1. Community Case Management for Neonatal Sepsis Bangkok 8 March 2010 NIC – C1 Penny Dawson MD JSI R&T, Nepal Family Health Program/MINI

2. 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

3. 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 illness Source: *Lawn et al., Lancet. Neonatal Survival Series 2005 ** WHO publication 1996

4. 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

5. 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

6. 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

7. 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

8. 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/Dead Facility-based health worker responds and gives gentamicin injection for 7 days Follow-up at two-months

9. Current Status IndicatorsResults for 4 th year (May 2008-April 2009) Birth Capture Rate74% 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

10. Issues for Scaling Up GLOBAL 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 supportNEPAL Morang – full district coverage/handoverMorang – full district coverage/handover National – inclusion of CCM for NN sepsis in MOHP’s CB –Newborn Care PackageNational – inclusion of CCM for NN sepsis in MOHP’s CB –Newborn Care Package Gentamicin in UNIJECT feasability trialGentamicin in UNIJECT feasability trial

11. 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

12. 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

13. Thank You