Dr Ornella Lincetto, MCA Department, WHO

Guidance and way forward for integrating PSBI into existing maternal, newborn and child health services and programmes

• Dr Ornella Lincetto | Newborn Health | MCA Department | WHO Headquarters

PSBI Webinar - Geneva, 28 August 2019

Neonatal mortality: decreasing but significant unfinished agenda

Estimated and projected 1990-2030 U5 and newborn deaths 56% reduction in U5MR

49% reduction in NMR

5.4 million deaths 2017

2.5 million deaths 2017

5.0 million deaths 1990

Source: United Nations Inter-agency Group for Child Mortality Estimation (UN IGME), Levels & Trends in Child Mortality: Report 2018

Every Newborn Action Plan goal:

National NMR of less than 10 in 2035National NMR of less than 12 in 2030 Global average NMR of 9 by 2030

Causes of death in children under 5 years, 2016

Prematurity is the leading cause of child death and important cause of disability

Infectious diseases are the leading causes of post neonatal deaths

Neonatal infections (21%)

Possible serious bacterial infection (PSBI), 2012 estimates

• 6.9 million cases of PSBI estimated globally• 3.5 million in South Asia• 2.6 million in Sub-Sharan Africa • More in male infants

• 0.68 million PSBI associated deaths globally• Case fatality risk associated with PSBI – 9.8% (95% CI 7.4-12.2)

• 8.7% (95% CI 5.6-11.8) in South Asia• 14.1% (95% CI 7.2-21.0) in Sub-Sharan Africa • Higher in male infants, 10.3% (95% CI 7.5-13.0)

Seale AC et al. Lancet Infect Dis. 2014

Reducing deaths due to neonatal infection

Prevention

• Improve hand washing and hygiene

• Exclusive breastfeeding

• Care of LBW/ preterm

• Kangaroo mother care

• Cord care

• Maternal immunization

Treatment

• Antibiotics

• Oxygen

• Supportive management of

severe illness

Conceptual framework: management of neonatal infections

ALL neonates with any sign of serious bacterial infection should be IDENTIFIED

ALL identified cases of neonatal infection should be CONFIRMED by a trained health worker at first level health facility

ALL confirmed cases of neonatal infection should be effectively TREATED at a hospital

ALL confirmed cases of neonatal infection should be REFERRED to a hospital

WHO - Three level guidance for the sick young infants and children

Community leveli) Identifyii) Treat or refer

Primary health facilityi) Identifyii) Treat or refer

First referral (hospital)i) Identifyii) Treat

Equipment, Supplies, Case management skills

Conceptual Framework: potential issues in achieving High Coverage and Quality of PSBI management

ALL young infants with any sign of PSBI should be IDENTIFIED

ALL referred cases of PSBI should be effectively TREATED at a hospital

Difficult to identifysigns of PSBI by

family

Low coverage of CHW’s home visits

Low care seeking to health centre

No point of care diagnostic

Limited skills to implement clinical

algorithm

Nonspecific referral criteria & low compliance

to referral

ALL identified cases of PSBI should be CONFIRMED by a trained health worker at first level health facility

ALL confirmed cases of PSBI should be REFERRED to a hospital

Low compliance to full treatment

Low quality of care

Conceptual Framework: Possible Solutions for Management of PSBI in Young Infants (1)

Difficult to identify signs of PSBI by family

Assess for danger signs and counsel on their prompt recognition and care seeking by the family (not feeding well, reduced activity, difficult breathing, fever or feels cold, fits or convulsions)

Home visits can reduce deaths of newborns in high mortality, developing country settings by 30 to 61%

Bang et al India, Lancet 1999

Baqui et al Bangladesh, Lancet 2008

Kumar et al India, Lancet 2008

Bhutta et al Pakistan, Bull WHO 2008ANC, childbirth and PNC contacts

Integration with ANC, childbirth and PNC services

Conceptual Framework: Possible Solutions for Management of PSBI in Young Infants (2)

Low specificity of clinical algorithm

Sensitivity and specificity of seven signs ranged from 74%-85% and 75%-79%, respectively

1. Not feeding well or2. Convulsions or3. Fast breathing (60 breaths per minute or more) or4. Severe chest indrawing or5. Fever (>37.5C) or6. Low body temperature (<35.5C) or7. Movement only when stimulated or no movement at all

Young infant clinical signs study Group, Lancet 2008 Build capacity of health staff

Signs of sick young infants by IMCI Chart booklet over time

IMCI 1997 IMCI 2014 IMCI 2019

1. Convulsions OR2. Fast breathing (60 bpm or more) OR3. Severe chest indrawing OR4. Nasal Flaring OR5. Grunting OR6. Bulging Fontanelle OR7. Pus draining from ear OR8. Umblical redness extending to the skin OR9. Fever (37.5 C or above )10. Low body temperature (less than 35.5C or feels cold) OR11. Many or severe skin pustules OR12. Lethargic OR unconscious OR13. Less than normal movements

1. Not able to feed at all or not feeding well, OR

2. Convulsions, OR3. Severe chest indrawing, OR4. High body temperature, OR5. Low body temperature, OR6. Movement only when

stimulated or no movement at all, OR

7. Fast breathing in 0-59 days

1. Not able to feed at all or not feeding well, OR

2. Convulsions, OR3. Severe chest indrawing, OR4. High body temperature, OR5. Low body temperature, OR6. Movement only when

stimulated or no movement at all, OR

7. Fast breathing in 0-6 days

Red umblicus or draining pus ORSkin pustules

Local infection Fast breathing in 7-59 daysLocal infection

Conceptual Framework: Possible Solutions for Management of PSBI in Young Infants (3)

Nonspecific referral criteria

Young infants 7–59 days old with fast breathing – no need for referral, treat with oral amoxicillin for seven days

No difference in treatment failure rate between procaine benzylpenicillin-gentamicin and oral amoxicillin for fast breathing pneumonia

Treatment failure rate with oral amoxicillin was substantially lower than placebo

AFRINEST Fast breathing, Lancet 2015

Tikmani et al Pakistan, CID 2017 Integrate PSBI in child programs

Conceptual Framework: Possible Solutions for Management of PSBI in Young Infants (4)

Low compliance to referral

Young infants 0–59 days old with clinical severe infection - when referral is not feasible OPD treatment.

Simplified regimens were as effective as injectable procaine benzylpenicillin–gentamicin for 7 days on an outpatient

Baqui et al SATT Bangladesh, Lancet GH 2015

Mir et al SATT Pakistan, Lancet GH 2016

AFRINEST Clinical severe Infection, Lancet 2015

Integrate PSBI in child programs

Remaining issues in achieving High Coverage and Quality of PSBI management

ALL young infants with any sign of PSBI should be IDENTIFIED

ALL referred cases of PSBI should be effectively TREATED at a hospital

Difficult to identifysigns of PSBI by

family

Low coverage of CHW’s home visits

Low care seeking to health centre

No point of care diagnostic

Limited skills to implement clinical

algorithm

Nonspecific referral criteria & low compliance

to referral

ALL identified cases of PSBI should be CONFIRMED by a trained health worker at first level health facility

ALL confirmed cases of PSBI should be REFERRED to a hospital

Low compliance to full treatment

Low quality of care

Use opportunity of facility births to

empower families

Evaluate revised algorithms

(including available lab tests)

Optimize criteria for referral to hospital

Simplify hospital based treatment and achieve high quality

Going forward and keeping eyes on targets set for 2030

Families and communities

aware of danger signs

THANK YOU and let’s continue to stand for newborns