Preliminary experie ence with CHX for cord care in Nepal p Dr - - PowerPoint PPT Presentation

Preliminary experie cord care

Dr Naresh

• Dr. Naresh

Direc Family Health D

ence with CHX for in Nepal p

Pratap KC Pratap KC ctor Division, Nepal

Existing Policy o Existing Policy o

• WHO Recommendation: I

revised to state:

“…in settings where the risk o g be prudent to use an antisepti

• Nepal National Medical S

d l cord care as general reco adequate hygiene cannot setting CHX should be us setting, CHX should be us

1 Source: http:/

• n Cord Care
• n Cord Care

Initially dry cord care; y y ;

• f bacterial infection is high, it may

g y ic as per local preferences” 1

tandards, volume 3 – dry d ti b t h

• mmendation, but when

t be assured in household sed sed.

//apps.who.int/rhl/newborn/cd001057_capurroh_com/en/index.html

Pil t t di Pilot studies o

• Initial studies on preparatio
• Pilot study designed to exp
• Pilot study designed to exp

compliance

• Pilot designed to be impleme

infrastructure—thus able to b successful

CHX i N l

• n CHX in Nepal
• n and acceptability

plore coverage and plore coverage and

ented through the Government be added to existing programs if

Initial stu Initial stu

• Maternity Hospital study done in 20
• Maternity Hospital study done in 20
• f gel compared to aqueous prepa

Objec Objec

“To establish whether or not 4% chlorhe efficacious as the aqueous formulation skin flora on newborn peri-umbilical

Conclu The study demonstrated superiority

• The study demonstrated superiority

application culture positive rates, w difference, in favor of gel.

udy on gel udy on gel

008 09 demonstrated comparability 008-09 demonstrated comparability ration ctive: ctive:

exidine in a gel formulation is at least as n, as measured by presence of culturable l skin 24 hours after CHX application.”

usion: y of gel with regard to 24 hour post y of gel with regard to 24-hour post with a statistically significant

Initial study o Initial study o

• Community acceptability study don

y p y y preference for the lotion

Obje

“To examine acceptability and ease of u formulations, for prophylactic applicati

Conclu Conclu

• Use of CHX has largely but not com

applying other substances to the co pp y g

• Although both products were liked

clear preference for the lotion.

• n acceptability
• n acceptability

ne in Banke (2009) showed clear ( )

ctive:

use of two different chlorhexidine (CHX) ion to the freshly cut umbilical cord stump”

usions: usions:

mpletely displaced the practice of

• rd stump

by almost all participants, there was a

R ti Rati

U bili l d i f ti i j

• Umbilical cord infection is a maj

(Neonatal Health strategy 2004 Infection was from umbilical infe

Morang)

• The freshly cut cord stump is an

there can be direct bacterial see apparent cord infection.

• Application of chlorhexidine to t

was associated with a 24% dec if li d d f d li if applied on day of delivery (Mull

l

• nale

j f t l i f ti jor cause of neo-natal infection 4)--62 % of local Bacterial ection in Morang (Report of MINI g (

p

n open wound through which eding, causing sepsis without the umbilical area of neonates crease in neonatal mortality, 34%

lany et al, 2006)

The P

• Kawach – “shield” (Nep

B d i

• Broad spectrum antise
• Gel (lotion) – 4% CHX

Gel (lotion) 4% CHX,

• Single application (3cc

d ti recommendations

• Applied by fingers (fres

Applied by fingers (fres water)

roduct

pali name for 4% CHX) i ptic thickened with guar gum thickened with guar gum ) – current cord-care shly washed with soap & shly washed with soap &

Interventio Interventio

• CHX use initiated at health fac

essential newborn care practi

• CHX distributed by Female Co

application by FCHV, mother

• CHX

id d f i l

• CHX considered for social ma

through retail sector

• n Channels
• n Channels

cility level as a part of routine ce

• mmunity Health Volunteers for
• r other birth attendant

k i i il bili arketing – to increase availability

Female Communit

Pillars to Nepal’s Pu 23,151,423 Total Population 3 915 VDCs 42,53,220 households p 3,915 VDCs NEPAL

75 Districts

48,5

75 Districts Source:

ty Health Volunteers

ublic Health Programs

FCHVs are involved in: FCHVs are involved in:

• Community based

management of pneumonia & diarrhea pneumonia & diarrhea

• Vitamin A & de-worming
• Immunization promotion
• Family Planning
• Birth preparedness and

neonatal care packages p g

• Innovative approaches

549 FCHVs

CBS 2001

Pilot district eva Pilot district eva aluation surveys aluation surveys

Pregnancy R Pregnancy R d S d S and Se and Se

New ERA

Related Care Related Care i ervice ervice

Proportion of R Proportion of R Exposure t Exposure t Exposure t Exposure t

80 90 100

• Most mothers had

contact with FCHV

40 50 60 70 80

Percent

and thus the

• pportunity to

receive CHX

10 20 30 40

P

receive CHX

RDW w

New ERA

DW Who had DW Who had to FCHV to FCHV to FCHV to FCHV

96 98 92 82 85 68 Banke (n=600) Jumla (n=600) Bajhang (n=600) who knew FCHV RDW who met FCHV in last pregnancy

Proportion of RDW Proportion of RDW Antenata Antenata

80 90 100

• ANC visit rates

were high

50 60 70 80 ercent 10 20 30 40 Pe Ban

RDW who had at le checkups from HW

New ERA

W Who Received W Who Received al Care * al Care *

* Among live births * Among live births

99 97 89 nke (n=596) Jumla (n=583) Bajhang (n=594)

Banke Jumla Bajhang (n=591) (n=578) j g (n=556) east 4 ANC Ws (%) 69 63 43

Place of Place of

among li among li among li among li

70 80 90 100

• Both health facilities

and FCHVs can make a contribution

5 40 50 60 70 Percent

make a contribution to CHX coverage

10 20 30 Ban

New ERA

Delivery Delivery

ive births ive births ive births ive births

66 71 50 34 29 50 66 29 nke (n=596) Jumla (n=583) Bajhang (n=594) Health Facility Home/ Other

Instrument Used for C Instrument Used for C

among home deliv among home deliv among home deliv among home deliv

• Shows disturbing

continued dangerous practices in some practices in some districts

New ERA

Cutting Umbilical Cord Cutting Umbilical Cord

very with live birth very with live birth very with live birth very with live birth

Coverage and Coverage and Coverage and Coverage and

• f C
• f C

New ERA

d Compliance d Compliance d Compliance d Compliance CHX CHX

Applied CHX on Co Applied CHX on Co

among among among among

100 67 70 80 90 100 67 5 50 60 70 ercent 17 15 20 30 40 Pe 10 Banke (n=596) J Banke (n=596) J Yes

*95% of don’t know are from institution

New ERA

rd Stump of Newborn rd Stump of Newborn

live births live births live births live births

47-67% coverage

58 47 45 24 18 8 Jumla (n=583) Bajhang (n=594) Jumla (n=583) Bajhang (n=594) No Don’t know*

nal delivery

Coverage of CHX by Coverage of CHX by

among liv among liv among liv among liv

65 70 70 80 40 50 60 rcent 20 30 40 Per 10 Banke (n=596) Ju Banke (n=596) Ju From Baishak - Kartik 2067

New ERA

y program maturity y program maturity

ve births ve births ve births ve births

Improving trend with program maturity

61

program maturity

53 42 51 mla (n=583) Bajhang (n=594) mla (n=583) Bajhang (n=594) From Mangsir 2067 - Jestha 2068

Timing of CHX Timing of CHX

among live birth w among live birth w among live birth w among live birth w

100 85 7 70 80 90 40 50 60 70 ercent 11 20 30 40 P 11 4 10 Banke (n=402) Ju

* Don’t know is high among institutio

Within 5 min

New ERA

X Application X Application

with CHX applied with CHX applied with CHX applied with CHX applied

Most apply early 76 78 20 18 5 4 umla (n=337) Bajhang (n=278)

• nal deliveries.

After 5 min Don't know*

Applicati Applicati Applicati Applicati

89 90 94 79 80 90 100 50 60 70 20 30 40 10

Banke J

Stump and surrounding area Whole content of Kawach applies

ion of CHX ion of CHX ion of CHX ion of CHX

Most apply correctly

86 95 89 90 84

Jumla Bajhang

Single application of Kawach

Compliance w Compliance w

90 100 68 50 60 70 80 ent 20 30 40 50 Perce 10 20 Banke (n=402) Jum

• Compliance refers to
• applied a full tub

pp

• in single applicat
• to the cord stump
• within 2 hours of

with CHX use with CHX use

77 70 mla (n=337) Bajhang (n=278)

cases who: be of CHX tion p and surrounding areas f cutting cord

Maternal and Neon which CH which CH

• Opportunities for providing CHX

1. ANC 2. FCHV contacts 3. HF deliveries 4. Social marketing

• Opportunities for scale-up:

1. Incorporation within Community-B Care Package 2. Introduced with misoprostol scale 3. Incorporate within other maternal p

atal Strategies into HX can fit HX can fit

X

Based Neonatal e-up / newborn programs p g

Conclu Conclu Conclu Conclu

• Implementation through ex

achieve reasonable covera ith t it with program maturity

• Compliance with correct us
• Based on RCT evidence, th

reduction in neonatal infect mortality

usions usions usions usions

xisting infrastructure can age which should improve se can be achieved his should contribute to tion and its contribution to