Mir: Increasing Coverage and Improving Quality of Facility-Based Management of Newborn Infection

7/28/2019 Mir: Increasing Coverage and Improving Quality of Facility-Based Management of Newborn Infection

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Increasing coverage and improvingquality of facility-based

management of newborn infection

Fatima Mir

Assistant Professor

Pediatrics and Child Health

Aga Khan University


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Contents

Facility based newborn care History Existing standards Possible Impact on newborn mortality

Newborn infection Case definitions and standard of care in different settings

Maternal infection Case definitions and standard of care in different

settings Field notes from Pakistan

First Level Second and Tertiary Level


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Shadoul et al. EMHJ Vol 16 Supplement 2010


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District Health care System in Pakistan

Tiers Health Houses : 99097 Basic Health Unit: 12449

Rural Health Center: 596

Maternal and Child Centers Tehsil Headquarter Hospital District Headquarter Hospital: 989 Tertiary Teaching Hospitals:

Capacity

100,000 plus

1/10,000-25,000

MO/LHV/Vaccinator/Health

technician/Dispenser/sanitary worker

1/50,000-100,000

MO/LHV/midwife/vaccinator/lab/dispenser/ radiology/OT/anesthesia

15-20 bed

LHV, TBA

0.5-1 million; 40-60 bed

1-3 million; 125-250 bed

Sabih et al. EMHJ. Vol 16, Supplement 2010


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Pakistan Maternal and Child Health Policy and Strategic Framework 2005-2015


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Gaps in quality & coverage

First level Antenatal care

Access UTI, fever in pregnancy, TT coverage Parenteral/oral appropriate antibiotics Laboratory support

Perinatal GBS prophylaxis, clean delivery kit, incentivizing facility based deliveries, vital

statistic registry, sensitizing to PROM

Postnatal Identification and diagnosis of serious bacterial infections in both mothers and

newborns

Case based management of common infections in newborns and mothers IMNCI

Facilitated and safe referral Plan B for refusals


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Facility based care for infection:

measuring impact IMCI

Gouws et al 2004 Appropriate dose, communication with caregiver, first dose at center

Arifeen et al 2005 Baseline survey pre-IMCI; danger signs, growth, correct classification,

correct treatment, correct counselling

F-IMNCI Bhandari et al 2012

Neonatal mortality in home births, neonatal care packages

FBC-newborns Neogi et al

Regionalization, quality of care at Level 1&2; training and investmentin level 3


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Newborn infections

10% of all child deaths Sub-Saharan Africa & South East1

Spectrum

Neonatal sepsis

Pneumonia/meningitis/omphalitis/ophthalmianeonatorum/HIV/tetanus

Signs and Symptoms Subtle

Overt

Black et al. Lancet 375:1969-1987, 2010Ganatra and Zaidi. 2010. Semin Perinatol 34:416-425


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Diagnosis and Management of

Newborn Infections

Facility

Case definitions follow standardmedical textbooks

Assessors more skilled and trained Assessor can distinguish to agreater extent btw infection,prematurity and asphyxia withlaboratory and radiology support

Gold standard managementpossible at secondary and tertiarycare facility

Quality of care at secondary andtertiary care facility poorlysupervised and non-harmonized

Community

Case definitions follow clinicalalgorithm validation studies invarious regions

Assessor may miss subtle signs

Assessor does not havelaboratory support due to whichoverlap/ambiguity may remain

Standard of care may be anunder-studied

Poor systems for facilitatedreferral of high risk newborns


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Case definitions in community settings

Ganatra and Zaidi. 2010. Semin Perinatol 34:416-425Young Infants Clinical Signs Study Group: Lancet 371:135-142, 2008


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Diagnosis and Management of

Maternal Infections

Facility Case definitions follow standard medical

textbooks and WHO recommendations

Assessors skilled and trained

Assessor is aware of referral tier Assessor can distinguish to a greater extent

btw infection, prematurity and asphyxia withlaboratory and radiology support.

Gold standard management possible at

secondary and tertiary care facility Quality of care at secondary and tertiary care

facility poorly supervised and non-harmonized

Community

Case definitions not clear

Assessors and recently delivered womennot aware of puerperal sepsis as a

individual entity

Assessor does not have a facilitatedreferral system in place

Not trained to utilize laboratory andradiology resources

Gold standard management at community

level not defined

Quality of care and referral tier at LHW

Facility based Newborn care operational guide. India. 2009

Bhutta. Semin Neonatol1999; 4:159-171

Meem et al. JOGH Vol. 1 No. 2 Dec 2011


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Field Notes from Pakistan

Neonatal Sepsis The SATT trial

PHC-tertiary care liasion Facilitated referral Other causes behind treatment failures (I-POP) Efficacy data in addition to clinical effectiveness data (POP-PK)

ANISA study Maternal Sepsis

M-ANISA CHW and PHC physician training PHC-tertiary care liaison Facilitated referral

Voucher schemes Greenstar voucher scheme

Jhang District (Punjab) Charsadda (KP)


13/38Courtesy: Dr Momin Kazi, Demogrophic Surveillance System , AKU


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Site Total Pop Male FemaleFemales

15-49 years

Number of

Children

Under 5

Rehri Goth 31,969 16,778(52%) 15,191(48%) 7721(24%) 4645(15%)

Bilal Colony 76,361 41,129 (54%) 35,232 (46%) 17,351 (22%) 11023 (14%)

Ibrahim Hyderi 65,891 33,984(52%) 31,907 (48%) 18,253 (28%) 8,939 (14%)

Ali Akber Shah 54,834 28,218(51%) 26,616 (49%) 12,710 (23%) 8,360 (15%)

Bhains Colony 45,801 24, 770 (54%) 21,031 (46%) 11,767 (26%) 6,061 (13%)

Total 274,856 144,879 (53%) 129,977 (47%) 67,802 (25%) 39,028(14%)

Population Under Surveillance

Courtesy: Dr Momin Kazi, Demogrophic Surveillance System , AKU


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Site GFR CBR NMR U5MR MMR

Rehri Goth 154.4 36.5 42.8 78.0 59.4

Bilal Colony 106.6 28.4 40.0 50.3 29.5

Ibrahim Hyderi 116.8 34.5 36.9 57.4 24.1

Ali Akber Shah 159.3 32.9 26.8 41.0 39.2

Bhains Colony 135.3 37.4 26.4 38.9 29.6

Total 128.3 33.2 34.4 51.9 33.9

GFR= General Fertility Rate (annual # of births per 1,000 women of reproductive age (14 49 years))

CBR= Crude Birth Rate (live births per 1,000 population)

NMR= Neonatal Mortality Rate (death of children 0-27 days/1000 live births)

U5MR= Under 5 Mortality Rate (death of < 5 years old / 1000 live births)

MMR= Maternal Mortality Ratio (maternal deaths per 100,000 live births)

Courtesy: Dr Momin Kazi, Demographic Surveillance Systems, AKU

Important Rates


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Center Para Block Structure Household Mother Child

Center namePara name

Block number

Structure number

Household number

Mother number

Child number

DSS ID

Courtesy: Dr Momin Kazi, Demographic Surveillance Systems, AKU


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Bilal colony primary health center


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Bhains colony primary health center


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This trial evaluates primary care clinic-basedsimplified antibiotic therapy options for young

infants, 0-59 days old in high neonatal

mortality settings in peri-urban Karachi wherehospital referral is frequently refused by

families

Simplified Antibiotic Regimens for the Management of Sepsisin Young Infants in First-level Facilities: Randomized

Controlled Trial


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3116


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The SATT Trial

Outcomes

Success

Treatment Failure

9-11% fail first line therapy

30% of 11% fail second line

16 children underwent an echo and a CXR

4 had life threatening heart and lung disease

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ANISA Surveillance Karachi site

Step 1: Married women

Surveillance and under

5 listing

Step 2: New pregnantwomen identified

Step 3: Pregnant

women follow ups

Step 4: Child birth and

Registration in ANISA with

in 0-6 days of birth

Step 5: New born follow

ups at day 2, 6, 13, 20,

27, 34, 40, 48, 59

Step 6: SEPSIS

screening by health

worker

Step 7: Referral of allthose who identified as

SEPSIS based on 7

criteria

Step 8: If referral

accepted Physician

assessment at PHC

Step 9: Enrolled as

SEPSIS if criteria meet

3-4 pairs

of CHWS

4-5 pairs

of CHWS

2 ANC

sessions

1 Senior

health staff

+ 1 CHW

4-5 pairs

of CHWS

1 pair ofCHW for

Pick/drop


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Integration of pulse oximetry intothe routine assessment of young

infants at first-level health centers

in Karachi, Pakistan

Hospital for Sick Children Toronto

Aga Khan University


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Aga Khan University (AKU) Young

Infant Surveillance in Karachi

Pregnancy

surveillance

Antenatal

visits

Birth

notification

Post-natal visits

(0-59 days)

Clinic

assessment

Self-referral (by

caregiver)

Diagnosis of

very severedisease

Treatment and/or

referral by physician

ANISA

SATT

iPOP

Community

Clinic


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High dose oral amoxicillin attainspharmacokinetic efficacy endpoints in

young infants (0-59 days) withsuspected sepsis

A population pharmacokinetic pilot study

Principal Investigator: Fatima Mir

Supervisers:

Drs Anita KM Zaidi and Shagufta Khan (AKU)Dr Susan Abdul-Rahman (CMH Kansas)Dr Harry Keyserling (Emory)

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Funded by a Fogarty grant 1D43 TW007585-01 as part of MSCR Thesis at Emory


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37 17


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Conclusion

Oral amoxicillin concentrations in 0-59 day old infantsexceeded the susceptibility breakpoint for S.pneumoniae (2mg/L) In 39 of 44 (88.6%) young infants at 2-3 hours of index

dose In 19 of 20 (95%) young infants at 6-8 hours of index dose

Strong support in favour of oral amoxicillin with IMgentamicin as second line sepsis therapy More information required on

renal clearance and trough levels at 12hours in this population

Funding from Save the Children for a larger study

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Yasir et al. J Obstet Gynaecol Can 2009: 31 (10); 920-29


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Supplement to ANISA:

Development of a community-

based presumptive clinical

diagnosis algorithm and treatmentregimen for maternal puerperal

sepsis

John Hopkins University

Child Health Research Foundation

Aga Khan University

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Project Goal: To prevent maternal deaths and long term health

consequences of PP sepsis among women in three low-

resource South Asian countries

Designed in 2 phases Phase 1

In depth interviews with Recently delivered women Care providers in

community and facility

Female relatives of RDW Collate findings in a clinical

algorithm to be administered byCHWs

identify women with probablepuerperal sepsis, otherconditions and local infectionseg. Mastitis or skin/wound

Designed in 2 phases Phase 2

validate a field-based clinicaldiagnostic tool

measure incidence anddetermine risk factors for PPsepsis to inform preventive

strategies and further refine thealgorithm

identify the aetiology andaetiology-specific incidence ofcommunity-acquired bacterialinfections among ill postpartumwomen

determine antimicrobialsusceptibility patterns ofbacterial isolates to informdevelopment of appropriatesimplified treatment regimensfor PP sepsis for use at thecommunity level.

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MANISA


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ANISA Surveillance Karachi site

Step 1: Married women

Surveillance and under

5 listing

Step 2: New pregnantwomen identified

Step 3: Pregnant

women follow ups

Step 4: Child birth and

Registration in ANISA with

in 0-6 days of birth

Step 5: New born follow

ups at day 2, 6, 13, 20,

27, 34, 40, 48, 59

Step 6: SEPSIS

screening by health

worker

Step 7: Referral of allthose who identified as

SEPSIS based on 7

criteria

Step 8: If referral

accepted Physician

assessment at PHC

Step 9: Enrolled as

SEPSIS if criteria meet

2 ANC

sessions

MANISA

Karachi site

Risk factors for PP sepsis

RDW Follow up visits

CHW follow up assessment

Physician assessment

CHW Suspected PP SEPSIS

Physician Suspected PP SEPSIS

At Health Centre:

Urine & Blood Specimen

collectionEndometrial specimen

collection

Hospital Management

Discharge

Referral to healthcenter

Hospital Referral &

Specimen collection

MWSR team/ Birth RA

NB team CHW


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Algorithm ( Tool for PP Sepsis Diagnosis)

Section 7 : ALGORIT HM WORK SHEET

SIGNS AND SYMPTOM SCLASSIFICATI ON (ENCIRCLE I F

INDICATED)

PP Sepsis

7.01 High fever (temperature 39.1C or higher) [Q6.01 =yes]Suspected PP Sepsis

(if present)

7.02 Fever (temperature 38.1C 39.0C) [Q6.02 =yes]Suspected PP Sepsis

(Fever present at

examination or history of

fever AND any other

sign or symptom listed is

present)

7.03 History of fever [Q2.01 =yes; Q 2.02 - response high or moderate], or [Q2.03=yes]

7.04 Abdominal or pelvic pain [Q2.04=yes]

7.05 Abnormal or foul-smelling discharge [Q2.09 =yes]

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Algorithm- other conditionsSection 7 : ALGORIT HM WORK SHEET

Other Conditions

7.06 Severe Vaginal bleeding [Q4.02=yes]

Other Suspected Illness

(any listed symptom is

present)

7.07 Severe headache AND blurred vision [Q4.04=yes AND Q4.05=yes]

7.08 Leaking urine and/or stool [Q 4.06 =yes]7.09 Convulsions or unconscious [Q4.03 =yes]

7.10 Abdominal pain (without fever)[Q2.04=yes AND 2.01=No]

7.11 Fever (temperature 38.1C 39.0C) only

-see list above to rule out sepsis symptoms/signs

Q. 6.02 =Yes

Suspected Local Infection

(any listed symptom is

present)

7.12 History of fever only [Q2.02 =response high or moderate], or [Q2.03 =yes]

7.13 Abnormal or foul-smelling vaginal discharge (without fever) [Q2.09=Yes AND2.01=No]

7.14 Burning on urination [Q3.07 =Yes]

7.15 Cough or difficulty breathing [Q4.01=yes]7.16 Pus or pain from tear, C-section or episiotomy wound

Q3.05 =Yes OR Q 3.06 =Yes

7.17 Swollen, red, or painful breast [Q 3.01=if answer is any of 1 or 2 or 3 (anyanswer other than 0)]

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Physician Assessment- form 5Section 6: CL INICAL ASSESSMENT OF THE MOTHER

6.00

Temperature.

May I please take yourtemperature?

Please record the current

temperature of the mother

(by placing thermometer

orally until it Beeps) if

allowed.

|___|___|___|.|___|Fput 999.9 if mother refused

[Measure again after 10min if

temperature is 100.6oF

(38.1oC in 1st measurement and

record bellow carefully and

classify according to 2nd

measurement]

|___|___|___|.|___|F

put 999.9 if mother refused

6.01

HIGH FEVER:temperature

102.4oF (39.1C)

or higher

1 Yes

2 No

6.02

FEVER:

Temperature

100.6oF -

102.3oF

(38.1C

39.0C)

1 Yes

2 No

Anemia

(by observing lower sclera)6.03

ANEMIA

1 Yes

2 No

Pulse

Count the pulse rate6.04 Pulse rate

|___|___|_

__|

Abdominal Tenderness 6.05 Abdominal

Tenderness

1 Yes

2 No

Blood Pressure 6.06 Blood Pressure (in

mm of Hg)

Systolic:

Diastolic:

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CRF 2 & 5

Section 2: Determine if the woman has any PP sepsis symptoms and assess the severity of her symptoms

2.00

Between today and your delivery day [or between last 2 visits ofCHW], did you have fever?

Yes 1

No 2

2.04

2.01 How many days had you suffered from fever? |___|___| days

If less than 1 day code 00

2.02 How severe do you think your fever was Mild/low grade fever 1Moderate fever 2

High grade fever 3

2.03 Did your fever make you feel unable to stand or unable to get out

of bed, or unable to complete chores?

Yes 1

No 2Don't know 8

2.04 Between today and your delivery day [or between last 2 visits of

CHW], did you have lower abdominal or pelvic pain?

Yes 1

No 2

2.08

2.05 Did the pain in your lower abdomen feel the same every day, or

has it increased since the delivery/ over the period between last 2

visits of CHW?

Decreased 1

Pain remained the same (until now) 2

Increased 3

2.06 How severe do you think the pain is (or was)? Rate the severity

from 0 to 10 looking at the following picture.

2.07 Did the pain become more severe when touching or pressing the

lower abdomen?

Yes 1

No 2

Don't know 8

2.08 Between today and your delivery day [or between the last 2 visits

of CHW], did you have abnormal vaginal discharge present?

Yes 1

No 2

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Facility based management of infection

Case management WHOs recommnedation of 3 IV antibiotics (Ampicillin,

Metronidazole and gentamycin) until the woman is afebrilefor 48 hours

Before providing treatment, specimen collection (urine, blood,endometrium)

Non-response to treatment Correlate with culture results

Admission/ discharge Obstetrician/gynaecologist history and exam Endometrial tissue culture

Antibiotic (parenteral)

Discharge plan

Performance based incentives to increase


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Performance based incentives to increase

coverage

Subsidizing Travel and Services in Pakistan

Greenstar voucher scheme (2008-09)

to encourage poor pregnant women to seek maternal health

and FP services in Dera Ghazi Khan District in Punjab More than 98 percent of women with vouchers delivered at health

facilities

97% of whom had previously delivered at home7

More than three-quarters returned for FP counseling after delivery

Two similar voucher projects in Jhang and Charsaddadistricts with a greater focus on sustainability8

Sohail Agha. Reproductive Health 2011, 8:10


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In summary

Census and demographicsurveillance

PHC Newborns

IMNCI

Facilitated and safe referral Liaision with tertiary care

center/physicians

Plan B for refusals

Mothers Puerperal sepsis algorithm Facilitated and safe referral Liaision with tertiary care center/

physicians

Liasion with local TBAs and maternityclinics

Plan B for refusals

Secondary Customized newborn case

management guidelines forPakistan

Customized maternal

infection managementguidelines for Pakistan

Tertiary Newborn Group within

Pediatricians

Optimize high level care Private-Public

Partnerships Advocacy

Mir: Increasing Coverage and Improving Quality of Facility-Based Management of Newborn Infection

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