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Newborn survival and perinatal health in resource-constrained settings in Asia and the Pacific: Applying Global Evidence to Priorities Beyond 2015

Newborn survival and perinatal health in resource-constrained settings in Asia and the Pacific: Applying Global Evidence to Priorities Beyond 2015
12 April 2013

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    Trevor Duke, Centre for International Child Health, University of Melbourne Trevor Duke, Centre for International Child Health, University of Melbourne Presentation Transcript

    • Models of neonatal care in the Pacific and Asia Trevor Duke Centre for International Child Health University of Melbourne Royal Children’s Hospital School of Medicine & Health Sciences University of PNG
    • •  Neonatal health as a research priority•  Linking models of care with NMR•  Components of models of care•  Evidence of effectiveness•  Resources for improving neonatal care•  Sepsis: new data on antimicrobial efficacy•  The “regional action plan for neonatal health”
    • Controlled trials in child health in developing countries n=1342 Pneumonia Parasitic Neonatal MentalYear   Malaria   Nutrition   Vaccines   HIV   Diarrhoea   ARI   Development   infections   health   TB   health  2003   4   15   2   1   6   3   1   4   0   1   0  2004   18   22   7   7   8   5   5   10   3   3   0  2005   22   17   6   7   2   5   3   4   2   1   0  2006   31   31   8   12   11   4   3   3   2   3   0  2007   33   40   10   13   10   7   6   8   2   1   0  2008   40   30   15   13   11   9   3   4   9   1   2  2009   29   29   18   11   10   11   10   11   5   0   2  2010   51   32   23   13   14   8   7   8   7   2   6  2011   42   39   24   21   20   12   8   11   8   4   6  2012   44   46   32   26   21   16   9   8   11   7   1  Total   314   301   145   124   113   80   55   71   49   23   17   3.7% of all RCTs in child health in developing countries were on neonatal care, or included neonatal outcomes
    • •  Community care: –  Skilled birth attendant delivery and essential newborn care leads to 30-50% reduction in neonatal mortality in communities with very high neonatal mortality rates (e.g. >45/1000 live births)… –  Where the proportion of health facility deliveries is low… –  Where health systems are weak…
    • Community based neonatal health intervention trialsReference Country Baseline or control Post Intervention NMR NMR*Bang AT et al. Journal of Perinatology 2005; 25 India 62/1000 25/1000Suppl 1, S92-107Kumar V. Lancet 2008; 372:1151-1162 India 58.9-64.1/1000 41/1000 (Essential newborn care-ENC), 43.2/1000 (Essential newborn care + hypothermia indicator)Bhutta ZA. Lancet 2011; 377:403-412 Pakistan 48/1000 live 43.0/1000Midhet F et al. Reproductive Health 2010, 7:30. Pakistan 48/1000* 30.5-32.4/1000Bacqui, AH. Lancet 2008; 371:1936-44 Bangladesh 46-48/1000 29.2/1000 (home care), 45.2/1000 (community- care)Jokhio AH et al. NEJM. 2005; 252(20): 2091-9. Pakistan 46-67/1000* 33-42/1000Gill CJ. BMJ. 2011; 342:d346 Zambia 40.4/1000* (actual 22.8/1000 (actual numbers 59/1466) numbers 43/1889)Manandhar DS et al. Lancet. 2004; 364(9438): Nepal 36.9/1000* 26.2/1000970-9Azad K. Lancet.2010; 375: 1193–20 Bangladesh 36.5/1000* (cluster level No significant decrease in mean NMR) NMR observed.Darmstadt GL. PLoS One 2010; 5(3); e9696 Bangladesh 25.2/1000 No significant decrease in NMR observed.Carlo WA et al. NEJM. 2010; 362(7): 614-23 6 countries (Argentina, Early (<7day) NMR No significant decrease in Democratic Republic of 23/1000 (ENC group) NMR observed. Congo, Guatemala, India, Pakistan,and Zambia)
    • Neonatal mortality rates for countries in the WHO South East Asian and WesternPacific RegionsCountry Neonatal mortality rate per 1000 live births (NMR) 1990 2008 2010 * 2011 (WHO) (WHO)NMR 30-40Bangladesh 64.5 (52.1-76.4) 33 31.3 (25.4-36.9)Bhutan 63.7 (40.9-91.1) 35 30.1 (19.1-41.5)India 53.9 (43.4-64.5) 37 34.3 (27.7-40.8)Nauru 33 21.7Niue 30 10.3PNG 46.6 (28.6-68.0) 26 39.3 (23.4-61.1) 22.6 * Li L, et al. Lancet 2012; 379: 2151-2161
    • NMR 15-29Country 1990 2008 2010 * 2011 (WHO) (WHO)Cambodia 41.5 (32.5-51.7) 31 26.2 (18.7-35.9) 19.4Democratic Peoples 32.7 (21.4-41.8) 29 21.1 (13.4-27.5)Republic of KoreaTimor-Leste 36.2 (21.4-57.2) 43 26.8 (15.6-42.3)Indonesia 27.5 (21.5-33.8) 19 17.8 (14.0-22.2)Kiribati 36.6 (21.8-51.9) 17 23.8 (13.5-35.0) 19.1Lao PDR 44.8 (26.8-71.2) 20 28.3 (15.8-46.5) 17.5Marshall Islands 25.6 (15.1-37.2) 15 23.8 (13.5-35.0) 11.7Mongolia 33.0 (19.5-53.6) 14 16.7 (9.5-24.8) 11.7Myanmar 40.5 (23.3-62.9) 48 24.4 (14.4-38.5)Nepal 59.1 (47.2-71.5) 31 25.4 (20.5-30.9)Solomon Islands 20.0 (11.8-28.8) 14 15.8 (8.9-23.0) 10.5* Li L, et al. Lancet 2012; 379: 2151-2161
    • When mortality less than 25-30 per 1000 live births•  Community care still important –  inequity•  Models of care needed at all levels of health service•  Questions•  What services are needed at –  health clinic –  district hospital –  referral hospital… –  to establish minimal standard of neonatal care•  What current capacity exists?•  What human resources are needed?•  What technical resources are needed (physical facility space, medications, equipment, guidelines, training)?•  What are the appropriate referral criteria and mechanisms?
    • Historical evidence Community based public health, sanitation, education, maternal nutrition Facility-based obstetric and neonatal care, improved access to antibiotics, attention to thermal care, infant nutrition and care of LBW and prematurity Neonatal intensive care
    • Models of care•  WHO/UNICEF Regional Action Plan for Neonatal Care•  Modelled on “The First Embrace”•  Philippines hospital survey Sobel HL et al. Acta Paed. 2011 –  51 hospitals, obstetric and immediate newborn care –  Widespread gaps in implementation of essential newborn care (e.g. skin-skin contact, drying, thermal care) –  Unhelpful interventions common (early separation, suctioning)
    • Regional Action Plan 2013-2020 Goals 1.  To reduce national NMR 10 per 1000 or less in all member states 2.  To reduce sub-national NMR 10 per 1000 or less
    • Models of care•  Quality improvement approach•  What services are needed at –  health clinic –  district hospital –  referral hospital… –  to establish a minimal standard of neonatal care•  What current capacity exists?•  What human resources are needed?•  What technical resources are needed (physical facility space, medications, equipment, guidelines, training)?•  What are the appropriate referral criteria and mechanisms?
    • Models of care: Health clinics•  Newborn resuscitation•  Support for breastfeeding•  Thermal protection, skin-to-skin contact•  Infection prevention: general hygiene, hand washing, cord care•  Eye infection prophylaxis•  Immunization and Vitamin K prophylaxis•  Identification, treatment or referral of signs of severe illness, injury or malformation (IMCI, referral guidelines)•  Birth registration•  Counseling regarding newborn care, care-seeking, health promotion including immunizations and avoidance of indoor air pollution•  Developmental care including newborn stimulation and play•  Follow up visits for vaccines, growth monitoring•  Family planning
    • Models of care: District and provincial hospitals•  All interventions at the clinic level, plus…•  A special care / high dependency nursery•  Management of a newborn with serious illness: –  Oxygen and oximetry –  Apnoea: monitoring and prevention –  Warming (includes KMC) –  Breast feeding and prevention of hypoglycaemia –  Safe administration of intravenous fluids –  Standard antibiotics•  Guidelines for management and referral of common conditions: –  Preterm and VLBW babies –  Severe respiratory distress –  Severe infection –  Severe birth asphyxia –  Severe jaundice - phototherapy –  Malformations and common surgical conditions•  Audit•  Prevention of nosocomial infection
    • Models of care: Referral hospitals•  All interventions at the clinic and district hospital level, plus…•  Respiratory distress: –  CPAP / high flow nasal prong oxygen therapy•  Surgical services for neonates•  Care for the VLBW baby (weight for referral depending on access and capacity at district / provincial hospital)•  Exchange transfusion for severe jaundice
    • Effect of minimal standards of neonatal care Admit Deaths Mortality Relative risk p value (%) (95% CI)Total admissionsA 1167 205 17.5B 1247 122 9.8 0.56 (0.45-0.69) <0.0001RR adjusted for higher number of neonates <2kg in ‘95-97 0.59 (0.48-0.74) <0.0001Birth weight <1000gA 17 15 88.2B 10 7 70.0 0.79 (0.51-1.23) 0.32Birth weight 1000-1499gA 90 60 66.7B 71 21 29.6 0.44 (0.30-0.65) <0.0001Birth weight 1500-2000gA 134 31 23.1B 120 14 11.7 0.50 (0.28-0.90) 0.02Septicaemia or pneumoniaA 341 47 13.8B 224 11 4.9 0.36 (0.19-0.67) 0.0006Birth asphyxia or meconium aspirationA 135 30 22.2B 137 18 13.1 0.59 (0.35-1.01) 0.057
    • Models of care: referral criteria Indications for referring newborns to hospital • Birth-weight between 1-1.5 kg • Birth-weight between 1.5–2.0 kg if: ¨ Respiratory distress or apnoea ¨ Signs of sepsis • Birth asphyxia • Severe respiratory distress • Severe infection ¨ Sepsis ¨ Meningitis ¨ Osteomyelitis / septic arthritis • Any infection that does not improve after 48 hours of appropriate treatment • Severe abdominal distension • Signs of shock (>3 seconds for capillary refill, weak pulse, cold hands) • Congenital abnormalities: ¨ Suspected congenital heart ¨ Open abdominal lesions ¨ Ambiguous genitalia ¨ Imperforate anus ¨ Bile (green) stained vomiting ¨ Frequent vomiting and lots of saliva in the first few hours of life ¨ Pain and swelling of the testes or the inguinal area • Recurrent apnoeas (>3 periods of no breathing for longer than 20 seconds per day) • Coma and / or convulsions • Uncontrolled bleeding despite Vitamin K injection • Pallor • Severe jaundice or jaundice that lasts longer than 2 weeks • Unexplained poor weight gain for more than 2 weeks after birth Call or radio National Referral Hospital or provincial hospital
    • Models of care: referral mechanisms•  Communication•  Transport•  Funding•  The model in Fiji
    • Other resources•  Training on the WHO Pocket Book of Hospital Care –  Training in care of the neonate with LBW, sepsis, birth asphyxia•  Assessment tools for neonatal care standards at hospitals•  Appropriate technology•  Posters•  Simple standardized data reporting system
    • Training strategies•  Training CD-ROM
    • NEONATAL RESUSCITATIONNeonatal resuscitation can be highly effective even without oxygen using a self-inflating resuscitation bag & maskAll newborn babies should be given their first dose of BCG and Hepatitis B vaccines and a dose of vitamin KBabies should be breast-fed within the first hour of birth Produced by the Paediatric Society of PNG and the World Health Organization 2008
    • Systematic approach to the use of oxygen•  Concentrators•  Oximetry•  Bubble-CPAP
    • Simple systems of data for surveillance
    • Simple standardised outcome reporting
    • Simple standardised outcome reporting 2010 2011Diagnoses Admit Deaths CFR Admit Deaths CFRAll neonatal 2752 335 12.3 4180 480 11.5Neonatal sepsis 592 37 6.3 2124 152 7.1Asphyxia 467 54 11.6 1219 165 13.5VLBW 106 32 30.2 518 169 32.6
    • Sepsis•  Half a million neonatal deaths each year•  WHO recommends treatment with penicillin / ampicillin and gentamicin•  Many countries use third-generation cephalosporins to treat neonatal sepsis
    • •  19 studies, 13 countries, >4000 cases of bacteraemia•  Staph aureus, Klebsiella spp. and E. coli accounted for 55% (39–70%)•  Penicillin/gentamicin had comparable in vitro coverage to third-generation cephalosporins (57% vs 56%)•  Resistance to the combination of penicillin and gentamicin and to third-generation cephalosporins occurs in more than 40% of cases
    • Implications•  How to determine criteria for second-line therapy that are implementable in resource-limited settings•  How to ensure recommendations are effective but minimise the development of further resistance•  How to make available more expensive or higher- generation antibiotics in resource-limited developing countries but ensure their use is based on evidence•  How to address the poor state of bacteriology services in most developing countries and improve local surveillance data
    • Summary•  Models of care at primary, district, referral level•  It can be done…and saves lives•  Tools available•  Implementation science•  Monitor neonatal outcomes – it can be done•  Antibiotic stewardship needed
    • How to start•  What services are needed at –  health clinic –  district hospital –  referral hospital… –  to establish a minimal standard of neonatal care•  What current capacity exists?•  What human resources are needed?•  What technical resources are needed (physical facility space, medications, equipment, guidelines, training)?•  What are the appropriate referral criteria and mechanisms?