This document discusses neonatal sepsis in sub-Saharan Africa. It summarizes previous research on diagnosing, estimating incidence and morbidity, identifying common causes, and highlights gaps. Most research has focused on hospital-acquired infections, but early-onset sepsis causes high mortality and is difficult to detect. The document calls for alternative study designs that include non-survivors and preventative interventions to better understand the true burden of neonatal sepsis in sub-Saharan Africa.

1. Meningitis Research Foundation
Neonatal Sepsis in sub-Saharan Africa
Anna Seale1,2,3,4
1London School of Hygiene & Tropical Medicine
2Public Health England
3 Haramaya University, Ethiopia
4KEMRI-Welllcome Trust Research Programme
I have no conflicts of interest to declare
18 October 2019

2. World War II Centre for Naval Analysis - warplanes
https://www.trevorbragdon.com/blog/when-data-gives-the-wrong-solution Syed, Matthew. 2015. Black BoxThinking. NewYork: Penguin Random House. pp 33-37Strengthen the planes where the bullets are causing most damage

3. Neonatal sepsis – the diagnosis
Seale et al Lancet Infectious Diseases 2014

4. Neonatal sepsis – morbidity
Seale et al Paediatric Research 2013

5. Neonatal sepsis – compartmental model estimates
Seale et al Paediatric Research 2013

6. Neonatal sepsis – population incidence based estimates
Fleischmann-Struzek et al Lancet Resp 20183·0 million cases of neonatal sepsis based on these data – none from sub-SaharanAfrica

7. Neonatal sepsis – the aetiology
Okomo U et al. Lancet Infect Dis 2019
• Staphylococcus aureus 25%
(21–29)
• Klebsiella spp 21% (16–27)
• Escherichia coli 10% (8–10)
• 151 studies
• (82 since 2008)
• 84534 neonates
• 26 countries
• Almost all in hospital

8. World War II Centre for Naval Analysis - warplanes
https://www.trevorbragdon.com/blog/when-data-gives-the-wrong-solution Syed, Matthew. 2015. Black BoxThinking. NewYork: Penguin Random House. pp 33-37
AbrahamWald: those that return to base are those that survive
Strengthening needed where the bullet holes aren’t seen

9. Neonatal sepsis – the example of Group B Streptococcus
Lawn et al CID 2017

10. Neonatal sepsis – the aetiology
Okomo U et al. Lancet Infect Dis 2019
• Staphylococcus aureus 25%
(21–29)
• Klebsiella spp 21% (16–27)
• Escherichia coli 10% (8–10)
• 151 studies
• (82 since 2008)
• 84534 neonates
• 26 countries
• Almost all in hospital
Late onset pathogens and typically associated with hospital outbreaks

11. Neonatal sepsis – what are we missing
Lawn et al CID 2017 Early-onset, high mortality, difficult to sample, difficult to detect in the lab

12. Neonatal sepsis – what does this mean?
Saha et al Lancet 2018
ANISA:
A robust, large, community
based investigation of
neonatal sepsis in South Asia
Even the most robust observational study will be limited by survivor bias

13. Neonatal sepsis – we need to look at alternatives
Blau D et alCID 2019 Study design – include those that don’t survive

14. Neonatal sepsis – we need to look at alternatives
Sobanjo-ter-Meulen,A.Vaccine 2019 Study design – an intervention to prevent the deaths

15. World War II Centre for Naval Analysis - warplanes
https://www.trevorbragdon.com/blog/when-data-gives-the-wrong-solution Syed, Matthew. 2015. Black BoxThinking. NewYork: Penguin Random House. pp 33-37
The analysis informed design of planes through theVietnam War and is considered to have
substantially reduced casualties.

16. Thank you
All those whose work is included here.
All my colleagues and collaborators at LSHTM, KEMRI-WellcomeTrust
Research Programme, Haramaya University and Public Health England.
Particular thanks to
Joy Lawn
Anthony Scott
Jay Berkley