initially dry cord care; y y ; revised to state: “…in settings where the risk o g of bacterial infection is high, it may g y ic as per local preferences” 1 be prudent to use an antisepti • Nepal National Medical S tandards, volume 3 – dry cord care as general reco d l ommendation, but when d ti b t h adequate hygiene cannot t be assured in household setting CHX should be us setting, CHX should be us sed. sed 1 Source: http:/ //apps.who.int/rhl/newborn/cd001057_capurroh_com/en/index.html
Pil t Pilot studies o t di on CHX in Nepal CHX i N l • Initial studies on preparatio on and acceptability • Pilot study designed to exp • Pilot study designed to exp plore coverage and plore coverage and compliance o Pilot designed to be impleme ented through the Government infrastructure—thus able to b be added to existing programs if successful
Initial stu Initial stu udy on gel udy on gel Maternity Hospital study done in 20 Maternity Hospital study done in 20 008-09 demonstrated comparability 008 09 demonstrated comparability • • of gel compared to aqueous prepa ration Objec Objec ctive: ctive: “ To establish whether or not 4% chlorhe exidine in a gel formulation is at least as efficacious as the aqueous formulation n, as measured by presence of culturable skin flora on newborn peri-umbilical l skin 24 hours after CHX application.” Conclu usion: The study demonstrated superiority The study demonstrated superiority y of gel with regard to 24-hour post y of gel with regard to 24 hour post • application culture positive rates, w with a statistically significant difference, in favor of gel.
Initial study o Initial study o on acceptability on acceptability Community acceptability study don y p y y ne in Banke (2009) showed clear ( ) • preference for the lotion Obje ctive : “To examine acceptability and ease of u use of two different chlorhexidine (CHX) formulations, for prophylactic applicati ion to the freshly cut umbilical cord stump” Conclu Conclu usions: usions: Use of CHX has largely but not com mpletely displaced the practice of • applying other substances to the co pp y g ord stump Although both products were liked by almost all participants, there was a • clear preference for the lotion.
R ti Rati onale l • Umbilical cord infection is a maj U bili l d i f ti i jor cause of neo-natal infection j j f t l i f ti (Neonatal Health strategy 2004 4)--62 % of local Bacterial Infection was from umbilical infe ection in Morang (Report of MINI g ( p Morang) • The freshly cut cord stump is an n open wound through which there can be direct bacterial see eding, causing sepsis without apparent cord infection. • Application of chlorhexidine to t the umbilical area of neonates was associated with a 24% dec crease in neonatal mortality, 34% if applied on day of delivery (Mull if li d d f d li lany et al, 2006)
The P roduct • Kawach – “shield” (Nep pali name for 4% CHX) • Broad spectrum antise B d i ptic i • Gel (lotion) – 4% CHX Gel (lotion) 4% CHX, thickened with guar gum thickened with guar gum • Single application (3cc ) – current cord-care recommendations d ti • Applied by fingers (fres Applied by fingers (fres shly washed with soap & shly washed with soap & water)
Interventio Interventio on Channels on Channels CHX use initiated at health fac cility level as a part of routine essential newborn care practi ce CHX distributed by Female Co ommunity Health Volunteers for application by FCHV, mother or other birth attendant CHX considered for social ma CHX id d f i l arketing – to increase availability k i i il bili through retail sector
Female Communit ty Health Volunteers Pillars to Nepal’s Pu ublic Health Programs FCHVs are involved in: FCHVs are involved in: 23,151,423 • Community based management of Total Population p pneumonia & diarrhea pneumonia & diarrhea • Vitamin A & de-worming 42,53,220 households • Immunization promotion 3 915 VDCs 3,915 VDCs • Family Planning • Birth preparedness and NEPAL neonatal care packages p g • Innovative approaches 75 Districts 75 Districts 48,5 549 FCHVs Source: CBS 2001
Pilot district eva Pilot district eva aluation surveys aluation surveys
Related Care Related Care ervice ervice i and Se and Se Pregnancy R Pregnancy R d S d S New ERA
Proportion of R Proportion of R DW Who had DW Who had Exposure t Exposure t Exposure t Exposure t to FCHV to FCHV to FCHV to FCHV Most mothers had 96 98 100 92 85 90 82 contact with FCHV 80 80 68 and thus the 70 60 Percent opportunity to 50 receive CHX receive CHX 40 40 P 30 20 10 0 0 Banke (n=600) Jumla (n=600) Bajhang (n=600) RDW w who knew FCHV RDW who met FCHV in last pregnancy New ERA
Proportion of RDW Proportion of RDW W Who Received W Who Received Antenata Antenata al Care * al Care * * Among live births * Among live births ANC visit rates 99 97 100 were high 89 90 80 80 70 60 ercent 50 Pe 40 30 20 10 0 Ban nke (n=596) Jumla (n=583) Bajhang (n=594) Banke Jumla Bajhang j g (n=591) (n=578) (n=556) RDW who had at le east 4 ANC 69 63 43 checkups from HW Ws (%) New ERA
Place of Place of Delivery Delivery among li among li among li among li ive births ive births ive births ive births Both health facilities 100 90 and FCHVs can 80 71 66 66 make a contribution make a contribution 70 70 to CHX coverage 60 Percent 5 50 50 50 34 40 29 29 30 20 10 0 0 Ban nke (n=596) Jumla (n=583) Bajhang (n=594) Health Facility Home/ Other New ERA
Instrument Used for C Instrument Used for C Cutting Umbilical Cord Cutting Umbilical Cord among home deliv among home deliv among home deliv among home deliv very with live birth very with live birth very with live birth very with live birth Shows disturbing continued dangerous practices in some practices in some districts New ERA
Coverage and Coverage and Coverage and Coverage and d Compliance d Compliance d Compliance d Compliance of C of C CHX CHX New ERA
Applied CHX on Co Applied CHX on Co rd Stump of Newborn rd Stump of Newborn among among among among live births live births live births live births 100 100 90 47-67% coverage 80 67 67 70 70 5 58 60 ercent 47 45 50 Pe 40 30 24 18 17 15 20 8 10 0 Banke (n=596) Banke (n=596) J J Jumla (n=583) Jumla (n=583) Bajhang (n=594) Bajhang (n=594) Yes No Don’t know* *95% of don’t know are from institution nal delivery New ERA
Coverage of CHX by Coverage of CHX by y program maturity y program maturity among liv among liv among liv among liv ve births ve births ve births ve births Improving trend with program maturity program maturity 80 70 65 70 61 60 53 51 50 rcent 42 40 40 Per 30 20 10 0 Banke (n=596) Banke (n=596) Ju Ju mla (n=583) mla (n=583) Bajhang (n=594) Bajhang (n=594) From Baishak - Kartik 2067 From Mangsir 2067 - Jestha 2068 New ERA
Timing of CHX Timing of CHX X Application X Application among live birth w among live birth w among live birth w among live birth w with CHX applied with CHX applied with CHX applied with CHX applied Most apply early 100 90 85 78 76 7 80 70 70 60 ercent 50 40 40 P 30 20 18 20 11 11 10 4 5 4 0 Banke (n=402) Ju umla (n=337) Bajhang (n=278) Within 5 min After 5 min Don't know* * Don’t know is high among institutio onal deliveries. New ERA
Applicati Applicati Applicati Applicati ion of CHX ion of CHX ion of CHX ion of CHX Most apply correctly 100 95 94 90 90 89 89 90 86 84 79 80 70 60 50 40 30 20 10 0 Banke J Jumla Bajhang Stump and surrounding area Single application of Kawach Whole content of Kawach applies
Compliance w Compliance w with CHX use with CHX use 100 90 77 80 70 68 70 60 ent Perce 50 50 40 30 20 20 10 0 Banke (n=402) Jum mla (n=337) Bajhang (n=278) Compliance refers to cases who: o applied a full tub pp be of CHX o in single applicat tion o to the cord stump p and surrounding areas o within 2 hours of f cutting cord
Maternal and Neon atal Strategies into which CH which CH HX can fit HX can fit • Opportunities for providing CHX X 1. ANC 2. FCHV contacts 3. HF deliveries 4. Social marketing • Opportunities for scale-up: 1. Incorporation within Community-B Based Neonatal Care Package 2. Introduced with misoprostol scale e-up 3. Incorporate within other maternal p / newborn programs p g
Conclu Conclu Conclu Conclu usions usions usions usions • Implementation through ex xisting infrastructure can achieve reasonable covera age which should improve with program maturity ith t it • Compliance with correct us se can be achieved • Based on RCT evidence, th his should contribute to reduction in neonatal infect tion and its contribution to mortality
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