This document discusses embedding infection prevention and control (IPC) practices in primary care with a focus on maternal and child health. It provides examples of common clinical practices that can contribute to or prevent neonatal sepsis. It summarizes evidence that early essential newborn care practices like immediate drying, skin-to-skin contact, delayed bathing and early initiation of breastfeeding can significantly reduce infection risks and improve outcomes. The document outlines IPC training and guidelines implemented across multiple countries in the Western Pacific region that have helped reduce neonatal mortality rates.

1. Embedding IPC in clinical
practices in primary care with a
focus on maternal and child
health
Howard L Sobel, MD, PHD, MPH
Regional Advisor, RMNCH, IPC, Clinical
Management, Patient Safety
Friday, 15 October 2021
14:00-15:30 CET │
8:00-9:30am EDT
Strengthening IPC in primary care: a new era
starts today
1

2. Infection prevention and control (IPC) for
neonates
What typical
clinical practices
contribute to or
prevent neonatal
sepsis?
2

3. Ospital ng Makati
partially closed for
cleanup
25 babies reportedly died
due to infection
By Julie M. Aurelio, Kristine L. Alave
Philippine Daily Inquirer
First Posted 01:42:00 06/07/2008
MANILA, Philippines – The neo-natal intensive
care unit, nursery and delivery areas of the
Ospital ng Makati (OsMak) will be partially
closed as sanitation measures are now
underway following several reports of infant
deaths in the facility.
Dr. Eric Tayag of the Department of Health’s
National Epidemiology Center however said the
sanitation measures were standard procedures,
and were not undertaken because they were
accusing the hospital of negligence.
This 2008 neonatal sepsis outbreak
in the Philippines started us on a
journey that helped improve
newborn care, now in 28 countries
In supporting Philippines, I reflected
that I did many harmful practices to
my newborn son (in 1997) and
hundreds of others
3

4. “Half of what we are going to teach you is
wrong, and half of it is right. Our problem is
that we don’t know which half is which.”
Dr. Sidney Burwell,
Dean, Harvard Medical School
1935-1949
4

5. Source: Sobel et al, Acta Paediatrica (2011), Philippines
Which of these practices
contributes to neonatal
sepsis?
Suctioned
Philippines: documenting practices subsequently
found in all our priority countries
5

6. FIRST, DO NO HARM
Do not suction
unless baby is:
1. born through
meconium
and
2. not breathing
• No proven benefit
except if air passage
blocked
• Delays other essential
actions
• Can cause
• vasovagal
stimulation
• Infection
https://apps.who.int/iris/bitstream/handle/10665/75157/9789241503693_eng.pdf?sequence=1
6

7. Immediate Thorough Drying
• Immediate drying
– Stimulates breathing
– Prevents hypothermia
• Hypothermia which can lead to
– Infection
– Coagulation defects
– Acidosis
– Delayed fetal to newborn circulatory
adjustment
– Hyaline membrane disease
– Brain hemorrhage
Tunell R., in Improving Newborn Health in Developing Countries; A. Costello and D. Manandhar, Editors. 2000, Imperial College Press:
London, UK. p. 207-220; Tollin M, et al.. Cell Mol Life Sci 2005; Safari, K., Saeed, A.A., Hasan, S.S. et al. Int Breastfeed J 13, 32 (2018).
https://doi.org/10.1186/s13006-018-0174-9 7

8. • Hypothermia which can lead to
– infection, coagulation defects,
acidosis, delayed fetal to newborn
circulatory adjustment, hyaline
membrane disease, brain hemorrhage
• Infection
– The vernix is a protective barrier to
bacteria such as E. coli and Group B
Strep; so is maternal bacterial
colonization
• No crawling reflex
Early Bathing Can Lead to:
Tunell R., Cell Mol Life Sci 2005; 62:2390-99; Righard L, Alade M. Lancet 1990; 336: 1105-07.
https://www.dreamstime.com/photos-
images/newborn-baby-first-bath.html
8

9. Skin-to-Skin Contact
Contributes to:
• Warmth
• Bonding
• Successful breastfeeding/colostrum
feeding
• Stimulate the mucosa-associated
lymphoid tissue system
• Calmness
• Protection from hypoglycemia
• Colonization with maternal skin
flora
Moore ER, Bergman N, Anderson GC, Medley N. Early skin‐to‐skin contact for mothers and their healthy
newborn infants. Cochrane Database of Systematic Reviews 2016, Issue 11. Art. No.: CD003519. DOI:
10.1002/14651858.CD003519.pub4. Accessed 13 October 2021; Brandtzaeg. Ann N Y Acad Sci 2002
9

10. Figure 1. Association of SSC duration and early initiation of breastfeeding.
Increased
duration of skin-
to-skin contact
was associated
with higher
likelihood of
timely initiation
of breastfeeding
Li Z, Sobel HL, Western Pacific Region Early Essential Newborn Care Working Group, et al. BMJ Global Health 2020;5:e002581.
10

11. Baguio General Hospital, Philippines, 1973-1977
Period I:
Neonates were
not rooming-in
with their mother
The hospital
allowed formula
Many cases of
neonatal sepsis
Clavano, J Trop Ped, 1982
Period II:
Neonates roomed-in
with their mother;
breastfeeding policy
promoted
89% reduction of
neonatal sepsis and
95% neonatal sepsis
deaths
11

12. Delaying Initiation of breastfeeding increases risk
of infection-related death
Nepal 2008 N = 22,838 breastfed babies
0
1
2
3
4
5
6
7
8
9
10
11
12
<1 1-24 24-48 48-72 >72
Relative
Risk
Hours after Birth
Mullany LC, et al. J Nutr, 2008; 138(3):599-603. 12

13. “The United States overall could save about $13
billion annually through improved exclusive 13

14. The benefits of breastfeeding
Long-term
benefits for
life
Short-term
benefits for
the first 6
months
63% less diarrheal infections
72% less hospitalizations
77% less diarrhea mortality
57% less respiratory infections
67% less respiratory hospitalization
70% less respiratory mortality
Higher IQ
Better school performance
34% less type-2 diabetes
24% less obesity
Sources: WHO (2013) Short-term effects of breastfeeding: a systematic review on the benefits of breastfeeding on
diarrhoea and pneumonia mortality; WHO (2013) Long-term effects of breastfeeding: a systematic review
14

15. WHO Recommendations on interventions to improve
preterm outcomes: Kangaroo Mother Care (KMC)
“Continuous KMC was
associated with a 40% lower
risk of mortality at the time of
discharge or at 40–41 weeks
postmenstrual age compared
to conventional care (RR 0.60,
95% CI 0.39–0.92; 3 studies,
1117 babies).”
https://www.who.int/reproductivehealth/publications/maternal_perinatal_health/preterm-birth-guideline/en/ 15

16. Other common IPC problems during maternal and
newborn care
• Co-bedding (maternal and
newborn)
• Unnecessary
– Separation
– Handling
– Frequency of pelvic exams
• Unhygienic surfaces
• Wearing rings
• Cell phone use during patient
care
• Footprint ink pads
• WASH (below)
16

17. The Action Plan for Healthy Newborn Infants in
the Western Pacific (2014 – 2020)
Goal: To eliminate preventable
newborn mortality by providing
universal access to high-quality early
essential newborn care (EENC)
Targets:
1. At least 80% of facilities where
births take place are
implementing EENC
2. At least 90% of births in sub-
national areas are attended by
SBAs
3. NMR ≤ 10 per 1000 live births
- National & sub-national
17

18. What is Early Essential Newborn Care (EENC)?
18

19. A data driven and systems approach to introducing
and scaling-up EENC
Module 2 Module 4
Module 3 DRAFT
Module 1
Biennial programme
reviews & planning
(national level)
19

20. A data driven and systems approach to introducing
and scaling-up EENC
Hospital-level
assessment
• Observation of hospital
environments
• Review policies and guidelines
• Review availability of essential
medicines and supplies
• Review staff training status
System-level
changes
• Identify priority actions
• Develop action plans
• Allocate resources
• Regular M&E
• Influence national policy
and strategy
Client-level
assessment
• Interview of caregivers
• Chart reviews
20

21. 0
5000
10000
15000
20000
25000
30000
35000
40000
2010 2011 2012 2013 2014 2015 2016 2017 2018
Number
of
health
facility
staff
coached
in
EENC
34,655 health facility staff have been coached in EENC
Health workers coached on EENC
21

22. Early essential newborn care in the Western Pacific Region
Data from nine priority countries
5,955 health facilities have introduced EENC
≈ 87% of facilities providing childbirth services have
introduced EENC in eight priority countries (excluding
China)
Outputs
Outcomes
91%
receiving SSC
78% EBF 48% ≤2000g
receiving KMC
22

23. From WPRO to other regions
Introducing the WPRO EENC approach in the SEARO, EMRO and
AFRO regions
Total countries: 28 23

24. Early essential newborn care in the Western Pacific Region
Impact
• Decreases in neonatal mortality:
- 33% in Cambodia (2010-2014)
- 44% in Lao PDR (2012-2017)
- 36% in Mongolia (2014-2018)
- 13% in the Philippines (2008-2017)
Sources: Demographic Health Surveys or Social Indicator Survey
• Significant reductions in risk of hypothermia on
NICU admission and all cause sepsis at the
hospital level
Source: Tran HT, Mannava P, Murray JCS et al, 2019
24

25. Case study: ĐÀ NẴNG
• Hospital catchment: 10 million
• Hospital births:~15,000
25

26. Feeding practice in NICU (all admissions)
Da Nang, 2013-2015
49 52
38.6
10
2.3
88.3
67
10.8
0.4 0.5
Exclusive
breastfeeding
% of babies <
2000g receiving
KMC
Predominant
breastfeeding
Mixed
breastfeeding
Formula only
Pre-EENC
(N= 2360)
Post-EENC
(N=1701)
(n=372 n=429) Tran HT, Sobel HL et al. Lancet E-Clinical Medicine 2018;6:51–58.
26

27. NICU admission and adverse outcomes
(All live births), Da Nang, 2013-2015
18.3
5.4
3.2 2.8
12.3
3.9
0.9 0.5
In-born NICU
admission
Hypothermia
on admission
Sepsis (all) Sepsis
(probable)
Pre-EENC
(N=13201)
Post-EENC
(N=14180)
Tran HT, Sobel HL et al. Lancet E-Clinical Medicine 2018;6:51–58. 27

28. Early essential newborn care is associated with improved newborn
outcomes following caesarean section; Da Nang, Viet Nam
Tran HT, Sobel HL, et al. BMJ open quality 10 (3), e001089.
28

29. Average monthly cost of infant formula in NICU and postnatal wards,
(2013-2015), Da Nang, Viet Nam
29

30. Availability of hand washing amenities in maternal and neonatal care rooms,
147 hospitals, 7 countries, 2016-17
The Environment is critical
Appropriate hand hygiene
was practiced for all
deliveries in:
• 50% of hospitals where
delivery rooms had a
sink with water and
soap
• 39% of hospitals where
these were not
available
Source: Mannava, Sobel, et al, J Glob Health. 2019;9(2) 30

31. Summary of gaps in WASH identified during assessments
of family planning and child health service delivery
• Single use towels or other hygienic ways to dry hands
• Cleaning stethoscopes and thermometers before and between
patient exams
• Having containers for and segregating wastes:
– Sharps (puncture proof)
– Biodegradable
– Non-biodegradable
– Recyclable
31

32. Simulation exercise and skills building for
establishing safe COVID-19 patient
management, Lao PDR, 2020
“Germs” spread everywhere
COVID-19 taught us
maintaining essential health
services requires carefully
planned IPC including
safe
• screening
• zoning
• PPE use
• referral
• sample collection
• disinfection

33. Take-away messages
• IPC for MCH service delivery needs to be wider than “standard IPC
precautions”: e.g., skin-to-skin contact, breastfeeding, KMC
• IPC breaches are common in maternal and newborn care
• Early Essential Newborn Care is associated with ¾ reduction in
neonatal sepsis
• WASH is critical for IPC but by itself does not guarantee hand hygiene
compliance
• COVID-19 has emphasized that IPC is critical for restoring and
maintaining essential health services
33

34. Mothers and babies should not get infected
during healthcare: Act Now!
34